Well, good morning, everyone. I was standing backstage and looking at the time. And I noticed that I think this might be the first time that we have ever started an OpenStack Summit keynote day exactly on time. It's also the first time we've done a summit in Germany. I don't know. Correlation, maybe. Very, very excited to be here and be having the summit in Berlin this week. The OpenStack community is truly a global community. And it's been two years since we've been in Europe. We had our summit in Barcelona in 2016. And so it's great to be here in Germany. And we have an incredible schedule this week. So many users that are speaking. An incredible program this morning. But throughout the week, a lot of users who are based here in Germany, who are in France, who are in Sweden, who are across Europe and really from around the world. So that's the thing that I love about our events. They're truly, truly global events. For the last couple of events, one of the things that you probably have seen on signage and in our sessions that we've talked a lot about is open infrastructure. And this is a concept that within the community and within the foundation, we've really been diving deep on open infrastructure. And I wanted to talk a little bit today about what that means and really think about what some of the opportunities we have are as we start to build out open infrastructure, both from a technology perspective and from a community perspective. So if we take open infrastructure and we break it down, it's got a couple of parts. Big one is open. Now, if you've come to the OpenStack Summit, then I probably don't have to sell you on open source. Within our community, open source is one of our guiding principles. It's one of our core values, for sure. But this year, one of the things that we wanted to do was to look outside our bubble a little bit and see what is the impact that open source is having in the world at large and across the entire technology community. And so we commissioned some research with a firm to do some focus groups, to do some surveys, and to try to get a pulse on what do people out there think about open source in general. We found a lot of really, really interesting data. We found a lot of data about how people are adopting it, how they're approaching it, and their attitudes towards it. But one of the stats that really stood out to me was that 81% of the respondents said that open source is becoming more important over the coming years for their company. And so this is, I think, a great sign and a great stat for a community like ours that is really founded on and built on open source principles. We also asked, why is this? Why is open source important? Why is it something that you think is going to matter more and more for your organization? And there were a lot of responses that we gathered around this. But there were a few that stood out. And one of the things that I found really interesting, this was global research that we did across 10 countries and from a very wide sample of organizations. But it actually matches up pretty closely to what we have found within our own user survey that we do within the OpenStack Foundation. One of the top priorities that organizations are looking to achieve with open source is to add flexibility and control into their environment. And a lot of companies feel like open source gives them flexibility, it gives them options, and that helps them have greater control over their business. And I think that, again, makes a lot of sense probably for those of us who have been working in open source for a long time because we know that's one of the great powers of open source is you have the ability to take the software and you can run it in a lot of different ways that fit your business. With OpenStack, for instance, we have many users who are running enterprise private clouds and we're going to hear from some of them this morning. But we also have a lot of companies who are building public clouds with OpenStack. We have 75 public cloud data centers around the world that are running OpenStack and powered by OpenStack. And that is a really strong representation, a very, very strong footprint of public clouds. We're also going to hear from a couple of public cloud providers this morning too who talk about this. And so I think that flexibility, those options, that is one of the most powerful things about open source. You can run it yourself, you can go get it as a service from a company like Deutsche Telekom with their open telecom cloud or OVH or Vexhost, three public cloud providers that are going to be speaking in a little while. Along those lines, another thing that we heard was a really important attribute and a strength of open source was having true interoperability. Because again, you have options within a marketplace. You have different vendors. You have different deployment options. And ultimately, you have the freedom to run it yourself if you need to. And you want to support your workloads that way. So we heard a lot of comments from people who said that they felt like open source was a key to protecting them from vendor lock in, a key to allowing them to work across multiple environments and in multiple geographies. One thing that we heard as an area for improvement with an open source was a desire to improve the integration and the implementation models for