Okay, yeah. So we'll get started. Why don't we take some time to pray, right? Let's, let's pray. And even as we pray, let's pray as the Bible says, let's pray in the spirit, right? We see in 1 Corinthians 14 Paul saying, I will pray in the spirit. I will also pray with the understanding. I will sing with the spirit. I will also sing with the understanding. So praying with the spirit is praying in tongues, praying as led by the Spirit of God, right? So whenever we see that phrase, praying in the spirit, it's about praying in tongues, okay? So let's take some time to do that. Yeah, Father God, we thank you. We thank you Lord.  So that you can hear your voice and also online students. I just want to encourage you to just pray so that it's loud enough for you to hear, right? If you're in a place and if your environment permits that, just go ahead and just pray in the spirit, pray in tongues. Let's go ahead and just pray, continue to pray, continue to pray strong, continue to pray. And for those of us who have not yet begun to pray in tongues, you know, maybe you've been praying and asking the Lord. I just want to encourage you to take a step of faith, okay? Like we saw earlier, we saw that the Holy Spirit gives us the utterance, but we are the ones who speak out. So the sounds are the utterances, the words are the sounds. So what He puts in our heart, just go ahead, take a step of faith and speak that out, right? After that out, yeah, continue to pray. Thank you, Lord. Thank you, Lord. Thank you, Lord. I just want to want us to know that the Bible declares that as we pray in the spirit, we are being built up. We are edified in the inner man. So we are becoming stronger in the inner man. Our spirit man is becoming stronger in the things of God, stronger to resist the works of the enemy. We are receiving discernment and sensitivity to the speaking or leading of the Holy Spirit, right? So continue to press in strong. Yes, Lord, we want more of that. We want to be strong in the spirit. Yes, Lord, we want to be strong and sensitive to the leading, the prompting of the Holy Spirit. We want to be able to receive the mysteries, the revelations of God from the Holy Spirit in our heart. Yes, Lord, we thank you, Father God. We thank you for this time, Lord. We thank you. We pray that for each one of us, Lord, we pray that we would increase in our prayer life for God. We would go to the next level in our prayer life for Father God, especially Lord, praying in the spirit of Father God. We pray that you would enable us to spend extended time praying in the spirit. And even as we do so, maybe be strong in the Lord and the power of His might. Maybe receive, maybe be recipients of the mysteries, the understanding of the mysteries of God. Oh God, we pray, oh God, may your love, the love of God may be shared abroad in our hearts by the Holy Spirit. Lord, may our faith increase, oh God, even as we pray in the spirit. And Lord, we pray, oh God, that we will be, Lord, diligent doers. Lord, off your work, diligent doers off the work, Lord, even as we pray in the spirit. We thank you, we come at this time, we come at these classes into your mighty hands. In Jesus' name, we pray. Amen, amen. Okay, so I just want to encourage us to pray. Those of us who can pray in the spirit, just continue to pray in tongues. You can pray whenever, wherever. So it's not like only when I'm in church or only when I'm in class, I should pray in the spirit. But you can pray whenever, wherever. When you're walking around, you can pray in tongues. You can, in your quiet time, when you're listening to music, you can pray in tongues. You can pray whenever, wherever. And that's the best part. The Holy Spirit prays that perfect the mind of Christ, the heart of God to us, in and through us. Right? Okay, so today's class, before we get into today's class, anyone remember what we studied yesterday? Our last class, last week, what is that one thing? Oh, lot of responses. Okay, one, yeah. Holy Spirit. The way Holy Spirit worked in Jesus' life, okay? What is that one thing that you remember? How He worked? How did He, how did the Holy Spirit work in the life of Jesus? Holy Spirit? No, in the life of Jesus, in the life of Jesus. Okay, so the ministry of Jesus, the signs, wonders and miracles, the supernatural things that He did. He did it by the power of the Holy Spirit. The Holy Spirit enabled Him to do that. How can you say that? How can you say that? How do you know that? How can we say for sure? Yeah, obviously the Bible says that, but where and where? We need to know for sure, right? Yeah. Okay, Acts chapter 10, verse 38, right? Where Peter's testifying to the fact that the Lord Jesus, He went about doing good and destroying the works of the enemy and He did so by the power of the Holy Spirit. Okay, another place is also in Luke chapter 4, where we see the Lord Jesus reading from the book of Isaiah and He says, you know, the Spirit of the Lord is upon me and He has anointed me. He reads from Isaiah and then He says, today this is fulfilled in your hearing. Right? And He went about, right. Okay, any other things that you remember from last class? What is it that you recall? Online students as well from last two hours that we spent last week? What is it that you remember? What is it that you learnt about the Holy Spirit? Okay, how the Holy Spirit worked in the life of, you know, these men of God, Jehaziel, Ezekiel and how when the Holy Spirit came upon Jehaziel especially, He prophesied, you see that as a recurring phenomenon in the lives of these men. Yes. Okay, what else? Anything that you learnt last class? Any one thing that you learnt, Joseph? Yeah, one thing that you learnt, right? Yeah, so about the birth of the Lord Jesus, how the Holy Spirit revealed to Mary and to Joseph and who He will be and what He will be called etc., right? Very good. Anyone else? Okay, so the Lord has given us the same authority power and Holy Spirit. We're going to look at that. Yes, Shani. About how the Holy Spirit revealed Himself to Mary and also Elizabeth and also about Sonship Glory. Right, yeah. What the Lord, how the Holy Spirit moved in Mary's life, Elizabeth's life and we also learnt about Sonship Glory, very important, yeah. I think that's where we stopped about the Glory, the Sonship Glory. Okay, so let's just revisit that again. Okay, so we read that the Lord Jesus, John chapter 1 talks about the fact that let's go to John chapter 1. Okay, John chapter 1 says that