What's up, how are you guys this weekend Frankie eyeballs is back, and we haven't been on a date in a while So I said why not find a beautiful German girl, which is perfect because I've only really had success with foreign woman And I'm assuming that's because if a girl actually understands the words coming out of my mouth It is a it's a done deal not getting a second date But uh, if they don't really understand what I'm saying and just smile and nod And I don't understand what they're saying. I smile and not it usually works out for the better So we have what I eat in a day as a professional athlete alika schmidt Do I get do I get a first date for my pronunciation? Yeah, it's in german so I'm gonna be focusing on reading today Experts Why do these people always start with a disclaimer? Like like your goal is to to sell products. You're assuming you have like some level of knowledge to be doing that Like like it's like a professional baseball player Doing a tutorial on how to hit a ball and saying by the way, I'm not a professional Why you're making a tutorial So It's No Is that a translation I've always eaten polish for a long time Oh wait, wait, is she I'm confused All right, I don't think uh, I don't think this I don't think the translator is 100 accurate, but You Germans have a reputation for being very boring, right? Cream cheese, honey, nut butter Banana Hey, hey, this might be one of the best breakfasts we've ever seen You know, I always say like the purpose of a meal is to either give yourself Chloric nutrition or like animal nutrition the vitamins minerals omega fatty acids all that stuff And this this is a combination of both The important thing here is there's no nonsense and you're not having acai smoothies matcha tea Downing greens no high volume fruit nonsense. It's just What you're supposed to be eating I mean, yeah, it's not organic. It's not high quality But you know, we're in the right direction of of base foods to choose from Because if you did go high quality and organic with every single ingredient here, this is something I would eat myself We had to ruin it I Mean I mean beetroot is is very high in nitrates. It's very very hard. I mean look at the color It's like deep purple almost black very hard on the liver The way you have to look at it is like the darker colored something is The more like flavonoids and polyphenols and compounds are in it Which means the liver has to process them and those those compounds like they're not needed for our body You know the the nitric acid the what people take sometimes in pre-workout supplements And and people are even drinking like beetroot juice now. It's just it's not good for you It's like an artificial inflammatory reaction in the body So she had The nut butter in there which she had for breakfast too and ideally you get macadamia nut butter, but Common butter peanut. I mean that looks like almond butter. I'm guessing that's what it is It's not the worst thing to have but it's also not that great if anything. It's just like energy and calories Uh, I don't want to touch too much on the organic versus not organic We've done a lot of videos on that but I'll briefly explain that if you don't go organic There's herbicide pesticide agrochemical concerns to at the point where you don't want to really have the food And although bananas are a decent source of calories We did a video on them explaining that they're like one of the worst foods from an anti-nutrient perspective Unless you cook them or ferment them We actually have a banana rice crisp bar on frankie strange foods But the banana In uh in that bar is like fermented. So it's broken down a little bit and we cook the bar too So we're greatly reducing the anti-nutrient content But to have bananas raw like that in the meals is Little little risky from a gut health perspective. The protein powder should use whey protein.  We have the collage and broth I prefer eating my protein sources But high quality whey protein is is great bioavailability of protein amino acids and also very high in minerals Uh, which is not something you hear people talk about a lot in regards to protein powder is the mineral content like calcium Magnesium really really everything and and b vitamins too. It's very high in b vitamins b12 Yeah, it shakes not that great, but it's not gonna kill you and uh We do we have to get into what type of water she used to I Okay, like I mean She was kind of dolled up in the beginning i'm a little I Still let her beat me up Well, I mean I think if we legitimately thought she would beat me up so Oh, she brought it with her My Oh, we're back with the makeup and the and the outfits Uh, these professional athletes to my understanding train between three and five hours per day So it's very intense And I don't like bringing this up because i'm already shadow band enough but every professional athlete uses performance enhancing drugs and and What like the people that control everything they they try to send in shills and say oh, woesh She doesn't look like she's on stairs. Well, yeah chess grand masters don't look like they're on stairs But they take that any any ping pong players don't look like they're on stairs But they take them the point is that You know just because you're taking hormones doesn't mean you're training like a bodybuilder to look muscular The the hormone levels will increase your muscle mass, but not to the point where you know, it's anything crazy Tomato Hey, maybe if I wasn't jabbed as a baby My brain would work well enough to to learn a few languages Then I could start speaking German to my Amish buddies, too So you see see the the yellow color in the potatoes Something else your body has to process. That's why I mean if I eat potatoes you want white russet potatoes preferably or uh white fleshed red potatoes And then I mean like when you when you're young and healthy and your liver isn't completely destroyed yet Yeah, yeah, maybe you can deal with all this stuff like the paprika the yellow potatoes, but eventually it gets to a point where you know I Mean fresh high quality salsa, she's using whole ingredients. She's make it from scratch. So It's not the worst thing, but she could definitely have a higher fiber content and I would definitely reduce the amount of paprika and seasoning That's something you got to be careful with that a lot of people do you know They'll have a super healthy meal like this But putting like two tablespoons of paprika on your potatoes is just gonna fry your liver Either the meal would be 10 times better if it didn't have that Oh my god So one has to maybe maybe we have to maybe have to Convince her to take me back to her place after the first date and I can like steal all the spices from her cabinets And confiscate them See like like her knife skills and the way she's cooking like This isn't one of those like fake cooking videos where these girls have like a spotless kitchen And and just pretend to cook because we know they're eating out every day It seems like she might actually be doing this every day and although avocados are definitely not german The base of a lot of the meals she's preparing is probably similar to a lot of like traditional german culture That's where she's getting you know the bread the potatoes the meat and stuff So even though she's adding like maybe a few modern twists and things that make the meal a little less healthy The base of nutrition is there, which is excellent She's putting so much seasoning and everything like like these foods would taste good with just a sprinkle of salt on them You shouldn't need to over season everything I mean this this is excellent though like like Besides the ridiculous amount of spices like this is how most people should be eating You have the base of meat and starch and if you want to add some you know Mexican twists for for flavor you can I mean like maybe double or triple the amount of potatoes and this would be good This might be this might be bad Sweet potatoes very hard on digestion Even though people think they're a good carb source like they're so high in beta carotene that it makes the other components And the starches and the sugars hard to digest I mean if she's about to put paprika on that too You know sometimes when you eat a lot of the same food, I guess your palate gets blown out Like like a lot of these Amish people I do business with they put so much salt on their food And they over smoke it so much like all like a lot of the meat They'll eat like the smokiest saltiest sausage that I can't even take a bite out of and they'll eat the whole thing every day so Definitely have to have a variety amount of taste buds Could be a nutritional thing too causing cravings. I guess And Looks like a go sheet you might have better better knife skills than me on that was the parsley dice the onion dice embarrassing all these other Day of eating girls on youtube Need the german precision I Yes, so if anything this is like the worst meal of the day Like as an athlete All you really need is fuel. I mean I mean regardless of whether you're an athlete or not There's a there's a lot of unnecessary things That a lot of people think is healthy that you don't have to eat like the greens lettuce salads If people knew the truth about nutrition Big lettuce would be 100 out of business because raw leaves Don't taste good to anything besides a gorilla and they don't do any good for you Like maybe maybe if you enjoy like a little bit of arugula with some tomatoes and mozzarella with a little dressing on it Once in a while, but having gigantic bowls of it is is is no one's enjoying that and it's not reasonable So we're so what are you actually getting when you eat something like that Maybe there's a small amount of digestible sugars and starches, but it's really just a lot of bulk And you're getting the salad dressing the fats in that and then whatever agrochemicals are on that if it's not organic, so It's healthier to reduce the food volume and have more calorically dense foods because you're you're also reducing the risk of Of pollutants and stuff She's gonna wear that shirt I can call her like boss mommy or something With this man Almond mousse with vanilla and cinnamon I'm down with that I mean, it's a healthy snack. I think I think organic almond butter is is pretty acceptable to have in your diet if you like it Uh chocolate, especially organic is okay, too. I mean that that snack in general is And and like most of the meals she's eating with the exception of the sweet potato Uh catastrophe for dinner Excellent excellent excellent food choices apple with almond butter and chocolate. I can't really Complain that there's too many downsides about about those foods, you know, they're all fairly calorically dense There there's pros and cons to each one of them, but for the most part it's it's pretty much a A net positive you're giving yourself calories and it's it's not too bad for you My out of focus Send photos. Hold on. What did she say? So wait, did she say I could send her a photo if I try the recipes Yo, should we should we recreate the recipe and then I'll take a photo with like a sign that in in german That says how much for a date All right guys enough nonsense Enough nonsense. She's half of a taller than me. It would never happen I I I need to start putting a disclaimer. I need to say like All the words that come out of my mouth for the most part appear nonsense But you guys can kind of gauge that.  I'm not gonna I'm not gonna go through this and translate everything. Hey, we got our buddy sebastian I didn't understand a single word you pronounce, but I love to see you. Hey, we got uh Some more english fanboys. All right, ladies and gentlemen that is enough nonsense for today I think it's a pretty good diet overall plus I have to get back to bed. My schedule is so fry, dude I took a nap way too long I got up at 4 a.m And now it's like 8 a.m And I have to go get some sleep before I go down to work this morning, but Um, so we're gonna wrap this up You guys can go to frank dash to find out com if you'd like to support me through all of my Unique and creative health businesses Make sure to sign up for the newsletter on on frankie syringe meet if you guys want to stay updated If you don't have time to watch the vlogs that we do every monday or tuesday Yeah, also just let me know if there are any day of eating or anything interesting or fun Do you guys want me to review? Let me know down in the comments below but outside of that I'll see you guys for the next video