open source technologies. I think that was something that about 75% of people said was an area that could be improved. And again, for us in this community, we've been talking about that for quite a while. Last year in Sydney, we talked about how one of our priorities at the OpenStack Foundation was going to be thinking more broadly than just the OpenStack software, but really thinking about an entire suite of open source technologies and how do you make them work together. And that is, I think, still the status shows it's still a very critical goal and a very critical task for us to take on. One of the things, though, that I think is awesome of those, when an organization is able to take open tools and integrate them successfully and build them, then it creates big, big opportunities for them. And one of the biggest ones is the ability to innovate faster. In some cases, the ability to innovate faster than the market. And that is when you get a competitive advantage. I keep talking about users that we're going to hear from. We have so many awesome speakers. Tomorrow, we're going to be hearing from AT&T. And they're going to be talking about how they have been doing this within their company. Specifically, they're going to be talking about their 5G rollout. 5G is the next generation of mobile technology. And AT&T is tackling this with an open source strategy, not just open stack, but multiple projects that they're putting together. And one of the reasons why they're doing that with open source is because they are rolling this out faster than the market is answering their needs with fully-baked, fully-built commercial solutions. So they get to iterate faster than the market. And that gives them a big advantage as a business. So open source is great, has a lot of advantages. But one of the things that I have been hearing and feeling is open source is only one part of the equation. Mark talked about this in Vancouver six months ago. He said, open source is required, but it's not enough. And that's why we've been talking about open infrastructure. Because infrastructure is really a key component of the way the world works today. What is infrastructure, really? Well, infrastructure is the environment that software, that applications, run on. And there's been infrastructure as long as there's been computing. As long as there's been software, there's been processors, there have been storage devices for all of the modern history of computing. There's been networking. And so that's not a new concept. But at the same time, in the last few years, we've seen a lot of things that have been changing, especially the needs of those applications. And those needs are driving requirements down into the infrastructure as well. I talked about AT&T. If you look at what a communications company does these days, it's not just about phone calls and text messages. It's about massive amounts of data, massive amounts of video, massive numbers of connected devices, connected cars, smart homes, smart cities. We now have far more data being produced by devices and systems than by humans. And that creates an entirely different type of network requirement, an entirely different type of storage requirement, and new kinds of computing requirements. You look to the challenges that we faced as humanity. And we want to solve those. And we solve those through computing now. Our most recent super user winner in Vancouver was the Ontario Cancer Research Institute.  So as the needs have changed, infrastructure has also changed. Infrastructure is now software defined. And that is a huge advance in terms of what you're able to do. And we get to see new patterns emerging, where people take infrastructure that is programmable. On top of that, they deploy cloud native frameworks. And they run next gen applications like AI and machine learning. But as we look at this, we are in a world where there are many, many options. And some of those are open. And some of those are proprietary. And this is what I think we are all here to work on. And the goal and the challenge that we have is we want to make sure that the infrastructure world has very, very, very successful, very, very powerful open options. So that when you go back and you think about a stack like this, you have open options at every level. Because if you don't have open technologies at the infrastructure level, then you lose some of those benefits that we talked about before. Even if you're using open source tools, open source databases, if ultimately you don't have that flexibility, if you don't have the ability to change what your infrastructure is doing when you need to innovate, like AT&T, then you are losing the benefits of open source that you would have if you have that throughout the stack. So open infrastructure is definitely a theme for us, something that you're going to see repeatedly through the week. Now, you're here, and no one here, I think at the OpenStack Summit, is here just for OpenStack. If you look at the schedule, you'll see there are dozens and dozens of different projects that are presented here that are talked about that are collaborated on here. It's one of the things that I really, really enjoy about our events. We love bringing communities together to collaborate. And so along those lines, one of the things that we're doing going forward is this event will now be called the Open