the Word was 14. Okay, John chapter 1 was 14 says, And the Word became flesh and dwelt among us and we beheld His glory. The glory as of the only begotten of the Father, full of grace and truth. Okay, so John is saying, you know, he came, he dwelt among us and we saw His glory and uses the word doxa, which means what God did, who He was and what He did in a very simple way. Right, so we saw His glory, he says, and what did they see? They basically saw the life of Jesus. They saw the life at the ministry of Jesus. He said, we beheld His glory, which means they saw what Jesus spoke or they heard what Jesus spoke. They saw the way He lived His life. They saw the way He ministered. Okay, which is again leading back to Acts chapter 10 38. The good things that He did, the good things, the supernatural works, the deliverance, the healing, everything that He did and the Bible calls it good. Right, and we see that they saw His glory. Okay, and in fact, it says in, so John chapter 15 talks about the fact that John bore witness, John chapter 1 verse 15, sorry, the John bore witness of Him and cried out saying, this was He of whom I said who comes after me is preferred before me, for He was before me. Okay, so it's talking about the eternal existence or pre-existence of the Lord Jesus, which means that it's not that this is something which happened at birth, but Jesus was. Right, He was there at creation, which is also scripture testified. So, when we now turn to John chapter 17, okay, John chapter 17 and verse 5, we see the Lord praying, He's talking to the Father and this is what He says, and now, oh Father, glorify me together with Yourself, with the glory which I had with You before the world began or before the world was. Okay, so the Lord is saying, you know, I was with the Father. In other words, we learn that He was with the Father and He had a glory which He actually stepped out of when He came to the earth. Okay, so John chapter 1 verse 14 says, we beheld His glory and here the Lord Himself says, now glorify me with the glory which I once had before the world was. So, we see two different things. The Lord is saying, you know, I'm walking, which in other words, the Lord is saying, I'm walking on earth, but it is in a different glory.  And that is why we said, we use that word, sonship, just to explain the kind of glory with which He walked on the earth. The things that He did because of that glory or what He did by the Holy Spirit. Now, the beautiful thing is this, right? The Lord wants to give us that same thing. The Lord wants to clothe us with that same glory or He has done that. How? By the power of the Holy Spirit. Because He's the same Holy Spirit. Philippians 2 verse 5, we saw that He emptied Himself when He came on the earth. And that is why He praised that prayer. He emptied Himself not of deity. We're not saying that He was not God. He was. He can never stop being God. But the things that He did, He did by the, with the help of the, help or empowerment of the Holy Spirit. Okay, so let's move on to John chapter 14. Now, John chapter 14 and verse 12 onwards. John chapter 14 and verse 12, the Lord says, Most assuredly I say to you, He who believes in me, the works that I do, He will do also. And greater works than these He will do because I go to my Father. It's an amazing statement. I can see some scriptures. Maybe I can share the notes as well, if you want. The references. Okay, there you go. So yeah, so we are looking at John chapter 14. And verse 12 says, Most assuredly I say to you, He who believes in me, the works that I do, He will do also. Okay, so that's an astounding statement. Whatever He did, He's saying the works that I did or works that I do, you know, He's telling the disciples the works that I'm doing, He will do also. Okay, and then He says, Greater works than these You will do. Okay, and He gives the reason for that. He says, Because I go to my Father. Okay, understood? Okay, so no doubt in this, everybody's clear. He's saying, This is what you will do. Whatever I'm doing, you will do. Right, in plain terms, this is what He's saying. Whatever I'm doing, you will do in terms of ministry. Because I go to my Father. Then let's look at the next verse. And whatever you ask in my name, that I will do, that the Father may be glorified in the Son. So which means in all the doing, the Father needs to be glorified, the Son needs to be glorified. Okay, and He says, If you ask anything in my name, I will do it. Okay, then verse 15, If you love me, keep my commandments and I will pray the Father and He will give you another helper that He may abide with you forever. So who is He referring to? Verse 16. And I will pray the Father, He will give you another helper. He's talking about the Holy Spirit, the Paracletos. And that's the word He says, the helper, the Paracletos. And He will abide with you forever. He will stay with you forever. The spirit of truth whom the world cannot receive because it can neither see Him nor knows Him, but you know Him for He dwells with you and will be in you. Okay, so the Lord is saying something very important here. You will do what I do because I go to my Father.  I'm going to send the helper and He is going to be with you forever. In other words, He's saying, Because I go to my Father and because I send the helper and He's the one who will actually enable you to do what I am doing. Simple words, He's just saying, This is what He will do. And then we read about all the things that the Holy Spirit or all the good things the Holy Spirit brings into a believer's life. Okay, so let's look at some of the things that the Lord Jesus taught about the Holy Spirit. What did the Lord Jesus teach His disciples about the Holy Spirit that's relevant for us even today? Okay, so let's look at Matthew chapter 10 and verse 20. Matthew 10 and verse 20. Okay, so here, maybe we should just read from verse 19 onwards. But when they deliver you up, do not worry about how or what you should speak for it will be given to you in that hour what you should speak. For it is not you who speak, but the Spirit of your Father who speaks in you. So He's foretelling something to the disciples. He's talking about the coming persecution or arrests that would happen. So He's saying, when you are arrested, when you are persecuted, don't worry about what you should speak in defense or in explaining what you are doing. Don't worry about that. For the Spirit of my Father, He says, the Spirit of your Father, He