Okay, so now we've got another one of these molecular total net ionic equations, okay? So we've got these four, well I guess it was written differently than this, it was given to us the molecular equation. Okay, so this was given to us, right? And we want, this is the molecular equation, we want to break this up into its total ionic equation, okay? So molecular, okay? So calcium nitrate, we remember what calcium's ionic charge is, hopefully. Well I guess the first thing we want to do is balance the equation, which it's not balanced right now, right? So we've got two nitrates here and three nitrates here. So we're going to have to do something to this. We're going to have to multiply this by three and this by two over here. So now we've got six nitrates and six nitrates. But now we've got three calcium's and only one calcium, so we're going to have to put a three there, okay? Now we've got three sulfates, three sulfates, two cobalt, two cobalt, three nitrates, three nitrates, three calcium's, three calcium's, okay? So everything's balanced now, okay? Now we're going to do our total ionic equation. Oh, yeah, this one should say aqueous, sorry. Okay, so now we're going to do our total ionic equation. Remember anything that has aqueous after it? We're going to break up into its ions, just like we did last time. Calcium we know is a two plus ion. We're going to put the physical state aqueous after it. So how many do we have? Three times two nitrates, right? So we've got six of them. Six and oh, three minus. How do I know it's minus? Just minus one? Well, if I haven't memorized it yet, which I should have, I would realize that calcium is two plus and there's two of them for each calcium, so it must be minus, okay? Or in other words, three times two is six, six times one is six, okay? We've got to put aqueous after that. Now let's go to the cobalt, okay? What cobalt is this? Well, we've got to remember some things, I guess. We could remember that sulfate ion or ionic charge is negative two. If we remember that, then we could get this directly. Or if we come over here and now we know nitrates is negative one, there's three nitrates. That must mean cobalt is positive three, okay? So cobalt two, or two cobalts, you know, three plus aqueous. So notice how I'm putting my ions and how it's different than the way you were writing them on your paper, okay? And then we're going to have to add our sulfates to it. Three S04, two minus, that's a two. I'll show you. Look at the top. See how it's much different? Do you see the difference? Okay, you've got to write it this way. Okay, this is a solid, right? Calcium sulfate, so it's not going to break up into its ions. And now we've got this, which is aqueous, so it's going to break up into its ions. Remember, cobalt's cobalt three, and we've got three nitrates. And remember, nitrate is negative one, okay? So that's the total ionic equation. And remember, when we want to do the net ionic, we want to do the net ionic. We just take out what's on both sides, or what we call the spectator ions. Let's do that with a different color, maybe red. Calcium two plus on this side, no calcium two plus on this side, right? Nitrate minus on this side, three of them. Oh, this should be, sorry. This is, sorry, three times two. I'm surprised you guys didn't catch me, okay? So the reason I realized that there should be six is because I looked over here and there's six of them here. There was only three of them there, right? So, yeah, it's kind of a giveaway. So we've got six. We're going to cancel that out, six nitrates. With that, six nitrates there. Two cobalt three plus, with two cobalt three plus, and then sulfates we have over here, but none over here, right? So let's write our net ionic equation now.  And if I were to ask you what are the spectator ions, you would say N O three minus C O three plus. Those are the spectators. Does that make sense? Make sense? Those are the ones that I crossed out. Yeah, spectators are what I crossed out. Any more questions before I shut off the video?


This paper highlights the growing use of social media by researchers to engage in public debates and rapidly disseminate research results, specifically focusing on TikTok's unique potential for collaborative knowledge mobilization with underserved communities who experience barriers to health care and health inequities. The paper presents analytics data from 13 selected TikTok videos on the topic of research on gender-affirming medicine to illustrate how knowledge is disseminated within the trans community via TikTok, while also discussing considerations for researchers planning to use TikTok for digital knowledge mobilization and other related community engagement with equity-seeking groups. The paper concludes that TikTok presents possibilities for achieving transformative, community-engaged knowledge mobilization among researchers, underserved health care users, and their health care providers. This article was authored by Kinan Ross McKinnon, Hanakia, and Ashley Lacombe Duncan.


So the questions are number one, which of the following past medical history as well, allow us a potential donor cornea for transplant, so another way to do that, which would not. Number two, we're going to go over the answers so, post-op complications and pediatric PK would include glaucoma, embliopia, slow or delayed healing, graft rejection, all of the following except which of those, slightly tricky question, I'm not going to read this part. According to the cornea donor study, how did donors over 66, or under 66 compared to donors over 66 years of age, higher rate of early graft failure of five years, no difference in rate of graft failure of five years, lower rate of graft failure of five years, higher rate of late graft failure of five years. I wouldn't know this unless you read about this. Based on curatoscopy, which is just what, this is a placido image, right? This is what standard topography is generated from, it's just a computer analysis. Which suture would you take out, 80, 170, 360, 350? There could be more than one right answer. Which of the following types of rejection is most detrimental to survival? This patient presents with increased irritation of his eye. What is the best management? So it's a transplant, sutures, you can see that the eye is red, and then this line is kind of what you're supposed to be looking at. You could see better if there would be some edema below that line. And so like that, again, could be a board's question, and you would try to elucidate, say, well, I think this is what I know, and this is what it could be, a world board's meeting. So you could repeat the transplant, increase the pred drops to every hour, increase the pred to three times an A, culture and start fortified antibiotics. Where would you place a PI to prevent pupillary block after endothelial keratoplasty, superior temporal infir, or nasal? Think about how fluid circulates, probably all of this, and then also the patient's going to be upright, and there's going to be an air bubble in the eye, those are the clues. Which type of refractive shift would you see after desec, myopic, hyperopic, or no refractive shift? Not intuitive, you wouldn't know unless you're right. It had a history of three failed transplants, and two in the right eye, and two in the left eye. It also has a long-term hospitalization after taking a back room, which would be the next, the best, next, best, I can't talk. Repeat for penetrating keratoplasty and desec, let's use this word de-mech. This could be a board's question. Which of the following does not increase the risk of rejection? Intergraph science, older recipient age, presence of peripheral anterior synechia, or at least suture? Which of the following past medical histories will allow the use of potential donor cornea used for transplant? Not a very good question, Annie, bad wording. We'll have to do that. So breast cancer, it's okay, even metastatic cancer, as long as it's not to the eye, is okay for transplant. Leukemia, active septicemia, it's kind of obvious you wouldn't want to potentially transplant bacteria, or, you know, grossly cancerous cells into an eye, and leukemia, the cells can circulate and get into the eye tissue. Parkinson's disease is kind of an interesting one. Most people don't feel like Parkinson's disease is transmissible, but it is on the list of, you know, it's more probably, people would not, there's no known transmission of Parkinson's disease, let's put it that way, but it is on a list of exclusions. There's a fair amount of eye banking in this chapter, we won't go into a lot of it, but we'll go into some really basic stuff. So kids heal fast, sometimes you can take their stitches out, literally you can have all the stitches out in a penetrating caroplasty in three weeks, I've done that before. All of the others are actually higher risk or pediatric corneal transplant. The corneal donor study was a big center trial, I was actually one of the investigators and compared donor tissue from younger and older donors, and the correct answer was there's no difference in graft failure. And there was about an 80, well 86% survival rate of transplants, I mean younger tissue, it's kind of intuitive, younger tissue, maybe a little better, but really this was a very important study to kind of validate the use of older donor tissue, which is obviously a higher supply because older people pass away. So it was really helped for surgeons to be able to be accepting of using older corneas, not just looking for young trauma victims or unfortunately we see a lot of suicide victims. So which suture would you take out? One where the mires are most flattened, the one opposite could be a correct answer because you do have a coupling. We aren't going to really talk about that this year, but in the refractive surgery lectures of the alternate year we talk about that. So if you took this suture out here, you would actually see a lot of effect overall probably, but taking this one out where it's most flattened is the correct one. That will be on OCAPS and board, I mean it just won't be, it always is. Endothelial rejection obviously, endothelial cells don't regenerate, so that's the most important type of rejection to prevent. This is a crudidose line, not a very easy one to see, but you'd want to increase the top of steroids to hourly and you can do other things, but that's the best answer. Inferior perfilarotomy, so that fluid can circulate, the air will be on top, fluid can circulate around through the iris to help prevent pupillary block. If you don't understand that at a