Infrastructure Summit. And that is to reflect that strategy and that goal that we have to build powerful infrastructure that's open, that's integrated, and that people can use to really drive change within their organizations. But just to be clear, we are not running away from OpenStack, because for us, open infrastructure starts with OpenStack. And so as we get today started, one of the things that we're going to be doing is we're going to be talking about OpenStack a lot today. And we're going to be talking about how it has been changing and growing and what people are using it for. Just to give you a couple of more pieces of data before I wrap up, when you look at just the OpenStack project, it still has an incredible rate of change. And the last year, OpenStack has had about 70,000 changes that have made it into the software. That is at a level that really, there are only about three projects out there, OpenStack, Linux, and Chromium, that have that level of change in the open source world right now. If you look at the Rocky cycle and you break that down, just to give you an idea of the velocity, that's 182 changes every single day. And that includes weekends and holidays. So how many of you here contributed to the Rocky release? Can I see a show of hands? Yes. Well, thank you. I want to give you all a round of applause. Yeah, I mean, this is a level of development activity that really is at the top in the world. And so thank you to everyone who contributed. A little later today, we're going to hear from some of the leaders in the technical community to talk to us about what's new in Rocky and give us a little bit deeper information on the technical side. So you look at that, and you're like, man, that is a lot of activity still. And you look across the world overall, and we see a lot of things happening in open source, a lot of new technologies that are driving interesting changes out there, things like containers and Edge and AI. And you might go, OK, so are these happening on different tracks? Is there this container and AI track? And then over here, you have OpenStack, and it's doing VMs and data centers. And what's the connection? But I think the connection comes when you think back to those needs that I talked about a minute ago. Because AI is driving infrastructure requirements. Where's the best place to run AI? Well, the best place to run AI is an accelerated hardware. How do you manage that hardware at scale? How do you bring GPUs and FPGAs into your cloud? How do you manage thousands of them? How do you manage tens of thousands of them? How do you take automated infrastructure and deploy it out to the edge for a telco use case or a manufacturing use case? These are all changes that the application layer is requiring of the infrastructure. And what's great about software-defined infrastructure, like OpenStack, is that it is able to evolve, and it's able to meet these needs. And so as we get today started, that's going to be our theme for the morning, is how open infrastructure starts with OpenStack. And to kick things off, we're going to hear what I think is a really, really interesting use case.


This study examined the performance of two types of electric traction drives, one with direct torque control and another with vector control under various operating conditions. It was found that the direct torque control had better accuracy in regulating the speed and torque at low frequencies, while the vector control had better accuracy at high frequencies. Additionally, the direct torque control was more resistant to power supply and low disturbances. This article was authored by Sergei Gulak, Boris Lubarskiy, Yvgen Ryabov, and others.


And Starbucks is one area, but there's always interesting company action. And recent days have been no exceptions. And we're lucky to be joined by, once again, by the founder and CEO of the stock, Swoosh, Melissa Armo. Melissa, thank you. It's always great to have you with us. We appreciate you coming back so soon. My first query, and I know that you will have some opinions, is sort of a twofer. And it is the headline we just talked about, the CEO of JC Penney, Marvin Ellison is leaving, but he's going to Lowe's, the home improvement store. How is this going to impact both of the companies, JC Penney and Lowe's? Well, hopefully it'll help Lowe's. As far as JC Penney goes, I don't think him leaving can hurt the stock anymore. I don't think anything can hurt the stock anymore. The stock gap down on the earnings this past week, and it was trading around $2 in some change. The stock is, it looks like it's going to zero. I don't know what, if anything or anyone can help JC Penney. They've really got to make some serious, serious changes. They haven't been able to compete with all the online. Sales, they haven't been able to bring people in the stores for a long, long time. That stock has been in a downtrend for so long. It was hanging on around that $4, $5, $6 area for a good amount of time. But now that it's down around $2 something that, I mean, it looks like it's going to nothing. It's sad, actually. It sort of begs the question when I talk about pennies because when I was a kid, the stores at the mall, one end was pennies and the other was Sears. Is Sears sort of in the same boat, Melissa? Same boat. I mean, same boat. That stock price is slightly higher than JC