will speak. Okay, in other words, He's saying He will give you the words to speak. He will give you the wisdoms to speak. He will give you the information to convey. Okay, and what is the situation when they are persecuted? Okay, so the Lord Jesus is telling us that He's saying, when you are persecuted and when you are brought up before these people, don't worry, what should I speak? What should I explain? Don't worry. The Holy Spirit will enable you to speak. Then Mark chapter 13 and verse 11. Mark chapter 13 and verse 11. Same about when, this is how He says it, but when they arrest you and deliver you, do not worry beforehand or premeditate what you will speak for whatever is given to you in that hour, speak for it is not you who speak but the Holy Spirit. Okay, now again, the context is being arrested, being persecuted for their faith and for following Jesus. And so He's saying, don't worry, the Holy Spirit will speak. Okay, now what could be a wrong application of this? Wrong application of this would be, whenever I need to speak, whenever I need to teach, whenever I need to preach, I'm not going to worry what I'm going to preach. That will be the wrong application. You know, I'm just going to come, the Holy Spirit will give me the words and only that I'm going to speak. I'm not going to prepare, I'm not going to... Because it says, don't premeditate, don't think about what you're going to speak. So is that right or wrong? It's wrong, right? That's not the right thing. So the context here is persecution. Don't think about what you're going, how you're going to defend and etc. Okay, let's move on to another thing which the Lord Jesus taught and He taught about the blasphemy against the Holy Spirit. I think we kind of address this a little bit. It's in Matthew chapter 12, okay, Matthew chapter 12. And if you look at verse 22, okay, Matthew 12 verse 22, this is what happened, let me just read out. Then one was brought to him who was demon possessed, blind and mute, right? So he was possessed, he was blind, he was mute, terrible combination. And it says, and he healed him so that the blind and mute man both began, both spoke and saw. And all the multitudes were amazed and said, could this be the son of David? Meaning, could this be the Messiah, right? Who was prophesied, could this be the Messiah? Now when the Pharisees heard it, what did they hear? They heard people exclaiming, you know, maybe he's the Messiah. Maybe he's the one who we are expecting, you know, when the scriptures talk about. So when the Pharisees heard it, they said, this fellow does not cast out demons except by Beelzebub, the ruler of demons. So here the Lord Jesus does a very notable miracle. There's someone who's oppressed, who's possessed, who's unable to see, unable to speak, right?  He's cast out.  And then the Lord explains, he says in verse 25, but Jesus knew their thoughts and said to them, every kingdom divided against itself is brought to desolation, and every city or house divided against itself will not stand. If Satan casts out Satan, he's divided against himself, how then will his kingdom stand? And if I cast out demons by Beelzebub, by whom do your sons cast them out? Which means that there were Pharisees who were casting out demons. And so they're saying, you know, if I cast out by Beelzebub, by what authority, by what power are they casting them out? Therefore they shall be your judges. Verse 28, but if I cast out demons by the spirit of God, surely the kingdom of God has come upon you. Saying, the rule and reign of the King, the rule and reign of God has come upon you. He's saying, if I cast out demons by the spirit of God. So the Lord is pointing or teaching us one very important lesson. The demons are cast out by the power of the Holy Spirit. It's not because of man's authority, or man's voice, or loudness of the voice, nothing. It's because of the power of the Holy Spirit. So he's saying, if I cast out demons by the spirit of God, surely the rule and reign of the King, the rule and reign of God has come upon you. The kingdom of God has come upon you. And then go ahead and say, how can one enter a strong man, house and plunder his goods, unless he first binds a strong man, plunder his house. He who is not with me is against me. He who does not gather with me scatters abroad. Verse 31, Therefore I say to you, every sin and blasphemy will be forgiven men. But the blasphemy against the spirit will not be forgiven men. So he's talking about blasphemy, meaning something that is said against God in a derogatory manner.  So that's blasphemy. So here is the Lord Jesus saying, what they have done actually is blasphemy. Blasphemy against the Holy Spirit. And he's saying that this will not be forgiven. And it's a serious thing. So the question is this, maybe I said something about the Holy Spirit. I made fun of the Holy Spirit. Will I be forgiven? Am I condemned? Am I in a place of not ever being forgiven? So that's the question. What do you think? Because we should, just like how we understood the previous one, teaching about the Lord Jesus, in the context of persecution, it will be given to us what to say. Same way, we should apply it correctly, what we are learning now. So what? What do you think? In other words, the question is, what is this blasphemy against the Holy Spirit? What do you understand from what we have learnt so far? Anyone? When we are denying the Holy Spirit's work. Is that blasphemy? Speaking against the Holy Spirit. So is that blasphemy? Insulting the Holy Spirit. So here, we see something unique. The Pharisees, what are the people saying? People are saying, this is a Messiah. He's done this miracle. This person was blind and mute. And wow, now he can see. He can speak. So this is surely the work of God. Can this be the Messiah? And to that, the Pharisees are saying that the work that he does, the work that he's doing, is empowered by Satan. The work of deliverance is not the Holy Spirit, but it's Satan. And why did they say that? They did not want to acknowledge that here was someone who was the... You see that over and over again. Wherever the people come, and especially... If you look at the same chapter, chapter 12, and if you go to verse 9, so he goes into the synagogue and behold, there was a man with a withered hand. So he couldn't stretch it out. And they said, is it lawful to heal on the Sabbath? Why did they say that? The Bible says that in verse 10, chapter 12 verse 10, says there was