more junior level, don't worry about it because it will be something that you'll understand. You get hyperopic shift with desec surgery, it has something to do with kind of a, maybe minus lens on the, maybe kind of the shape of the tissue, no one really knows exactly why that is. We published a paper on it with some kind of ray tracing suggestions, but we don't really know for sure, but generally it's hyperopic. You can get any, but if that's worth to a test question, you would say hyperopic. Three failed transplants in the right eye, two in the left, and then this implies what? Any resident, hospitalization, this person was in the burn unit after taking a Sulfa drug, he wanted to make it have a surface, acetic actinosis, and the prognosis would be crappy for that. So the best answer might be none, one that was available. So older recipient age actually is associated with less rejection, because the recipient immune system is weaker, so the less likely you're dead. So now we're just going to move into a lecture. So why would we do, and this says for PK, but also could apply to some of the other cornea transplants, particularly lamellar, anterior lamellar keratoplasty. The most obvious reason is that the patient can't see, and there's something in the way. So a visual or optical reason, it could be an actual scar that's blocking the vision, or it could be a deficit in the curvature of the cornea that can be overcome by a contact lens of severe thinning, severe irregular stigmatism. Things like edema, obviously, would also block vision. Structural refers more to that shape part, or could refer to patient with trauma, or infection, perforation, that kind of thing. But number two is related to number one, because if you don't have good structural cornea, you can see very well. And that therapeutic is the least commonly performed, but would be for an infection that can't be controlled, and you're going to get this out before it spreads. And then sometimes just tectonic to restore the globe, but maybe a temporary thing as well. So perforation, things like that, which are rheumatoid mel, would be a good example of something where you're just going to have to do a patch graft and then try to do a definitive repair. So this just shows right even indications. I won't quiz you guys, but slip meme, showing thickness, that's herpetic stromal edema. You would call that down before you. So this is a classic disco form, herpetic edema. You would call that down. You wouldn't do a transplant if they have that active edema. Fluke's dystrophy with goutte, obviously, perforation, keratinonus or pollucid. Granular dystrophy, herpes simplex. All kinds of, this could be interstitial keratitis or infection. Veiled graft is a very common one. This would be more of a possible therapeutic indication. I'm not even sure what that is. It's probably an infection, as we read. But I mean, there's all kinds of different reasons. So just a little bit about eye banking. The book says 2 to 75, and I think that's fairly, each eye bank has its own acceptable criteria, but that's pretty standard. Again, the cornea donor study, justify and validate using older tissue. Cell count, most people use a higher cell count than 2000, but that's kind of what is written in the EBAA, Eye Bank Association of American Standards. We generally use tissue over about 2,300 cells in our eye bank. I feel like we have a surplus of tissue. And then for endothelial careplasty, because there's so much manipulation, we usually use a little bit higher cell count, 2,500. And so as a surgeon, you can kind of specify to your eye bank what your own criteria are within reason. Death preservation is really, the standard is really 12 hours, but most of the time, most eye banks go out to 24 hours if the body is not too warm.  You guys might have seen this rotating on medicine or whatever to put the ice and gloves, and close the eyes and put the ice over the eyelids. And the idea there is to help preserve the corneal tissue. So usually out to 24 hours is totally fine. If somebody passed away out in Death Valley in the summer and it was 19 hours, you probably would not use their tissue because the heat just speeds up all of the enzymatic degradation of the tissue. There are different storage media. The book goes into this a little bit. We don't use organ culture in this country, but you should know about it. The common way of storage here is cold storage might be good to know that the temperature ranges. You don't want to freeze the tissue. There are a couple of different preservation media. Preservation media, I don't know that that would be a really important thing to memorize, but GS stands for gentamicin and streptomycin, so it has antibiotics in it, it has some nutrients in it. There was another study that, again, I was an investigator and called the Corneal Preservation Time Study, which was a DSEC study that proved that it really was safe and effective to use tissue out to 14 days, although the corneas really did the best when they were used by 11 days, so that's kind of my preferred. We had a cornea last week, or the week before the function was doing fine. So we still use them. And that was in response to surgeons not wanting to use the tissue after those. I think it is one area where there really has been some good prospective studies to help surgeons understand what's advisable or clinically appropriate. So the required testing is HIV, hepatitis B and C and RPR. There are other tests, for example, California Requirements Testing for HDLV 1 and 2. We had a donor recently, Maddie, again. Organ donors are tested for CMV and EBV, and often those titers are positive and we still accept the tissue. They just want to know for their organ donor patients. Things like Zika, I don't think Zika has been transmitted by corneal transplantation, but that is a really important recent infection, where people might not be sick, they might be past the sick phase of the illness, but still be able to pass it. So fortunately, the Zika thing kind of died off. I'm not aware of any, but you can kind of foresee other infections. West Nile virus is another one that people can get and maybe not know that they have, which could be important and detrimental to at-risk recipient. It tells you what diseases people have transmitted. AIDS has not been transmitted. No known transmission. Hepatitis B has C probably. Rabies, interestingly, when I was in practice in Idaho, the guy, I was only in private practice for two years before I came back here, but the guy whose practice I took over was the first guy to report a death from a re-stoner. His patient died from corneal transplant from somebody who had died from rabies, so that wasn't really known, then it was the first case. So that was awful, obviously. So when we're looking at the tissue in the eye bank, we look at it with the microscope for all these things, pretty obvious, then we do blood work. The social and medical history is really important. I'm not gonna go into that, but the book kind of talks about it again. That's maybe not as important as some of the other stuff. But for example, people who've been incarcerated or are very promiscuous, we don't use the tissue. And most of this screening is done via a coordinator over the phone with a family member or sometimes with a physician. And it doesn't talk at all about consent, but in Utah, most of you probably have Utah driver's licenses, there's a registry and so there's an implied consent law. Consent from the family is not required in many, many states now if the person has signed up to be a donor. Now, as a kind of a nicety, the donation coordinators will usually try to verify that with the family, make sure everybody's on board, but if the person signs up for it, they can legally take the tissue. So one of the most important things that's not really emphasized in this chapter is when you're thinking about doing a transplant, just think about the whole patient. We have two eyes, many times you can't restore a perfect function to the eye in question. So if you do a lot of complex surgery and try to make them better, is it still gonna be kind of a crappy eye compared to their good eye? That's a really important consideration. I cannot overemphasize this.  Many times you cannot see the pupil, but you can still do a subjective affair or reverse affair test. I get referred to so many people that are blind from glaucoma that have cladincornea and you're like, well, we had one last week that we didn't have serious retinal problems. We didn't have very high hopes that he would restore, have his vision restored based on testing. And then chart review is really helpful to try to figure out, mostly for glaucoma and retinal disease, and you can kind of try to go back if you get old records, kind of see if they could see a few years ago and kind of what's been going on since. And that's really helpful in my opinion. So you wanna do a little detective work. You have to pay attention to what else is going on the eye, particularly glaucoma surgery, really important. If you're gonna change or remove an IOL, you gotta think about, is it scarred in there, et cetera, et cetera. Pretty common sense stuff. If you're gonna do IOL surgery, how do you do IOL calculations? If you're gonna do a cornea transplant, that is for another day, but basically you have to estimate the curvature of the new cornea. Sometimes if they have really bad, we had a patient just recently with really bad, well, it was last week also, really bad edema on his cornea so we couldn't get any K values at all. So we kind of estimated from the other eye, you know. They kind of look back and say, well, your two eyes were pretty similar. Sometimes you just have to, because it was a combined DMACC and FACO. You really have to plan ahead. You have to know all your equipment that you might need. Think of plan A, B, and C when you're doing cornea transplants. It's nice to have an assistant. Even if it's a scrub nurse who can kind of help, you know, sometimes if there were a more emergent situation or something, just kind of help know what's going on. Ultrasound is really useful. If you have an opaque cornea, you can see how thick and nasty that cornea is. But, you know, there's a paroidal infusion. There's lenses right up against, right up in the front of the eye. This person has an RD. So we're very spoiled to have Dr. Harry here. But even if you do your own ECM, which we find really, you know, bad stuff that maybe need to be addressed, either during surgery or possibly, even as a contraindication for surgery. The criteria for success for corneal transplantation is very dependent on the premorbid diagnosis or pre-surgery diagnosis. So, for example, Stevens-Johnson syndrome would have a horrible prognosis and curative bonus would have a great prognosis. There's a whole spectrum in between. Recipient age is really one of the things that is perhaps counterintuitive, but generally the older the recipient, the better they do. Because, again, they don't have such a strong immune system. But all of these other things can factor in. And I would just really, really, really emphasize this one. Patients with poorly controlled ocular surface disease do not do the treating care of plastic or anterior lamellar care of plastic. With EK, they do better. And pretty much all old people in Utah have dry eye. So you gotta kind of think about that and try to control it. That's usually one of the biggest uphill battles. It's not rejection. It's just trying to get the ocular surface rehabbed. Compliance also is huge, huge, huge. Anesthetic, generally, we do mostly blots, but also general anesthesia, nothing fancy there. Certain types of surgery, namely EK, can be done with topical anesthesia very effectively. But I wouldn't wanna do penetrating curative plastic with topical anesthesia just because the eye can squeeze and move and you're more likely to have expulsion of contents. So we'll do a couple of little videos of operative technique, hopefully this plays. So that wasn't care to call this patient, so we cauterized to flatten the hand chair profile of the cornea so that the tree fine cuts more vertically.  