Penney, but not that much. Anytime a stock starts to dip under that $10 range, it's very dangerous for the stock because then they tend to keep going, going, going, and that is what happened with both Sears and JC Penney. And they're both in the same boat. Again, Sears was a big place to buy appliances. And now, guess what? People are going to lows. People are going to other stores. Like even places like Home Depot, Target, these are all of these companies are, people can buy the same types of products at the cheaper places, Walmart, Target, Home Depot, then they can at the Sears and JC Penney's and they're just not that exciting. People aren't excited to go to Sears and JC Penney's like they used to. Well, we didn't practice this, but that is a perfect segue to what I want to talk about. And that is the retail apocalypse, Melissa. And supposedly I read that Mr. Allison actually did work at Home Depot for a number of years, 14 years or something as I recall. And the question is a lot of these retail stores that are going down because of Amazon are just gonna be fodder for the trash and maybe that's Sears and Penney's as you're describing. But what about stores like Home Depot and Lowe's?  So is the retail apocalypse actually something that is not going to impact sort of these big box home improvement stores? Well, they're all trying to compete against one another. I'll definitely say that, but Home Depot stock looks great compared to a lot of other ones. Even Lowe's Home Depot is in a strong, strong uptrend. I really like Home Depot a lot for whatever reason they've been able to market and they also probably sell to a lot of little small builders that are building stuff, not just the regular home buyer. So people are still going into Home Depot, like you said, and buying things at stock looks great. And hopefully Lowe's is gonna start to look a lot better in the next six to 12 months. Melissa, we've just got a few seconds here, but I wanna get your take on housing stocks. They were on a roll last year, but they've had some bumps on the road. How do you see housing stocks going forward for the end of the year? That's another tough one. Toll reported this week. Toll brothers, that stock fell on the earnings. The stock isn't a down trend. It doesn't look that good. Now it doesn't mean things can't turn around for the home builders before the end of the year, but we are into almost half of 2018. And the market has been holding the uptrend. So to see an earnings report like that with a miss, it's not great for the builders. And of course, as you know, mortgage rates are on the rise. And I do believe they continue to rise into the end fall and end of the year 2018. So people are slowing down with the building. Now, the one thing is I thought I was surprised that they didn't have a little pop with interest rates rising, that maybe mortgage rates would make people come in and wanna lock it down and buy homes now, but the home builders are the stock charts. They could recover by the end of the year, but if you combine that with looking at the rates for mortgages and the interest that people will have in doing home improvement loans, home equity loans, refinancing or even buying new houses, it's not looking that great with interest rates on the rise. That's the problem. Always a fountain of information. Melissa Armo, thank you so much for your time. Appreciate it. Thanks for having me.


S tractor. A couple weeks ago on this channel I talked about improvement patches that added some fixes or quality of life improvements to certain Nintendo games, and one of them was for this game, G.O.D. or, growth or de-evolution, Mesami Yōtū Yobukōika Kikoi, which basically translates to HEED the Call to Awaken. This game got a lot of comments asking to know more about it, so I thought I'd once again dive into the strange and murky waters of unlocalized role-playing games that never left Japan. And yes you will need an English patch to play through this one, and thankfully there's a really good one available, made by the reliable folks at Dynamic Designs, so big thanks to them and their work. Growth 3D Evolution is full of surprises, it's a long game with lots of content, a strange story that goes all over the place while nicely staying together as one cohesive narrative, with some interesting quirks with the typical combat system that you're used to with lots of RPGs, but I should mention right away that it's also a game that in many ways stays firmly in December of 1996, when it was developed by Infinity and published by Imagineer, since it has a lot of the old turn-based RPG tropes that we've all been annoyed with for years and years. Now a common question about games like this is, why wasn't this ever properly localized? And I can only speculate, but the two obvious answers are that it was released way too late in the Super Nintendo lifespan, with the N64 already in full swing, and it would have taken forever and a day to translate this one, this is a very long and very text heavy game, so keep that in mind.  You eventually head to the top of the mountain and uh, well that doesn't seem good. Right after that, you wake up in a bed 10 years later as part of an army fighting invading aliens. Yes that's right, it's an amnesia storyline, but the whole story isn't hinged on this, it's just part of the setup.   