a man whose hand was not working well. He's in the synagogue. Now Jesus goes into the synagogue and they ask him this question. Is it lawful to heal on the Sabbath when we are supposed to rest and not do any work? Is it lawful? Is it the right thing? Now, why did they ask that question? Huh? Sorry? Stim? Yes. What does that mean? To test. So they can? Okay. I think somebody raised the question. I mean, Han, go ahead please. Who's that? Yeah, go ahead. Oh. They were just trying to, I guess, catch him in doing something wrong because they were jealous. I'm sorry. Say that again. I said they were just trying to trying to catch Jesus doing something wrong that was against the rules because they were jealous of him. Okay. They wanted to catch him do something wrong. Okay. I think Gertrude and Daniel also says, okay, jealous of Jesus, trying to find faults, the Sabbath is holy and no work is done, etc. If you look at the same verse, verse 10, it says, this last part of the verse, that they might accuse him. Right? That they might trap him, that they might accuse him. So the intention was not to learn. Is it lawful to do this? The intention was not to learn from Jesus, but to put Jesus down, to trap him, to accuse him. So that was their constant motivation of their heart. So also with the Pharisees, the Pharisees, when they heard, it was not from a place of learning. Of course, there were some who were, like Nicodemus, who would come and wanted to know from Jesus. But here we see, all of them, they wanted to accuse, they wanted to trap, and their questions were based on that. How can we put him down? How can we trap him? How can we accuse him? Find something wrong with him. So the intentions were that, motivation was that. Because of which, they actually said that this work of God, they knew that this is something supernatural. This is something miraculous. Because the Lord Jesus says, hey, your people are also casting out, in the name of Yahova. In the name of Yahweh, there's power and they were casting out, the Jewish itinerant exhausts, they were there doing ministry. So the Lord is saying, how do they do that? Is it because of God's power? So they knew that this is God's power, but they were actually attributing that power to be the power of Satan. So knowing the truth, knowing that this is actually God's work, to say, no, this is the work of Satan, because, you know, they did not accept Jesus, because they did not want to lose their, maybe religious authority, position, whatever, be the reason. Knowing the truth, being hypocritical, and saying that something that God is doing, is actually the work of the demon. Something that the Holy Spirit is doing, to say that that's not the Holy Spirit, that's actually the work of the demon. So that's blasphemy against the Holy Spirit.  When you go back and ask the Lord for forgiveness, the Lord is able to save to the uttermost, he will definitely forgive.  When you talk about blasphemy of the Holy Spirit, this is the category. You know for sure that this is the work of God. You know for sure that's a supernatural work, not man can do, but you attribute that supernatural work of the Holy Spirit to the work of demons, to the work of Satan, then that's blasphemy. So the Lord says this, you know, there's a serious thing, serious matter. So that's what we learn from you. Okay. What else? Yeah. Yes. Yes, Shani. So you're saying that, because I always thought that blasphemy can be forgiven, but you're saying that it can if somebody could ask for forgiveness if they do blaspheme. I'm sorry, tell me again. I said I always thought that blasphemy wasn't, you know, was unforgivable. I was always taught that that's the one thing that, you know, the Lord won't forgive you. You know, it's unforgivable, but he won't forgive you for. So you're saying that if somebody does blaspheme the Holy Spirit, that God can't forgive them. I just try and get an understanding. Yeah, I'm just saying the context in which, you know, the Lord is explaining this blasphemy of the Holy Spirit, because, you know, if you look at the lives of all the, I'm sorry, you're here. And if you look at the lives of all the, you know, all the people who were enemies of the cross, enemies of Christ, you know, Paul himself, you know, he, he persecuted, he did things against the, what was called the way. He did. But there was forgiveness, right? And so we, throughout his church history, we see people who did, you know, people who were worshiping Satan, Satan worshipers who did it in ignorance and maybe as an act of rebellion from a place of hurt, whatever. The Lord is talking about people who are, who know the truth, right? Who know the truth and who blaspheme God despite knowing the truth. And he's, he's qualifying blasphemy as that. Yeah, that's the, and he's saying this will not be forgiven. Hope that helps. Okay, thank you. Yes, I clarify a lot. Thank you. Right, right. Okay, so let's move on. Let's move on to what the Lord taught further about the Holy Spirit. Okay, so it's, so it's, now these are the words of the Lord Jesus. So, so let's, you know, let's just pay attention. What is he saying about the Holy Spirit? Okay. Okay, let's look at some of those references. Luke chapter 11 and verse 13. What is the Lord saying? If you being evil know how to give good gifts to your children, how much more will your heavenly Father give the Holy Spirit to those who ask Him? Okay, let's look at the context. Let's start reading from verse 9.  Seek and you will find. Knock and it will be open to you. For everyone who asks receives, he who seeks finds. For him who knocks it will be open. Okay, then he talks about verse 11. If a son asks for bread from any father, will he give him a stone? If you ask for a fish, will he give him a serpent instead of a fish? If you ask for an egg, will he offer him a scorpion? Okay, so he's just contrasting. If you're asking, if your son is in need, you're asking your earthly father, Father, give me bread, will you give him, no, I don't have bread, take this or, you know, I have bread, but you take a stone instead. Okay, so he's talking about the, you know, the foolishness of such a response. And he's saying if you then being evil know how to give good gifts to your children, how much more will your heavenly father give the Holy Spirit to those who ask him. So that should settle some of our fears or sense of unworthiness. We sometimes say, you know, I'm not worthy enough. I'm not good enough. He's