Yeah, trying to keep the scissors vertical, kind of hug the wall where the tree fine is. We use viscote. We talk a lot about tissue distribution. You can already kind of see that this tissue kind of fits in the hole well. That's one of the goals, especially with keratoconus, you wanna flatten the profile of the cornea. So again, really the first two sutures and the first four are kind of determined where that tissue's gonna be. So simple interrupted running sutures are also used. That's pretty fast transport. So just to kind of go through the steps more, sometimes a fixation ring can be used. Maddie, what have you learned about how to suture the fixation ring? And to have it loose, right? Because you don't really wanna create a lot of astigmatism, but the idea is, I don't know if any of you have seen the eye collapse, probably in retina surgery you see it. Sometimes if you drain, you're doing a buckle or whatever. But you know, you don't want the eye to collapse. So if you have that kind of scaffolding on there, at least you'll have some structure, but it's, the eye can just, it can just turn inside out almost. It's really nasty. So having a, this is called a McNeil Goldman ring. It's incorporated into the lid speculum, but we often use what's called a fluorine ring. This is like Dacron suture, but we usually use silk. Handheld trefine, but most of the time we use suction trefines. Entering, we enter in flight with viscote. One important thing on the cutting is to, again, try not to leave a ledge. So most of the time the trefine will bevel out just a little bit. So if you have the dome of the cornea, the trefine's gonna bevel out a little bit. So if you're not careful to get your blade of your scissor in the groove that's already established, you're gonna leave a rim. And so I always say, hug the outer wall. So you get your blade of your scissor in there and you're kind of coming down. And then you're just kind of pushing centripetally a little bit to try to get that, get the, the suturing is just something that is fairly straightforward. But it's good to practice. So you guys should all practice on styrofoam. You don't need an eye bank eye. Syrofoam works great. Just practice passing angles. We would again offer to all of you the microscope out at mid valley in the minor room on the first floor is just like our microscope foot pedal everything. So that's a really good place to practice. So this just shows a combination of running in interrupted sutures, just different ways of suturing. So interoperative complications, I was kind of, I thought it was interesting in the book. They kind of minimize the most dreaded complication or don't really discuss it that much, which is what Maddie? Supercroyal hemorrhage.  So as you get into, you know, kind of cornea rotations or whatever, we can talk about how to help minimize that. I'm not gonna spend too much more time on this. This is important for you guys because you take call. So the early post-op care, you see these patients unfortunately, I apologize for that, but you know, they might have pressure issues that they could have.  But if you kind of just follow these principles, then the first stages are really to get that barrier function back to make sure the eye's not leaking, make sure the epithelium's intact. And one thing to really remember is try to avoid too aggressive topical medications. Many of these patients from glaucoma medications, for example, carbonic and hydrase inhibitors are pretty toxic to the surface. So if you're trying to promote epithelialization, you might even wanna stop their co-sops for a week and you know, watch their pressure closely, that kind of thing. Obviously pressure. Pressure is really a huge thing and many transplant patients, many, many, many of these patients have glaucoma and it's usually complex, so that's important. Don't forget about the macula. A lot of patients with IOL problems or other complications that cause corneal problems will have either acute or chronic macular edema. It's amazing what OCT can pick up pre-operatively even through cloudy corneas. So somebody comes in with kind of a cloudy cornea and you're like, yeah, your endothelium is bad but your vision's really horrible. It's good to get an OCT and I've picked up CME many, many, many times and you can still treat them and just know you can rinse up on steroids. What have you. This just emphasizes that you wanna try to get the cornea. I thought this was funny, it popped up on my, just one of those spontaneous random things, the backward d-sec and I just took a picture because I thought that was, it never, I don't know if they have kind of a random thing but it would keep up. I thought that was cool. 20, 50 line. So in the middle phase, which would be, I would consider that somewhere between one month and two months out to maybe six months out, you're just trying to make the stigmatism less, maybe get the patient into glasses or contact, you're starting to taper your immunosuppression, you're starting to take sutures out and usually the patients on cruise control unless they get stuck in the eye by a laundry basket and rupture their eye at day 10 like one of our recent patients. It was now a fake, but seeing .25 with her sclerolins, so she's doing all right. Anyway, eye protection, you know what I said. And then late care, really one of the most important thing is just trying to decide what to do with immunosuppression, you know, we, a lot of that. I really think having been in practice for 25 years now and seeing all different styles of managing transplant patients, if you see your patients more often and you keep them on a little bit of steroid, they do better. The rejection rate is definitely lower on low dose steroid, but also just compliance. I mean, people can, and kind of compliance implies that you need to see them too. The doctor needs to put forth effort to keep seeing their patients.  And it's kind of like macular degeneration, you know, people have two eyes, maybe it's not their preferred eye anyway, so they're just going to kind of ignore it. So really educating the patient is important. Prevention of a problem is much easier than fixing it in most cases. So there's all kinds of reasons that graphs can fail. We'll kind of scoot through some of this. And I've seen this multiple times where, you know, the patient's IOL is kind of hanging out of their eye. This isn't actually my patient. This is a file photo, but this is probably the most common blinding complication of corneal transplantation is trauma with glaucoma being probably a close second. But all of these other things are important. Cataracts are fixable rejection, you know, depending on when you catch it. The book says endothelitis is much more common than cataract surgery. I don't know that that's actually true because, you know, endothelitis rates for cataract surgery vary a lot, but I've seen some studies saying endothelitis after corneal transplantation is at as high as 2%.  But, you know, if you're endothelitis rate for cataract surgery is 0.1%, then probably just based on volume, endothelitis is more common. I don't look on when, I've never had a patient with endothelitis in 25 years. You know, I've had patients with suture abscats get endothelitis years out, but it's uncommon. Yeah? Rimcultures, the EBA recommends them. I don't perform them routinely, Dr. Lin does.  Fungal endothelitis with EK is really the pertinent issue because, you know, if somebody has a candidate on their rimculture and they're getting endothelitis, and that's probably where it would be helpful to put them in for a year or so, so the fungal infection is opposed to a, so anyway, you know, we just don't get as many. Yes? No, no problem. Agent Aventurer, we're in transplant. Is that solely related to the steroid use or is that something else? You know, a lot of it is just their pre-transplant state because many, many patients have other complications which give them secondary glaucoma, and many, many patients, their glaucoma surgery has given them a failed cornea.  You were kind of managing their transplant, and so that's the point. It's like, you just really need to, once you kind of get through this, you know, first few months, you really need to think about, okay, what else is gonna blind this person? Trauma for sure, so eye protection. Glaucoma is a good close second. So, and that is just, again, it's not really, if you're seeing your patients, you're gonna recognize steroid responder issues.  You gotta keep them on steroid, you have them on load of Pratt and Hall.  You know, they just need to send them. They get a tube, gets their pressure down to 22. They're on three drops and they're fine, usually. But there are those instances. And then there are certainly instances where the high pressure is just not recognized for whatever reason. You know, you may have a patient where you can't check pressure very well, or, you know, not compliance or what have you. But I just would say that personally, for me, that is like one of my, one of the things that I really hate is when I haven't been aggressive enough on somebody's glaucoma and then they're, you know, lost their central vision because of it. Measurement of glaucoma, parameters after corneal transplant can sometimes be difficult. If they don't have a great surface, you may not get great pictures for your RNFL. Sometimes they can't see well enough to do a great visual field. Checking pressure itself can be a little more difficult sometimes in these patients with sutures in, et cetera. Corneal thickness can be a factor. Cataracts, pretty obvious. One thing that's really, again, Maddie, hard-bun, you can give a person a cataract with fairly uncomplicated surgery just by not being gentle with the lens. So I always tell my helpers, you know, squirt the saline back towards the iris, not towards the center of the eye, like we're always used to doing. You have to be kind of careful when the eye's open not to push too much on the lens. But generally, most of the cataracts that are transplanted are caused by steroids. And the rate is not actually that high comparatively to, like if you compare it to the tractomy surgery or something like that would be more close. Many, many, many patients get corneal transplants in their 20s and don't get cataracts until their 60s despite being on a drop a day of pretty slow for life, pretty much. Graph rejection, there was quite a bit in the book about graph rejection. I don't know why that picture didn't copy, but this is supposed to be subepithelial infiltrates. And that's supposed to be an epithelial rejection line. And those are KP. I won't, I mean, rejection is pretty straightforward. You can kind of learn about it. One thing, again, in the book, and this is kind of propagated in the literature, if you, epithelial rejection, I'm not sure is even a real thing because the donor epithelium usually dies off and the recipient epithelium should push