You eventually run into other folks who help you out, like this American dude who suspiciously looks a lot like Gile, there's Mina who's a cult leader that has powerful psychic abilities, and Basil, no not that Basil, this guy's a monk who actually wants to try and learn and understand the aliens and what their real motive is. Your quest eventually turns into just finding other people who have the same power that you do, that was granted by that mysterious stone at the very beginning of the game. I really dig how the story is told here because there's so many small touches that add so much, for instance every time you save your game, it creates a new page of notes in a journal, this really added a lot for me, because it gives the game an uncommon personal touch. Notes come along in other forms too, like helping explain certain game mechanics or helping fill in the blanks in certain parts of the story. The notes are essentially a makeshift instruction manual, they're extremely useful, and again big time props to dynamic designs, because as you can see there's tons and tons of text here. The overall tone of growth and de-evolution is reminiscent of stuff like Soul Blazer and Earthbound, and I gotta be careful with the Earthbound comparison there, because I know that's really high praise, but I don't say that necessarily because of the wacky dialogue or all the goofy characters you come across, and there's plenty of that here, but it's because all of that belies some heavy stuff that this game addresses, and I don't want to spoil any of that here. All I gotta say is, uh, the game is called God for Pete's sake, so yeah, things are gonna get pretty serious. Some people might roll their eyes at that, and that's fine, but bear in mind that this game was made when themes that tackle faith and human nature were extremely rare, and I liked how it was handled in this game. In addition to all that, this game takes place in a regular, modern, everyday setting, using real locations with real historical figures occasionally showing up as well. While the story is closer to stuff like Soul Blazer and Earthbound, the combat is not. This is by and large your typical turn-based Dragon Quest style stuff with an over-the-shoulder viewpoint, and random battles that you get sucked into when walking around the world map. Thankfully, there is an auto battle option, which comes in handy for some of the more tedious parts of the game, but yeah, this is an old-school RPG all the way.  But thankfully, if you're not into that, there's that improvement patch I mentioned earlier called Easy Mode, and it cuts the encounter rate way, way down, and rebalances the experience and gold you earn from each battle, so you're able to enjoy the story instead of laboring through the same battles over and over. Despite the shortcomings of the combat system, there is some interesting stuff here. Yeah, there's the usual magic spells with each party member having different kinds of spells and all that, but there's also the Chakra system, which kind of works a little bit like how Espers work in Final Fantasy 6. This gives you some control on how you want each character in your party to level up and what kind of spells you want them to learn. There's seven different Chakras you can eventually find, and they all have their own separate leveling system, so you can equip and unequip for each character at any time. You can eventually combine Chakras, so you can learn even more stuff, so that's pretty cool. One other thing I gotta mention is how this game ends. Getting the quote-unquote true ending and beating each of the bosses is pretty dang frustrating because there's an exact methodology to it. Each boss has its own gimmick, and if you don't know what to do, you're pretty much stuck. But there is a helpful guide on Game Facts available if you're not opposed to using it. The boss gauntlet at the end, however, is a little bit of a downer, but it's definitely not game-breaking or anything. I should also mention very quickly that this game was remade for PlayStation as G.O.D. growth or de-evolution pure. And that one also stayed in Japan, but it looks like the English translation for that one is only partway done, at least as far as I could find. So if you wanna play this one today, you gotta stick with the Super Famicom version. So yeah, when it comes to import RPGs, growth or de-evolution is an impressive piece of work and well worth playing. The story and the overall tone this game strikes is unique.  Plus you get some genuinely humorous moments like this old dude getting mad for you wandering into his house with his wife chiming in saying that her husband's favorite pastime is yelling at kids who wander into houses without knocking. Now I will say, I think sometimes it's easy to get carried away with expectations, especially when it comes to these recently translated Super Famicom games, but I mean, look at the space they're occupying with Final Fantasy VI, Earthbound, Lufia II, Chrono Trigger, and on and on. That's just a crazy high standard and I don't think growth or de-evolution reaches the same heights as those games, but man, if you dig JRPGs and you haven't played this one, put it near the top of your list and make sure to check this one out. It is a great time and you won't regret it. And that's all for now. I wanna thank you for watching and I hope you have a great rest of your day.