talking about the goodness of God, goodness of the father in giving, in extending the work or the ministry of the Holy Spirit to us. And we ask, he says how much more will your heavenly father, you know, because we know how to give good gifts to our children, how much more your heavenly father. So he's not the one who is withholding the Spirit from giving to anyone. Okay, so the Lord talks about the heart of the Father. This is the heart of the Father. He desires that you and I be filled with the Spirit and walk in the Spirit. Okay. Okay, so we don't have to twist God's arm. We don't have to prove to him that we are worthy. We don't have to come to a place of saying, I'm holy enough now Lord so please fill me. No. Right. The Father knows how to give good gifts to his children. Okay. John chapter 3, verses 1 to 8. This is the conversation between the Pharisee Nicodemus and with Jesus. So let me just quickly paraphrase a few things. So Nicodemus comes. He says, Rabbi, you are a teacher and so no one can do these things unless you do them, etc. Unless God is with him and then he says Lord Jesus says, unless one is born again, he cannot see the kingdom of God. Okay, unless one is born again. So Nicodemus is puzzled saying, how can a person be born again? Right. So what are you saying? Because he was a grown man and he's saying, how can I be born again? What is he considering? He's considering the natural. He's considering the natural birth where the Lord is teaching about something else. Okay. So the Lord says assuredly I say to you, unless one is born of water and the Spirit he cannot enter the kingdom of God. So he's continuing to talk about how one can see the kingdom of God, how one can enter into the kingdom of God. This is how it is. Unless one is born of water and the Spirit. Okay. So Nicodemus asks the question was, how can a man be born again? Right. How can he enter a second time into a mother's womb and be born? So what birth is he talking about? The natural birth, the physical birth. Right. So he's saying, how can that happen? He's all the time thinking about the physical thing. But Jesus talking about spiritual matters he's talking about the kingdom of God and he's saying unless one is born of water and the Spirit. Now water could refer to many things. Right. Water is a picture type of the Holy Spirit and here the Lord is saying unless one is born of water and the Holy Spirit, he's contrasting between physical birth and spiritual birth. Okay. Yeah.  That's a natural birth. So he's talking about water which is a natural element unless one is born of water and the Spirit. Okay. Unless one is born of the Holy Spirit, he cannot see the kingdom of God. Okay. So then continuous verse 6, that which is born of the flesh is flesh and that which is born of the Spirit is spirit. So he's talking about this born again experience which is a spiritual experience for those of us who are born in the flesh. Right. So Lord is saying that which is, he says unless one is born of water and the Spirit cannot see the kingdom of God. Again distinguishing between physical and the spiritually saying that which is born of the flesh is flesh that which is born of the Spirit is Spirit. Okay. Then do not marvel that I said to you you must be born again. The wind blows where it wishes and you hear the sound of it but cannot tell where it comes from and where it goes. So is everyone born of the Spirit. So he's saying he's talking about how one is born again and the nature of one who is born again. He's saying you see, you don't see the wind but you hear the wind because you see the outworking of it and so is everyone. You don't know the source, where it comes from where it goes. So is everyone who is born of the Spirit in the sense the way they are born again in the Spirit, the way the Holy Spirit causes them to be born again. Well it's a spiritual matter we don't see it, we cannot understand it we cannot tell but he says so is everyone who is born of the Spirit. So the Lord is teaching about what happens to a person when he is born of the Spirit. So what we understand is that the Lord is teaching saying the Holy Spirit he is the one who causes one to be born again. This new birth is new life. We use the stones I got a new life I was a changed person my old life in my old life I used to do it but I'm a changed person and how did that change happen? Something deep inside happened. It is not that we decided, yes of course we decided, it's not that it's like a resolution and we are following through with a resolution because of our own self-control and our own will. No. Something happened in our Spirit and I'm sure you are learning in this whole subject of in Christ identity. How we are Spirit, Soul and Body. Are we learning it? 1 Thessalonians 5 23 Spirit, Soul and Body. So our Spirit which was dead to God comes alive to him meaning it's now our Spirit man is now open sensitive to the things of God desires the things of God is able to communicate with the Holy Spirit. How does it happen because our Spirit man is born again? There's a spiritual rebirth that happens. So the Lord is teaching about the born again experience. Is baptism necessary for the Holy Spirit? You put it back in the sense. Is there anywhere to see and the notes online? I can see myself and the notes probably if you are connecting from a phone that might be a little difficult I think. I'm on my computer and I can't see you at all. That's strange. How is it? Only the notes. Okay. I will figure that out. I'm not sure. Okay, thank you. Okay, great. So we see that the Lord is talking about we'll address these questions. So the question is, is what about baptism necessary for the Holy Spirit to come into our heart? No. We see very clearly and we will also learn further that we receive the Holy Spirit by faith. And when we are talking specifically about Holy Spirit baptism, yes, that is also by faith. Jesus is the one who baptizes us. And when we receive Jesus, Lord and Saviour, we are sealed by the Holy Spirit. And that's because of an act of faith and not because of water baptism. Okay. Okay, any other question? Okay, I think that's it. Okay, we'll take a break now and then we'll come back. Thank you. I can see you now. Yeah, that's because I stopped sharing the notes. Okay, Sam is posting something on the chat. I think that's to help you. So you can take the, when you see the list of people you can just pin Pastor Jay Kumar. You can see both the notes and him.