it out eventually. But subepithelial infiltrates, there's kind of a thought that those don't need to be treated. Usually they will progress into a more serious rejection. So if you see somebody with subepithelial infiltrates, then you should probably bump up their steroid. You don't need to like do hourly bread like the question, but you know, you might want to, if they're on once a day, you might want to put them on twice a day and have them come back in three weeks. So steroids just kind of know basically the categories. Many patients don't need much steroid, even fluoromethalone, which is, it's a strong steroid, but doesn't penetrate the eye well, is, you know, one drop a day will often be enough to prevent rejection. Durazol is stronger than prednisolone or dexplosone, but we don't, I don't use it as much just because it tends to be a little bit more expensive. Pred's pretty cheap. Prednisolone acetate is what we use on those patients. Lodopretinol is a great drug. There is a 1% Lodopretinol now, but it's a little more expensive, but it's a really good drug. Medium strength steroid, much lower incidence of steroid responder, elevated pressure. So I didn't really talk at all about, back to that other slide, HSV or Zoster Prophylaxis, but we generally keep anybody who has those diseases. We keep them on oral acyclovir or, you know, similar for at least three months after surgery, sometimes a year, because you're having a lot of steroids and you may cause recurrence of disease. So this is just some reasons that graphs fail. Dislocated DSEC, swollen button. This is also a DSEC with a fluid cleft that's not attached. It's just showing microcystic and stromal edema, failed PK. Suture problems, all kinds of suture problems, including a suture abscess leading to it. In this case, a pseudomonasculcer and loss of the graph. I have had two patients, one patient and not that long ago lost her eye due to a suture abscess which became, it was kind of chronic, she didn't really come in. This was my patient, I did her transplant. She lives out of town. She's a very compliant patient but was treated by local doctors and unrecognized, formal lost her eye. Unfortunately, so I was only a couple of years ago. So you gotta manage these degrading sutures. So we already talked about astigmatism a little bit. What about wound healing? I mentioned in babies, you can take them out really early. Kind of wanna take them out before you get a lot of vascularization because vascularization can bring blood vessels to the new donor tissue and bring the immune system to the donor tissue. So blood vessels in general are a reason to take sutures out. You have to balance that with the risk of trauma. If you have a young active person, sometimes you wanna keep the sutures in a little bit longer. Sutures are a risk factor for rejection even if they're not loose because they're a little bit of an immune stimulus. So even if they're not vascularized or loose, I usually would rather have a patient on some steroid if they still have sutures in. This is hugely important because sometimes you take that one or two last sutures out and they go from two diopters of the stigmatism to 12 and then you need to do a wound revision. So sometimes if it ain't broke, don't fix it. If they're seen and functioning, you like to leave the sutures in. So you have all these kind of balancing acts of how to manage sutures. And then the most important one is once they start to break, you just gotta get them out because they can cause really bad complication. All different kinds of contacts. We often use soft bandage contact lenses early in healing. They improve comfort and promote epithelialization. Scleral lenses are awesome. Even a regular gas permeable contact could be used as soon as one month after.  Don't ever suggest a hybrid lens because I'll just delete it from the epic. But they're just horrible. I mean, in the age of sclera, either an RGP or a scleral lens, hybrid lenses just cause a lot of hypoxia. They're particularly bad in transplants because they get vascularization of their lumbus and they're really, oh, let's see what else. You can do refractive surgery on cornea transplant patients. We don't do LASIK much anymore, but PRK works fairly well. The patients don't really hold that well sometimes, but you can get rid of lots of nearsightedness and stigmatism. And I definitely have patients that are 20, 20-ish years out from PRK after either penetrating or even anterior lumbar. Cateract surgery is really an ace up our sleeve and many patients to kind of get rid of large spherical or sometimes even astigmatic refractive errors.  What else? You just have to do really careful FACO. And I always use viscote and I use a soft shell technique, so if you don't know what that is, you'll learn it when you get to cataract surgery, but you squirt the viscote in there, which is a dispersive OVD, and then you put proviscin, you have dooviscin. The provisc comes out really easy when you FACO, but you inject a blob of it and it just pushes a layer of viscote up against the cornea. So then when the cohesive OVD comes out, I know some of this is over, you guys have said, so don't worry, but the more senior you are, the more you'll understand. You still have a nice layer of viscote in there to protect the donor tissue. So that's called a soft shell technique. Tube shunts are better than traps just because you don't get hypotony and flat chambers and stuff as much. But you have to be careful to keep the tube. Our glaucoma surgeons are great in getting the tube in a good position. I won't go into this too much. There's the safety glasses. You can do EK after PK. This is just a picture of a patient he's had. EK, you can see the EK, in this case, desec inside the old PK wound, you know, it works great. So I often call it a retread, but you can also do other surgeries. You can do K-Pro. Sometimes the eye doesn't have much potential, but they have a failed graft and other issues where you might do a caulching type of flap or all kinds of other things. Sometimes when a graft fails, we just keep it as a, we know that the eye has potential, but it might be an uphill battle in trying to get a clear graft to get in. So we just kind of manage it medically and keep it as a spare tire, knowing that it can be rehabilitated if they need it. And that happens a lot in transplant patients. You have one, you know, quite good eye and one not so good eye. It's just like uphill battle and try to keep that eye with a clear transplant. But as long as you manage their pressure and things like that, you can say, well, we could do it again. And then sometimes when they're older, they do better. Just a little eye banking stuff. We can use LASIK tissue for EK, which is nice because they're a lot of refractive recipients. I'm just gonna go through some slides. Obviously a dendrite. The disease can recur in the graft. Another broken suture, kind of vascularization along sutures. How do we get the suture out? Another kind of suture vascularization with some thinning. This is crystalline keratitis in a graft patient, which the book mentions is strep veridansis, fairly common. You can kind of sit on these and just treat them. And many times if you have them on vanco for a long time, they'll go away. Vanco in a little steroid, but it's a little scary. Sometimes when you see something like that, you're like, oh, I got to take this graft out and replace it to a therapeutic keratoplasty, but most of the time you can clear it medically. Just a suture abscess. Broken and running suture. Probably an interrupted suture. Wound dehesants. Maddie, we've done at least one wound revision, right? It's amazing how easy you can cut into a cornea transplant when we get it to open up. So it's not surprising that you see these patients on call with dehistornias. They'll get eye protection. Even dalk patients can get dehesants pretty easy. They're just graft failures. The book talks a little bit about vascularization. Certainly that is a risk factor for rejection. If this person, you can see there's some edema there. This person had a repeat transplant. You would kind of worry about this ingreeness over here or maybe try to calm that down with lots of topical steroids before repeating the graft. You can use other modalities. You can use HGF inhibitors. You can use laser. But generally, corticosteroids weren't the best. You need to slime them with topical steroids and the blood vessels will often regress. KP, rejection. Bimodal, cododose line, KP. This one has everything. I think it has sub-epithelial infiltrate, cododose line, KP, sub-epithelial infiltrates. Quote epithelial rejection, but I'm not sure that it really is. That's another quote epithelial rejection. Just failed graft with stromal edema. Another bunch of failed grafts. Perforation from recurrent herpes, patch graft. So just a quick word about, because I want to get to EK, we can use a femtosecond laser to cut our donor and recipient tissue. Not really better than traditional methods, but it's kind of cool. I've done it on several patients. Just adds expense. KPRO, we're not gonna really talk about that, but it's a PMMA button. You can kind of see there, kind of screwed into a rim of a donor cornea and then sutured onto the eye. Glaucoma is really the main problem with these, but you can also get infection or melting. This is just, I'm not gonna talk about that because we talked about an ocular surgery. This is a grainy video. You couldn't find a short, this is a dalk. You can find a short dalk. So I had to go to this really old video. You can see it says infinity cataract machine. I think it's been like 15 years since we've had an infinity cataract machine. So this is a keratoconus patient. So for deep anterior lamellar keratoplasty, as you read about in the book, endothelial rejection is not a problem. So it's a really good surgery for young patients who need cornea transplants. So you do a trefination, a lamellar dissection. You wanna take off about maybe 50% or a little bit less. And then the idea is you, this is a paracentesis to put some to relieve the pressure a little bit. And then I'm just making a track. I'm trying to be as close to the top of decimates without perforating. And then I'm gonna inject air. That's just air in the interior chamber for an indicator. You'll see in a second here when we get the big bubble that you're pushing decimates back with air. And so those bubbles in the AC will kind of, they'll peripheralize again. They'll move out. And you can kind of see the interior chamber bubbles kind of move perforately.  It's not as easy as it looks. I would say my success rate is only 50% probably. Getting the big bubble. Most of the time the fellows are doing it in cases.  Even so, like internationally, when I go I see maybe two thirds of the time again. But you can do lamellar dissections and to your lamellar keratoplasty. That was just putting the viscote on there was just so the air bubble wouldn't escape so fast when I cut through that last layer of stroma. This is like the most nerve-racking surgery when you're, all you have is decimates membrane and you're trying to cut off the residual stroma without popping decimates.  You have just this beautiful, clear, perfect decimates membrane. So less chance of endothelial rejection. It's kind of thought initially that maybe these eyes are stronger but I don't think they really are. Maybe if you do lamellar dissection where you just leave a thin lamella of stroma. Sometimes with the air it's really hard to see the rim so I'm just trying to put some ink on the rim so I can kind of see where the edge of the treflination is.  