in this video right here you are going to learn why you still cannot read without haraqat in the arabic language and how to not experience the situation you're about to see right now right so you just take this and you read it i got it bro how you doing bro yeah i'm good bro just here learning how to read arabic with the arabic like another program that i just joined last week learning arabic now how to how to read arabic oh how to read arabic no no no arabic man come on man i'm tell why would i lie i know how to read arabic i just learned so you telling me that you know how to read it you hate it man i read arabic i'll be reading reading like no no no arabic all right let's see let's see right you know how to read arabic right yeah okay all right okay read this read bro um come on bro read what have you read it when you first learn how to read arabic with a haraqat and little by little you start getting faster reading with the haraqat meaning the vowels you obviously want to jump into the next level and start reading without haraqat right because that's what most texts are in the books etc but then all of a sudden you take a book or a text without haraqat and you start reading and you realize that it's not the same you went from being able to read arabic to not being able to read arabic because there is no vowels salam alaikum warahmatullahi my name is mohammad al-Andersi i'm the founder of andersinstitute.com and the reason why you cannot read with all the haraqat is because you don't have arabic vocabulary so let me give you an example i will show you on the screen a text in english and what i want you to do is pause the video and try and read the text to see if you are able to read the text or not and then tell me in the comment section if you was able to read the text or not so was you able to read it i don't think so or maybe you struggle a little bit but the only reason why you are able to read this is because the words that appear in that text are familiar to you and the context as well so the context being a simple context it makes it easier for you to decipher what words are the ones that appear on the text so the thing is that this same exact thing happens with other languages as well when when you're learning a new language and in this case with the arabic language you cannot read with all the haraqat if you don't know the word itself and if it's not part of your mental dictionary yet so the same happens when the topic of the text you're trying to read it's not a topic you are knowledgeable about you're not familiar you don't talk about it every day like these two texts that i'm about to show you so i want you to pause again the the screen and let me know if you are able to read these two texts now i'm pretty sure you have struggled with these two texts and the reason why is because the topic is not something we speak about every day so let me know in the conversation be honest if you have struggled with this i want to know uh you know what do you guys think about it based on what we spoke about there's two conditions for you to be able to read in arabic with all the haraqat with all the vowels now the first one is that you know the words you are reading like you have memorized them before you know what it means and that you understand the topic context of what you are reading about now if these two are in place if these two conditions are in place then get ready to read arabic without haraqat like a pro but until then what you need to focus is on building your vocabulary and um and building your mental dictionary of arabic so if you want to know how to do that inshallah there is a webinar that um that um you know that i explain more in depth on how to do that and how to gain vocabulary and you know how to basically be confluent arabic in 15 months so if you like uh this type of videos don't forget to give me a thumbs up inshallah don't forget to subscribe to not miss out the ones upcoming and uh let me guys know in the comment sections what you guys thought about this phenomenon of uh of how to read with other haraqat and uh i will see you in the next one inshallah um


I've taken the liberty of changing the title slightly to say, should renal mass biopsy be performed routinely? And my answer would be no. Conflict of interest, I have none, although I would tell you that I do order some renal mass biopsies in my patients. So if we look at the AUA guidelines for renal cell carcinoma, and these are presented frequently, and we usually focus on the lower boxes in terms of treatment options, but actually in that upper evaluation box it says something pretty interesting, which is a good place to start and probably a good place to finish our talk as well, which is that percutaneous renal mass biopsy for patients in whom it might impact management, particularly patients with clinical or radiographic findings suggestive of lymphoma, abscess, or metastasis, that's what's recommended. So it's recommended when it may impact management. So what about historically and what about today? Is that how it's being used? Well, renal mass biopsy has not been used routinely. For three main concerns. First is the fear of tumor seeding, which Dr. Krutikov mentioned already, and I would reiterate is unfounded concern. This is not a dangerous procedure for patients. Secondly is the undesirable rate of finding indeterminate or inaccurate diagnosis, and I'll touch on that more in a few minutes. The third is that 80% of renal masses are cancer anyway.  