Save 10% with my code Bobby10 on raw, organic, grass-fed and grass-finished, freeze-dried organ meats from grassland nutrition. Link in the description box. All right, guys, welcome back to the channel. If you're new, Manus Bobby, guys, something new today, we're going to react to the Lex Friedman podcast with the video Torah versus Koran versus Bible. His guest was David Wolpe, who is the max web senior Rabbi of the Sinai Temple. He previously taught at the Jewish Theological Seminary of America in New York, the American Jewish University in Los Angeles, Hunter College and the UCLA. I personally chose this video because I was interested to hear what a Jewish Rabbi has to say about the Bible and the Koran of the Abrahamic faiths. Judaism is, so to speak, the oldest and therefore they have the Torah. But what do they believe about the Bible and the Koran? I'm super excited for today's video. With no further ado, let's have a look. Could you maybe talk about the difference between the Torah, the Bible and the Koran? So there's the Hebrew Bible is actually what's called a step canon. That is, there are the five books of the Torah. Then there are books of history and the prophets. So books like Samuel, Kings, Judges, and then the prophets, Isaiah, Jeremiah, Amos, Ezekiel, so on. And then there are what are called the writings. The writings are books like Psalms, Proverbs, Job, the Migiloth, which are Esther, Daniel, all of those books, Ecclesiastes. Many Christians don't realize how much they share with the Jews. So in Hebrew it's called the Tanach, Torah Navim Ketuvim, the Torah, the prophets and the writings. And that is the Hebrew Bible. Sometimes that's also called the Torah, just to be confusing, but really the Torah generally refers to the five books. Then there is the New Testament, which the Jews don't recognize as a sacred book. They recognize it as the book of another religion. And I sometimes say to Christians, in order for them to really grasp this, Jesus has as much religious significance to Judaism as Muhammad has to Christianity. That is, Jesus, although Jewish, became the founder of another religion. And for Judaism, that's not only in as much as Christians and Jews have had a lot of interactions. It's interesting description, but more over to the Jews, this implies Jesus and Muhammad. They don't believe in neither. Religiously, Jesus has no significance. Said many beautiful things, said some things I don't like so much. Like what? Leave your father and mother and follow me. I don't like that as a religious model. Now, Christians will say that I don't understand that, but that's because Yeah, but just because you don't like it doesn't make it true. There are many things that I don't like. For example, I would really like to eat kebabs and burgers every single day.  Because Christians like Jews interpret their texts different ways at different times. So anyway, the Quran, which I know less well, I have read it, but I know it less well than I know the New Testament, certainly less well, obviously, than I know the Hebrew Bible, is in some ways a parts of it are, I don't say this word, I say this word because I can't find a better descriptive word, but Muslims will not accept this. Okay, is it take off on the Torah in some things? That is, it's the same stories as the Torah, but they're different. Now, so ultimately he makes the claim that Muhammad copied off the Torah, as if we didn't hear this before. Jews will say, and I being a Jew will say this, that that's because Muhammad heard those stories from Jews, and also heard Midrashim, which are rabbinic interpretations of those stories. And he wrote those down. Muslims will say, no, the Jews got it wrong. And Muhammad came along to correct the record and tell the real story. But they're all telling the story of the same thing. The Hebrew Bible part, the Abrahamic part, they all tell the story of the same characters, but tell them, they obviously Christians accept the Hebrew Bible as sacred scripture, the Muslims retell many of the stories in the Bible. What is common to all of them is that all of them are monotheistic faiths. Now, in Christianity, that's more complicated because of the Trinity. But as Christianity has developed over time, it clearly presents itself and thinks of itself and is a monotheistic faith as well. What's the role of the word? Yeah, the claim is there of being a monotheistic faith. Of course, however, if you really dig into it, you will have to come to the conclusion yourself, what you believe is a truly a monotheistic faith. If it concentrates on personages of God, or at least perceived personages of God, that then can be worshiped as well. You can worship the Father, but you can worship the Son. However, you can worship the Holy Spirit as well, because in the Christian ideology, those things are inseparable. However, this is not much different from Hinduism, for example. In Hinduism, you have the Godhead, which is Brahman. So you do have a monotheistic faith as well, if you want to look at it like that. And from there on, you have the manifestations of God. What is the difference if you call it persons, manifestations, deities or what not? Ultimately, you're further attributing things onto the essence of God. And therefore, if it is really a monotheistic religion, I'll let you decide. Which are these religions in the scriptures? So first of all, the role of oral traditions, the power of the exactness of the words in the scripture. Does it differ? Or is it really within the communities? It differs because his approach here is a very secular approach. Of course, he simply asked if those stories differ a bit. That is not really the question here. We are talking about the core message of religion, or at least that should be the interest in my opinion. What is the core message of the religion? And did other religions deviate from that core message? The true question becomes, is there a true religion that comes from God? Christianity. That's how I see it. The words are not all the words of Jesus. They're the words of Jesus' disciples. None of the books of the New Testament were written by people who met Jesus in person. So they're different. And also, we don't even know sometimes the original language of some of the things in the New Testament. Correct. It's Aramaic, but the New Testament is in Greek. The Bible, and I understand in the Qur'an, but I'll speak for the Hebrew Bible, the idea is that that's Lashon HaKodesh. That's sacred language. And Hebrew is in its, that's the language according to the tradition that God actually spoke to Moses. And therefore, the exact words are infinitely interpretable and meaningful. But the words are spoken by written by Moses, and the same with Muhammad, but from memory? Or no? There are different theories. I won't speak for Muhammad. You should ask. I don't want to get that wrong. I don't want to get another religious tradition wrong. In Judaism, the words are written by Moses at God's dictation, basically. That's the traditional view. There are other views that I'm happy to. The Qur'anic view is that the Qur'an is the uncreated word of God, the eternal word of God. Go into it if you want to, but basically that's the traditional view. So it's pretty close. Right. What makes it different, what makes Judaism and Christianity different is Christianity has an