And then we're going to prepare our donor tissue. Sorry, the video's so crappy, it's just really old. But we have it stained with Tri-Pemble. You can't really see it on this exposure. And I just kind of scraped it a little bit and then I wiped it off in the WECSO.  The suturing is very similar and that's awesome but sometimes the next day this is a picture of a double anterior chamber. So I didn't leave any air in the sigh and you can see the donor tissue is the convent, that's the recipient decimals. But the good news is even without, I didn't even put an air bubble in the sigh, I just waited. And this guy's like a nurse manager over at Primary Children's and he just reattached. Wasn't completely reattached in one week but by two weeks he was and he has really good vision. He's like 10 years out now. This is a DSEC surgery and again, I didn't really have any really short edited clips so this is a little bit older surgery, older video. We stripped SMAs. This is really easy and fuchs patients and can be really hard in pseudo-faking corneal and even patients. We've prepared the donor tissue by punching it and then we're putting it on a little glide and we make it into a taco, taquito, roll it up. And then we can put this through, you can put them through, you know, maybe a lot of people use injectors. This is called a Booson Glide. But you can put it through an injector. You can put it through about a three and a half millimeter incision. I usually make a four and a half millimeter incision. Most of the time we have a chamber maintainer but I think this was early enough in DSEC days. I didn't put it in, I was just having my assistant put it in, which actually works too. You don't want to open up a Finko machine. So anyway, a little painstaking. Put it in there. The nice thing about the glide is it's very easy to make sure that you don't flip it over. We don't usually mark DSEC tissue with S-stamps. We're going to show you a D-mech here in a bit. But then once you get it in there and kind of get it centered, you just inflate it. This step just, there's some venting incisions to try to remove the fluid from the interface. And just make sure it sticks well. Detachment rate is actually really low with DSEC with modern techniques. A little bit higher with D-mech. Again, there are tables and things in the book. So this is Dr. Betts doing a, I didn't have a short D-mech video. There are some good videos in the links in the book though. It was just too hard to put it all through the S-stamps there, this is kind of D-mech surgery. It's very interesting how that S-stamp is created. It's a gentian, violent guy. It's actually toxic. So you can imagine, you wouldn't have stamped it right on the, in the anterior stroma and replaced that little, you could kind of see that on. I was like, I don't know, you're so antsy to read, right? Yeah, oh yeah, it was programmed. Well anyway, so we saw most of it. And this is like your D-mech where it's in the eye and it's nice, these fold tabs and it opens up. But it's not always that easy, right, Matty? Matty did her first two last ones, and she developed a new technique. But personally, the camera was broken, so we don't have it with us. We had a constricted, myocall constricted pupil and she was able to shoot that D-mech tissue into the pupil. That sucked her out. So there was a mistake in the book. It seems like there wouldn't be, but one of the tables said that, for contraindications for PK donor tissue, that hepatitis C and hepatitis B surface antigen would have, it was just a dumb thing. I don't know if you guys noticed that, but table 15-3, that wrong statement's wrong. It said positive HIV and negative hepatitis surface antigen, whatever. So I still want to do some clinical conferences, hopefully this year. This is an ad for La Sportiva. We hike, four of my kids, I have five kids, one couldn't become, but we hike to the top of King's Peak and we kind of all looked and said, hey, we all have La Sportiva, so let's take a picture and see if we can sell it to the company. So that's our La Sportiva ad. So my financial disclosure. We're also going to do some corny and journal clubs and we'll try to invite you guys. We don't really expect you to be there because we do most of them at Mid Valley, but they're usually pretty good. So thanks, any questions?


There's seven things, there's seven steps that are going to take you from the beginning to the end. So I'm going to help you out with that. Number one, you need to get a pre-approval and there's lots of reasons why. Number one, you need to make sure that you can afford the house. Number two, all of the sellers are going to require that you have a pre-approval and then number three, timing, you're going to need to be able to quickly pull it out if you find the house that you love. So the next step after you get the pre-approval is actually defining what is your dream home. Now everybody has a different version of what their dream home is and sometimes this is a fluid process where you think you want X, Y, and Z until you start to tour houses and then you realize, oh, I really don't want that. So you need to write down on a piece of paper or whatever in your email, whatever it works for you. And just journal what you're really looking for and then articulate that to your agent so we can try and help you find what you're really looking for. Number three, so first you're pre-approved, second you know exactly what you want, number three we get to start looking for houses and this is the fun part. When you first start looking, you're going to fall in love with the first three houses and you're going to think that, oh, these are the best things ever, but you really need to stick through it. You need to look at least seven houses so that way you can see what the market's like, what the neighborhood is. And when you find the house that you like, you need to stock it. So before you go and put it on the, put in an offer, you need to drive by it night. Make sure you like it at night. The neighborhood doesn't have some type of weird chemical plant that has a glow in the background or has a busy road that you didn't warn aware of. So you need to really just take your time, slow down, and enjoy the touring process because the next part is going to be a little bit more stressful. Number four, we make an offer. Okay, so you find that dream home finally.  There's a lot of ways, a lot of things that are going to come into consideration in order for you to make a good solid offer. Okay, so you're most likely, unless you're going to buy the house in cash, you're going to have a mortgage contingency. That's why you have the pre-approval in the beginning. So that already puts one contingency on for the seller that they're not going to like, and then you're also going to pick probably, you're going to pick an inspection contingency. That means that you are not going to buy the house unless you go through the inspection contingency with an inspector and you look at all the ins and outs, the mechanicals of the house. Now at that part there, that doesn't mean that you get to go through and pick dents in the wall, places that need repainted, cracks in the floor. This is for major mechanical issues. That's what the inspection's for and we negotiate on those. Say there's a broken AC or the roof is bad or there's a structural issue. Those are the things that you negotiate on an inspection contingency. So once we make the offer, we make a contingent on the inspection, make a contingent on the mortgage and then we go and put in the offer. I highly recommend if you really like the house that you don't low ball it.  Remember this is a human transaction and they have feelings too. And the whole point of this is to get your dream home is not to offend everybody. So then the other thing I always recommend if you really love the house, write a short letter, make it a human process. Tell the tell the sellers who you are. You don't have to make it super personal, but let them know that you like the house. It always goes so far when you're able to make that human interaction, that human connection. So that takes us to the next step. Number five, your offer has been accepted. Everybody is excited. The ball is moving forward. There's going to be a lot of emotions here. You're going to wonder, did I make the right decision? Do I really want to buy this house? Can I really afford it? Now, the reason why you've done all those steps beforehand is because you were able to now make that final decision and know and feel confident that you are buying the right house. So once your offer is accepted, now we're going to move on to the home inspection. After we get past the home inspection, there's going to be one more hurdle to go over and that's the appraisal, the appraisal contingency. And that is when the bank is going to loan you the money, they have to make sure that the asset that they're loaning you the money for is worth it in case you walk away and they have to resell it. So once we get to the appraisal contingency, it's basically out of everybody's hands and it moves to the bank. The bank hires up an appraisal company. They come in, they pull the comps within a mile or so of houses that are equal value to the one that you're purchasing. Then once we get past that, that gets us to the next step. Number six is closing day. This is very exciting. Now either the day before or a couple hours before the closing, we're going to go and do a final walk-through. That is to make sure that there wasn't an explosion in the house, the roof isn't leaking, there wasn't a water main break, or somebody didn't break it and punch holes in the wall. That's basically all the final walk-through is for. It takes about 15 minutes. You kind of just blow through it, make sure everything is in working order and then we go to the closing. The closing is a very exciting time. There's a lot of paperwork for you to sign, so make sure you get your hands all warmed up ahead of time. You're going to need your driver's license and then the funds that the title company tells you in a check. Now you just can't bring a personal check to closing and you can't bring a bag of cash. You don't allow that anymore. You have to go to the bank and you have to get a certified check or a money order, preferably a certified check. So then we go through the closing process. We exchange keys in the check and you sign all the paperwork and then you get to move in. Hey, and don't forget right before the closing day, usually three to five days ahead of time, you want to call all the utilities and have the utilities put in your name and then they're going to start on the day of the closing. You don't want to forget that, especially in the winter time. And they forget to turn the gas on. You walk in your frozen pipes, things go very bad. So just remember three to five days before the closing, you want to make sure you put the utilities in your name. Number seven, moving day. How exciting. You finally own your first house. There's a lot of things that have gone into consideration to get you to this point. Now this is the fun part. You remember, you don't have to unpack all those boxes in one day. Try and make this as stress-free as possible. Try and make it fun for small children and make sure that you take your time introducing pets into your new space. And if you have any questions or concerns, please don't hesitate to reach out to me. Have a great day.