And that, again, has been the mantra for many years. Nevertheless, I will assert that renal mass biopsy is clearly the correct diagnostic step in some patients, as indicated in the guidelines, and sort of blast biopsy completely would be a poor position to take. So how have we been doing now in the 21st century? Well, our group released a review article several years ago comparing results from 2001 to 2005 with results obtained previously, and clearly there were some improvements. So there's increased accuracy for cancer that's seen for these studies up to about 96%. But, again, the total success rate's about 91% better than had been reported previously at about 81%. An update to this, which, again, reviewed the literature for the last five years or for the next five years, revealed similar findings. Again, about a 95% accuracy rate. But, again, we really need to think about this a little more clearly. What does that mean? I mean, are we talking about if it's cancer? Is it really cancer? Or are we talking about the biopsy giving you a result that you need? And if you look through all of these results, they may term them differently, but biopsy failures or indeterminate biopsies or non-informative biopsies are as high as 29% in some series. And so caveats about these accuracy claims would be, it's true that it's 1% or less biopsies that are wrong. So false positives, false negatives. The majority are infirmative and confirmed to be true. But if you look at the literature, a lot of them are informative and presumed true. There's no actual pathologic confirmation on the biopsy that's obtained. The bigger concern is the 10% to 20% that remain non-informative. And those could be failed either because tissue was not obtained or the pathologist couldn't make the definitive diagnosis. As Dr. Kudakov mentioned, you have options here. You can do a repeat biopsy. And Dr. Jewett's group and others have shown that that is a successful strategy. Or you can just treat them as though they have cancer. So with all this encouraging thought about renal mass biopsy, several groups have decided that routine biopsy is the way to go. And so here's a series from Dr. Jewett's group published in 2011. And reading from their paper, it said, our policy has been to recommend biopsy for all. Small renal mass is less than three centimeters. And to discuss the role of biopsy for patients three to four. Well, what were their results? So again, about 80% were diagnostic. Among those, you can see that about 80% were malignant. Most were RCC. And you could get a subtype on close to 90%. But importantly, there were 67 non-diagnostic biopsies and 12 of those patients underwent a repeat biopsy. The author's conclusions, renal mass biopsy is safe. It's accurate. A non-diagnostic biopsy is not a surrogate for the absence of cancer. Rather, repeat biopsy can be performed with similar accuracy. I'd say alternative conclusions would be number one. Two out of 10 patients underwent a non-informative biopsy. And although the repeat biopsy found cancer in eight of the 12 patients who had one, fewer than 20% of those patients were willing to have a second biopsy or the provider was not willing to do another one. What's missing from this report is how often are treatment plans changed because of the biopsy and how many more kidneys may have been spared based on this approach. So I'd really ask us to go back to what's the question we're asking. I mean, what's the goal of this biopsy? I think our goal is to better match treatment to the biology expressed by the tumor. And that's very compelling. But are we really doing that? And how exactly would that happen? So first of all, are we reducing the overall morbidity to our patients of this diagnostic and therapeutic paradigm? We're adding a biopsy for 100 patients to avoid surgery for five to 10. We're identifying and risk-assessing cancer or lack of cancer without performing an operation. Is that the goal? Again, I think it's a laudable goal. But 80 to 85% of the biopsies are diagnostic. We talked about the indeterminate rate. And then the grading is very unreliable. And so again, if we're talking about those man-eaters versus the other sharks, biopsy is not doing it for you. Next goal could be to prevent the removal of kidneys lacking cancer. And I think that's where a lot of us are concerned and public health concerns about taking out the whole kidney for a 3-centimeter oncocytoma. But is that really happening? 