ideal life. Judaism doesn't have an ideal life. Judaism has an ideal book. So the holidays of Christianity are events in the life of God, God's birth, God's death and resurrection. In Judaism, the holidays are all events in the life of the people, like the liberation from slavery, or in the people's relationship to God, like Yom Kippur, which is a day of atonement. But there are no holidays in Judaism that are events in the life of God because in Judaism, God doesn't have a biography. God is eternal and God never came to earth. Alright, this is already it for today's short clip. I expected a little bit more of an in-depth explanation. However, of course, he's a rabbi and therefore he concentrated more on the Jewish worldview and respectfully said as well that he doesn't want to mischaracterize Islam, for example. He knew quite a bit about Christianity on the other hand. However, into Islam he hasn't looked himself. That being said, his perspective is nothing new here. We heard it all before that Prophet Muhammad, may peace be upon him, copied the books, even though he was illiterate or moreover that he was possessed. He didn't know what he was talking about. All of those allegations we heard a billion times before. And in most instances it comes from people that haven't done their own research. Here you have him sitting there not having researched the Quran, but saying he probably copied it. So this, of course, a beautiful display of absolute ignorance and arrogance yet again. Alright guys, but this is it for today's video. If you liked it, leave it a thumbs up. If you haven't subscribed already, guys, please do so. And if you want to support this channel via Patreon, for example, all the links are in the description box below. Thank you so much for your ongoing support, guys, really from the bottom of my heart. As always, may God bless you all. Much love and peace.


Religion and World Politics, Part 11. When we look at contemporary international politics, we often look back to the Second Gulf War, the war against Saddam Hussein and his much-rumored, much-vaunted but non-existent weapons of mass destruction as the beginning of an adventure full of hubris and containing a nemesis that's come back to haunt us. The unleashing and the aftermath of that war of war kinds of seemingly religiously based powers that threaten the Western project and which have spread their tentacles around the world in terms of terrorist actions, not to mention in terms of developing a huge amount of turmoil in the Middle East itself. But are we right in terms of attributing all of these things to one war that we ill-advisedly decided to begin? My mind goes back to an earlier prototype of what happened in Iraq, and that is with the struggle for the decolonization of Algeria. There you had resistance to French colonial rule, and in fact it was colonial rule which was aided and abetted with settlerdom. The colons or those who had left metropolitan France to settle in Algeria had made of particularly northern Algeria a département of France itself. Life could be French. And so decolonizing the country, giving in to the demands for independence, led to a huge resentment in terms of the settlers and in terms of French national interest that were able to project itself from both sides of the Mediterranean. And the huge violence that followed, was that in any way attributable to a French reluctance to embrace the more Islamic view of the world in terms of the greater population of Algeria?  As the resistance to French rule continued to grow, as it became more violent as women using bombs in marketplaces, for instance, became a favored device of resistance to the French, the French developed what later became known in southern Africa as the South African apartheid doctrine of total strategy. That put a total military stranglehold on any possibility of resistance on the part of the Algerian fighters. And this was a smothering of the possibility of resistance, which did not of course work, but none of it had any direct reference to the fact that the resistance might have Islamic roots or that it might have Islamic tendencies or even Islamic affiliations in a remote sort of way. And yet, when we look today at North Africa, we see not only modern nation states, but we see also the advent within a comparative modernity of Islamic movements that are not satisfied with the status quo, not satisfied with the projection of a Western project, even though it's taken on independent local dress. And yet it was the struggle for an independence with Western institutions clad in local dress that someone like Franz Fanon was attracted to. Fanon from Martinique in the Caribbean could not have been further removed from the Algerian project at the moment of his birth and during the time in which he was growing up. But he became affiliated to it as a form of modernity that could be sympathetic to the aspirations of people within a context of political freedom and in terms of a context of self-determination and self-choice. All of these things drew Fanon to the struggle in Algeria, which the Algerians recognized. He was given proper respect and in fact, buried in Algeria after his death, his body smuggled across French lines so it could be buried by freedom fighters on Algerian soil. And yet there was nothing in the struggle at that point in time, even on the part of the liberation front that was anything but secular. The secularity of the struggle for self-determination is something which speaks to a modern effort at nation building and state building, which is present also in Iraq. So whether or not what you had in the ill-advised Second Gulf War was a dismantling at the effort of state building and nation building, or whether it was the unleashing of a religious genie from its bottle, or some curious combination of the two is a matter yet to be resolved, but it is a combination of the two. To be a reductionist and to say it is only one is I think a mistaken attribution. You can look at what happened for instance during Fanon's years in Paris. There were also the years when the Iranian philosopher Ali Shariati was also studying in that city the same influences and these years of exile and study as it were in Paris overlapped with the years of exile of the Ayatollah Khomeini. And it's not as if the Ayatollah Khomeini who later became the supreme ruler of Iran was uninfluenced by intellectual currents in Paris. He knew he had to pay attention to the developing thought of Shariati. He was very much advised and in fact had long conversations with intellectual, Palestinian exiles who talked to him about doctrines of immiseration, who talked to him about the Latin American school of neo-Marx's dependency, who talked to him about modern currents of thought which was proposed in terms of opposing international capitalism, not on a religious basis but on a secular basis, on a basis of the distribution of capital. All of these things had to be taken on board by Khomeini so he had not just a religious imprint on what he wanted to do but he had to have an imprint on how his new state supposedly a theocratic state of Iran could in some way survive in a modern world.  