تشرف بالاشتغالي بالعلم ولا تبغي به ما عشت يا دا دا دا لا وياله من شراف عظيمي الآثور الشيب now is what we are going to move on to speaking about the works that have been written in this particular timing because if you learn the books that are written at this particular time as a student of knowledge it gives you thick and understanding and how to study the metham or how to even be gradual in learning as we mentioned the hashir of the abideen is what is the pluralist I'm now going to mention insha'Allah and ta'ala the books that are most important in the Hanafi metham now اهم المؤلفات في الفق الحنفي the most important books in the Hanafi metham brothers it is the Qutb of Muhammad al-Hassan al-Shaybaniyuh which are referred to as what بظاهر الرواية it's called what it's called ظاهر الرواية this is the umdah the reliance of the Hanafi metham is in these the books of him these books Muhammad al-Hassan al-Shaybaniyuh and the most important book of Muhammad al-Hassan al-Shaybaniyuh is المبسوط so pay attention there are these two kitabs that are written they are known as المبسوط in the Hanafi metham two kitabs the first one is Muhammad al-Hassan al-Shaybaniyuh is one and the next one is called المبسوط written by السرخسي سرخسيه هذا كتاب called المبسوط he died in 483 the one Muhammad al-Hassan al-Shaybaniyuh wrote he said it's called he also has Muhammad al-Hassan al-Shaybaniyuh has a kitab with زيادات has a kitab called الجامع الصغير he also has السيل الصغير السيل الكبير يدار all of these six books العسلو زيادات الجامع الصغير الكبير السيل الصغير السيل الكبير these six books which will be behind the story all of them are summarized in the book they also summarized in the kitab al-Kafi they also summarized in the kitab al-Kafi written by the حاكم الشهيد also the kitab al-Mukhtasar al-Tahawi the kitab al-Tahawi has a muhtasar we mentioned it it's another kitab which is very important there's a student of knowledge within the Hanafi manhub gives importance to so we we're mentioning the six books and who summarized all of it الحاكم الشهيد we're now moving on to the other kitab which is al-Mukhtasar al-Tahawi the kitab al-Mukhtasar al-Tahawi is muhtasar he even placed a sharah on it by who but al-Jasas Abu Bakr al-Jasas with a 370 هجرية there's also another kitab al-Mukhtasar al-Quduri which I mentioned this kitab al-Mukhtasar al-Quduri the Hanafi they gave importance to it a high importance اهتماماً كبيراً this kitab has been given it has been given a lot of explanation a lot of تعليقات and a lot of hawashi and hawam and mission etc so this kitab al-Mukhtasar al-Quduri you see a lot of Hanafs telling it from the kitabs اه تحفة الفقها باستمرقني this kitab مختصر تحفة الفقها written by Samarkand it goes back to the Muhtasar al-Quduri it's basically a توضيح of the مشكلات he's explaining the ambiguity and the vague things that are in the Muhtasar al-Quduri the kitab تحفة الفقها باستمرقني and he added on some extra things of course كاساني is the one who done a shara'ah on that he placed a shara'ah on تحفة الفقها باستمرقني كاساني did and he called it بداع الصناع and this kitab is a kitab which is Mu'ataman it's a kitab which is truly relied on and it's very nice the way it explains the madaaib the madham and the qawal that it holds there's another kitab a small matan which is called بداية المبتدي written by Barghinani many ulama have gone to that book بداية المبتدي by Barghinani and they placed shara'ah on it and they made it the mu'awal the reference point and one of the shara'ah that has been placed on the بداية المبتدي is the al-Hidaya which is the shah of the bidaya so the author he explained his own kitab and he called it what he called it al-Hidaya and the kitab which we mentioned that the Hanaf they went extreme on it they said إن الهداية كالقرآن قد نسقط ما ألف قبلها في القتل ما ألف مثلها في القتل فحفر قواعدها وسلق مسالكها تسلم قالك مزيد ومن كدري they said kitab al-Hidaya is like the quran I'm going to get it I'll get it there's no شافعية always there's a rivalry between شافعية and the Hanaf so the shafia they said this is the quran of the Hanaf and the quran and the quran is aggregated صح so this kitab al-Hidaya means a lot and if you look if you look if you look at نصب الراية by Zayla I it's the تخريج أحاليث الهداية he does the تخريج of the kitab al-Hidaya is an al-Hadith that he uses the shuru'h وشارحه he explains it he goes in it also from the shuru'h that have been placed on the works that have been put on the Hidaya itself the Hidaya became a there's all the 70 works have been put on the kitab al-Hidaya over 70 from them is البابرتي the kitab called البابرتي has a kitab called العناية of the Hidaya there's also and there are many other other books but the most clearest, the most simplest شرح of it is the فتح القدير by كمالي بلو همام with that he 861 we're now going to move on to the books have so much within the madham there are many شروح شحواشي متود تعليقات تحقيقات that are طالب العلم لتك can go into and see for himself we're now going to move on to the مصطلحات الحنفية if you could do with him the حناف they have terms which they use in their books there are terms which they would use in their books such as the term الامام قال الامام عني الامام اندل الامام who do they mean by that they mean of course الامام for them بوحانيفا رحمه الله تعالى or the term الامام الأعظم the word الامام الأعظم فهي them his who فينم يريدون به أبا حنيفا رحمه الله they intend by that الامام بوحانيفا also from those terms is الامام الثاني okay they use that term as well they would use that الامام الثاني some of them would say اندل الامام الثاني or they would say even athani they would say or they would say عني الثاني if you find that in the books of the حلاف the usage of this word اندل الامام الثاني or الثاني عني الثاني or عني الامام الثاني they mean أبو يوسف رحمه الله they mean who أبو يوسف if they say الثالث رسطري ثالث or third or they say الامام الثالث or third imam they mean by this who محمد من الحسن الشيباني also they say about him they say الامام الرباني الامام الرباني they mean محمد الحسن الشيباني if they say الائمة الثلاثة the three imams who do they mean when they say this is clear right who they mean by it if it comes to أبو يوسف و محمد محسن الشيباني هذه are the three imams that they are referring to so in the litlaq unrestrictedly when they said الأيمة الثلاثة احناف what did they mean محمد محسن الشيباني أبو يوسف أنا أبو حنيفة so don't think yourself when you read نحن في big book الأيمة الثلاثة that they mean the other three imams or شابعي نحمد من مالك these are the جهلات that sometimes people come with when they read books yeah for example when أئمة say in the books قال الأصحاب what do they mean by الأصحاب yeah the ashab said you might think some people say صحابة said this yeah are you with me brothers الأصحاب they mean the followers of the madhhab or the followers or the students of the imam of the madhhab صح so they all mean the companions of the صلى الله عليه وسلم you have to realize when they say الشيخان the two sheikhs for example they say وعند الشيخين خلافا له عند الشيخين they shoot two sheikhs what do they mean they mean أبو حنيفة أنا أبو يوسف so when they say عند الشيخين خلافا له the two sheikhs there's a khilaf basically against them who is the person that they say against them محمد محسن الشيباني خلافا له they refer to محمد محسن الشيباني شيخين هي ميز أبو يوسف أنا أبو حنيفة خلافا له they mean محمد محسن الشيباني محمد محسن الشيباني so the term الشيخان عند الحلاف يطلقوا على الامام أبو حنيفة أبو يوسف if you hear them say for example و عنده كذا عنده with him is this و عند الصاحبين كذا and the two students are this who do they mean the صاحبيني they mean here who so the صاحبيني the two sheikhs they mean here who أبو يوسف محمد محسن الشيباني because they are the أصحابه when they say the other term that they use is الآخريني آخريني آخريني who do they mean الآخريني the other two و عند الآخريني again they mean أبو يوسف and محمد من الحسن الشيباني when they say for example وقال الطرفاني كذا خلافا له when they say الطرفاني the two engines the two sides the two sides who do they mean الطرفاني they mean أبو حنيفة محمد محسن الشيباني أبو يوسف he is in the middle the two sides are الامام because remember who do we say was the first word الامام who is next who is last so who is on two sides الطرفاني they mean الامام أبو حنيفة on one side and محمد محسن محمد محسن الشيباني on one side they are used to in the middle so sometimes when they both agree is they will say اتفق الطرفاني the two groups the two sides have agreed from this if they say و عند أصحابه according to our أصحاب our followers this is what we believe who do they mean أصحاب here they mean أعمة التراثة ترى أعمة هو دائمة التراثة أبو حنيفة أبو يوسف and محمد محسن الشيباني or sometimes they might mean by that the فقاها of the مدهن we believe this they can mean that sometimes when they say شمس الأعمة the son of the أعمس شمس الأعمة شمس الأعمة what do they mean they mean أسرخسي أبو أسرخسي how will you want to say but if they say شمس الأعمة الحلواني they will restrict it they can't leave it unrestricted if they want to say somebody other than سرخسي أو سرخسي unrestricted قال شمس الأعمة they mean سرخسي أو سرخسي if they say شيخ الإسلام when they say شيخ الإسلام who do they mean they mean إبن عابدين إبن عابدين sorry sorry they mean أبو بكر إبن خواهر زادة as إبن عابدين mentioned إبن عابدين mentioned sorry it is رد المحتار they mean أبو بكر خواهر زادة that is 483 when they say شيخ الإسلام that's who they mean أبو بكر خواهر is who they mean إبن عابدين mentioned that sorry أبو محمد القرش who did he 775 he said no when they say شيخ الإسلام they mean أبو بكر إبن خواهر زادة they mean عليبن محمد عليبن محمد الإسبي الإسبي جابي الإسبي جابي sorry عليبن محمد الإسبي جابي who did he 535 so here we find إبن عابدين took the opinion by one particular person and القرش he held that it was referred to another person when they say فخر الإسلام said this فخر الإسلام said this yeah who did they refer to they're referring to they're referring to أبو العصر the person who they're