15% of surgeries that have no cancer or 15% of the surgeries done presently have no cancer, but the vast majority are nephron-sparing techniques. And so finally, are we really going to reduce over treatment of kidney cancer by doing biopsy? I don't think that's the issue. I think the issue is sparing kidneys. So let's look at another group that has pursued routine biopsy. And this is the group at Michigan. And I apologize. I put my conclusions on top of those right away. But they performed a biopsy 38% of the time. And if you'll see actually in the bottom, if they compared the group that got biopsy versus didn't, active surveillance did increase. So five more percent of patients were surveilled, but actually radical nephrectomy increased dramatically from 8% to 21%. So again, was this used uniformly when their intention was to do it? No. Did it increase surveillance? Sure. But it also increased radical nephrectomy. So if those were the goals we just discussed, these are the conclusions we could draw from another group's experience with routine biopsy. We may be better matching treatment to biology. It's unclear whether we're reducing morbidity from what I can tell from the report. We are identifying cancer without surgery. Maybe we're preventing the removal of kidneys that lack cancer. But really, we did not reduce the number of nephrectomies. We increased them. So further support for the decision not to perform a biopsy is from Dr. Kudakov himself. And this is a preoperative nomogram looking at whether we can predict the features of the cancer prior to surgery. And so if you look at examples here, and I apologize it's somewhat small, but the top gentleman, for example, who's 50, has a large tumor. It's exophitic. You have the nephrometry score listed. 99% of cancer. So my question is why would you biopsy a patient with a 99% chance of cancer based on your preoperative suspicion? What gain will we have there? So final point would be about practicality. At most centers, the logistics of coordinating arenal mass biopsy necessitate a further delay in treatment. Usually it requires scheduling with interventional radiology. They may not like the initial CT scan. They may not like the ultrasound. They may need another study before they do the biopsy. The pathology may or may not be as other centers would have come to expect in 2013 in terms of sub-specialty pathology availability. So it may need to get sent out. You may need to do initial appointment in almost all these patients to rediscuss options. And so you're introducing a delay. Some of these concerns could certainly be addressed by an in-office procedure. But this is not routinely available. Here's some images from an in-press article from Dr. Landman's group where they're actually now performing these in the office. And I think that could be a good step for the future. So what I would leave you with is will a renal mass biopsy really affect the treatment recommendation you'd make for a 50-year-old with an 80-metre renal mass or a 50-year-old with a 4-centimeter renal mass or an 80-year-old sick patient with a 2.5-centimeter rest? I mean, those patients, I pretty much have already decided what I'm doing right now. And you probably have as well if you see these patients. A lab nephrectomy, a partial, or surveillance with short follow-up imaging to rule out interval growth without a biopsy in that older patient. So I would not use a biopsy for all patients, but maybe for this gentleman at the bottom. He's got multiple comorbidities and a completely intraprankable tumor. He actually is the third patient on this list, and he was biopsy found to have amnesia in his tubular spindle cell carcinoma and therefore is being managed with surveillance. But other personal experiences you see above, I had a young gentleman with a history of TB who wanted to rule out renal TB. He had a bleed and delayed his surgery. There's a 36-year-old with what turns out to be a cancer delayed unnecessarily because of a biopsy. I have another patient who I didn't want to do surgery on. He's once get listed for a transplant, but the biopsy again didn't help me a lot here with an oncocytic renal neoplasm. So my experience is, as a frequent performer of these tests, is I only use it sporadically during the last five years. I only performed a radical nephrectomy four times for benign disease, and if you look at how that happened, one's a patient with a known and large symptomatic AML. Two are patients on dialysis, and one's a tumor with a tumor thrombus that was on necrotic when it came out. So I don't think in this paradigm we're removing kidneys unnecessarily. So in conclusion, R&B should be performed only when it will affect management of a suspected renal mass. It's not always necessary. As the results of renal mass biopsy will not change management in many situations and only rarely change management in others. And again, it's not without cost. Thanks for your time.