referring to here is أبو العصر البزدوي because the بزدويان are two there's one called أبو العصر and there's another one called أبو العصر أبو العصر and أبو اليس the two individuals the reason why أبو العصر was called أبو العصر is because his works are very hard the عصري تقليف is hard his works are very hard عصر شده and حاشي is in it whereas أبو اليسر his works are easy and simple and summarized to the point what about when they say صدر الشريعة صدر الشريعة صدر الشريعة when they say صدر الشريعة they mean عبيد الله المحبوبي that is 745 or 747 when the أحناف use the word سلف the term سلف وعند السلف كدا and with the سلف is this what do they mean by that? they mean anybody from أبو حنيفة from أبو يوس or from محمد محسن الشيباني any one of them سلف to them is that that's their sلف if they say خلف who do they mean they mean anybody between محمد محسن الشيباني and الحلواني if they say خلف that's what it means to them it's between محمد محسن الشيباني and الحلواني are you with me if they say المتأخيونة it means anyone after الحلواني even زفر will enter سلف to them does that make sense so anybody between محمد أبو حنيفة محمد محسن الشيباني and أبو يوس and زفر any one of those are sلف between محمد محسن الشيباني محمد أحسن الشيباني and الحلواني this is خلف anyone below الحلواني is متأخر سكون متأخرين ليس المتأخر ومسلم when they say the term if they use the word مصطلح المشايخ the مشايخ the مشايخ to them is any imam who didn't reach أبو حنيفة when they use the word there's another term which they use it's called العامة عامة what does the عامة mean عامة عند العامة they mean here أكثر أهل المدهب the majority of the people of the madhab that's what they mean and there's also another تقسيم which they have for the term متقدمين أن متأخرين the way I mean there's one I mentioned which is سلف and خلف متقدمين they use they also have something they call متقدمين أن متأخرين and it's another way that they do it what's the other way that they do it so example when they say دهب المتقدمون إلى كدأ عند المتأخرين كدأ the intent behind the word متقدمين here is it is علماء الحنفية الذين أدركوا العلمة التلاثة it is every imam who met أبو حنيفة محمد الحسن الشيباني or مأبو يوسف anyone who met those three متقدمين إذا and the متأخرين are those who didn't meet those three imams that's another way that they divide things إذا so when they ever they mention the متقدمين and the متأخرين together in an issue you need to know this is what they mean by it but if they randomly just mention the word سلف somewhere or they mention the word خلف somewhere randomly or they mention the term المتأخرون is randomly in a place then it's as I told you before they also have terms that are referred to as their books their terms that they now use for their books when they say الأصل الأصل وفي الأصل what do they mean here أصل المبسوط of محمد الحسن الشيباني are you there brothers when they say وفي الأصول if they make أصل plural now and they say وفي الأصول they make it plural what do they refer to كتب السبتة كتب السبتة وفي الأصول they make كتب السبتة the books that we mentioned ظاهر الظيواية ده محمد الحسن الشيباني أولا when they say والمتوني ثلاثة أنه ثري متون when they say ثري متون what do they mean وفي المتوني ثلاثة ثري متون ده مختصرات which three مختصرات they refer to so the first one is ده مختصروا قدوري number one the second one they talk about is بقاية الرواية بتب باي بحبوبي and the third one is كنزل دقائق بيتب باي نسفي these three are called المتوني ثلاثة they call this what متوني ثلاثة the three متون وستفاس one مختصر القدوري مختصر القدوري the second is بقاية الرواية للمحبوبي written by him المحبوبي the second one is كنزل دقائق written by نسفي yeah they are brothers written by نسفي these are referred to as المتوني ثلاثة there is what's called المتوني الثلاثة the four mutunes the four mutunes are the three that I already mentioned to you المختصر القدوري وقاية الرواية باي محبوبي and the third which قاية those three are added on to it المختار by موسيلي that's one opinion that the مختار الموسيلي is the fourth one others have said no the fourth one is مجمع البحرين by ساعاتي ساعاتي's كتاب مجمع البحرين is so this dispute what about when they say مبصوط when they say مبصوط when we see المبصوط if they say المبصوط here سارخسي's كتاب سارخسي's كتاب they don't mean محمد حسن الشيبان محمد حسن الشيبان they refer to his as well as the أصب عند الإطلاق when they say المبصوط المبصوط رتبع محمد محمد حسن الشيبان and they restrict it وتبع المحيط when they say المحيط they mean المحيط المرهاني رتبع مرهاني دينا البخاري 616 very good now we're going to also mention مصطلحات that they use the أحناف use when they are actually doing ترجيحات they're strengthening opinions and views in the مدهام like the أحناف you have to realize they're very دقيق in their terms very دقيق ما شاء الله for example when they say وعنده وعنه is different وعنه and وعنده is different and even if we just say from him وعنه وعنده there's a difference between the two for example if they say وعد أبي حنيفة وعند الإمامي وعند أبي حنيفة وعند الإمامي and when they say وعد أبي حنيفة وعن الإمامي it's too different when they use the word وعنده it means يعني يعني أن مدهامه كده that his madhab is this but when they say وعنده they mean the narration that has been transmitted from him الريواية عنه كده the rewire that has been transmitted from him is this so the عنده who is talking about the madhab itself and the عنده who is talking about the rewire that has been transmitted the narration has been transmitted and which one is more comprehensive مدهام of the rewire مدهام the madhab is more أو صعب من الريواية what about if they say عليه عمل أمة this is the action of the أمة what do they mean to them the أمة is the حرفية so they are trying to say that إجماع المتأخيرين من علماء الحرفية they mean they mean that this is the consense that is connected by the late commons from the علماء of the حرفي مدهام if they for example say عليه الفتوة عليه الفتوة the فتوة is in this regard what do they mean especially you find this in many of the كرامة of ابنو نجيم he says ذهب محمل حسن إلى كده وكده وعليه الفتوة and the فتوة is in this he means here that this is الصحية this is called صحيح and the فتوة should be given based on this opinion if you given a فتوة it should be based on this statement and there's a difference between عليه الفتوة وبيه يفتا عليه الفتوة وبيه يفتا is two different things it's مقلدنا don't confuse the two there's another one called وبيه يفتا وعليه الفتوة do you see why I say to sometimes students of knowledge that they spend a lot of time looking at these terms of what a man means and what the man had means why it may sometimes cause you to not be a مجتهد have you realized because you're gonna busy yourself a lot learning terms of the Imam but you still haven't dealt with the نصوص الوحيين فحا are you there brothers you're not learning a نعم or a خاص a مطلق or مقيد or مجمل or مبين sometimes it can make it higher a person and you can keep them in the fold of blind following for a long long time okay as long as the person learned them and hadjiya properly from the beginning and he does everything correct he starts with the right book does the next book and the next book and the next book until he gets the final book understand the مدهب he then has the right to say I agree or disagree if you don't know nothing who are you to agree or disagree صح agree and disagreeing comes from a preconceived mindset a person who's previously got something was so when he sees the knowledge that's information that's coming to him he's able to say yes and he's able to say no a جاهل can't say no or yes صح there's only one way open for him to say yes نعم صح so there's a difference between عليه الفتوة و به يفتع عليه الفتوة و به يفتع there's a difference between the two I think you guys should go look at the difference between عليه الفتوة و به يفتع again another term that they use الأصح and الصحيح الأصح and الصحيح what do they mean by this they mean رجحان القول this is the strongest in the madhab صحيح means are you there brothers صحيح means this is the strongest opinion okay okay but when they say أصح it shows that there is another opinion out there أصح is a comparative it shows that there's another compared opinion which this opinion has been chosen from okay they also have a term which they say المعتمد كذا المعتمد كذا المعتمد means here what we rely upon that's what they mean they also use the term الأوجو الأظهر the word أوجو and الأظهر أقول into the أحناف it's the same and الأوجو and أظهر is any opinion that has come strong to the individuals given a verdict according to the حناف in madhab okay الذي ظهر رجحانه للمفتي so أوجو and أظهر is what's meant what about الأشبه الأشبه is anything that's strong and it's closest in meaning there's no it's not as strong as the word أصح it's أشبه كان راجحا وأقربا في المعنى للمروي عن الإمام and it is the closest thing that has been narrated from the إمام so for example if somebody said something and then people are views that are there the person would say this is the most closest in appearance to this إمام what about when they say جرى به العرفة جرى جرى به العرفة جرى به العرفة جرى به العرفة جرى به العرفة means that at that particular time this was the norms this was what people do so here we're going to now أودة الفاض الترجح الدلحنفية أحناف when they are strengthening an opinion this is the level that they take and this is the order it would be in the first and the strongest way that they will strengthen an opinion is when they say عليه عمل الأمة if they say عليه عمل الأمة this is the strongest okay or if they say عليه عمل الأمة both of them are the same that's the strongest and then next comes what به يفتح and then comes after عليه الفتح and then comes after الأصح and then comes after الصحيح this is توروق الفاض الترجح الدلحنفية according to the Hanafis this is the sequence and the order of when they want to strengthen an opinion now this my beloved brothers and sisters is a very summarized knowledge pertaining to the keys to the مدهب الحنفية now insha'Allah after the break we're going to go into المدهب الماليكي