What you had however in terms of the residue of the French colonial project particularly into Islamic areas of Africa, West Africa as well as North Africa is a very very curious fight back not only in terms of religious values but these were civilizations, African civilizations which were not only religiously based but city based. In other words, they were kingship societies, urban societies and cultures of organization and urban cultures of resistance which were possible within that form of social organization that were able to fight back from an autochthonous foundation. This is something which I think is commonly overlooked that this combination of sophistication was part of the fight back. It wasn't that the French went with a Christian mission to civilize vast open spaces that was part of it certainly but what they found in countries like Mali for instance in other Islamic kingship states in Senegal were cultures, sites, organized urban polities that were able to self organize and also to resist so that the world politics of today mistakes not only the wide open space as a tabular rouser a blank board upon which the colonial project could write but mistakes also the foundations of sophisticated resentment and resistance and yet the idea of the wide open space remains resonant for every much part of the whole Mormon project in the United States of America Jesus went to the wide open spaces even though when you read the book of Mormon it was curiously and urbanized wide open space with great cities the Africana project in South Africa to develop a new frontier because there were wide open uninhabited spaces to be met in particular by the ferocious resistance of the Zulu kingdom all of these things tried to imprint upon something sophisticated an image of something simple a condensation of complexity into something that needed all the same to be filled by something superior all of these things of regard and of denigration infiltrate into today's religion and world politics the way they mix, the way they mesh and they make of something very very complex something very simple at first sight but the aim of this lecture and of this course is to resurrect the full complexity of these relationships


Thank you for the kind introduction. So before we start, I just want to kind of go through the disclosures here. I'm what I'm going to be presenting are a series of ideas that we have come up with and we have developed over the course of the past few years. To be clear, none of these at this point have been clinically cleared. Some are very close and on the precipice but at this point nothing is cleared for human clinical use and here are my disclosures.  To make the point that as doctors, at least the clinicians in this audience, that you have a unique opportunity that if you kind of take some time and try to think a little bit outside the box that you alone really can understand what is needed in the heat of the moment. Then you create a network and here at Texas Heart and at St. Luke's you have a very, very unique opportunity to integrate your clinical knowledge with the engineering expertise with all the other resources that are basically you're embedded in. So I would advise that you take this opportunity very seriously and make the most of it. So having said that the way I'm going to proceed is I'll start with some clinical problems and again the solutions and what we've done with them. So I was advised to use the computer scroller so we'll do that. So I'm sure everyone here who has done any type of a procedure has had to deal with the hematoma, growing hematoma, access site hematoma, or a bleed or even worse potentially a retroperitoneal hematoma because of my field of work in electrophysiology that's much less of an issue but especially with some of these newer technologies with mechanical support with the aortic valves and the triple A repairs that continues to be something that bedevils everyone. Here's a kind of a literature review of the incidents of vascular access site complications and I'll tell you a couple of things. In addition to this slide being a little bit confusing it's also a little bit old. So with those provisions in mind if you look at some of the major and earlier studies done looking at the incidents of complications the area of the circle represents the number of patients in the studies and the height on the Y axis represents the incidence of complications and so you can see you're ranging anywhere from 7% in the case of STEMI's to 29% and typically for them PELAS and typically the classic definition to make this threshold cut is any clinically significant bleeding but in turn in addition to that a 3 gram drop on your hemoglobin level immediately pre versus post-bleat. This is a problem that continues to be an issue and you know recently we looked at about 14 million discharges in the CMS data between 2012-2013 and identified about 37,000 target procedures. So again those target procedures were everything that you just saw except for the STEMI's. So mechanical support also no balloon pumps. So mechanical support with impellers or ECMO, the tavers and the triple A vascular repairs. So those 37,000 target procedures about close to 9,000 had what was defined as a bleeding complication and a bleeding complication was actually a pretty rigorous definition. They had to either be taken back for a repair they either had to or most likely and most commonly they had to have a transfusion. A drop in a hemoglobin was not part of the defining features of vascular access complication. So the majority of these patients vast majority actually ended up getting transfused. So the threshold again it's a pretty high bar. Those patients who bled had a 40% increase in the mortality rate. They stayed in the hospital longer and the cost of the system was significantly higher. Of these patients again as I said a significant percentage actually required transfusion by definition. So 20% of these patients actually ended up with transfusions and there was a clear correlation between the number of transfusions and their outcome. But that's for another day. So again though if you bled you were the bleeding either kills you or it maims you. You stay in the hospital longer and in addition to doing all that it really provides a significant increase increment in the cost to the to the system. Again this is in this cohort that was looked at and again the weakness of this study is that it was 2012 to 2013 and I recognize that much has changed. But again when you're dealing with CMS data there is a certain lag that is going to be unavoidable. And so you know this is a problem that probably significantly less than a few years ago but it continues to bedevil all of us even in the field of electrophysiology and the thought is is there a way that we can detect this early. And you know I had a situation about seven years ago. I was I had just finished a case here and most of you may know I you know every third week I go to Webster and Clear Lake area and so I finished a case here. I was on I-45. I get a phone call that you know one of my patients is not doing well and actually it was probably even longer. It was probably about eight years ago. At that point we were still doing lovenox and lovenox was really really bad when it came to the incidence of bleeding. He had a really high risk even with us in the venous system of growing complications and hematomas. And so the patient is hypotensive and I'm thinking to myself God I wish there was a way I could kind of interrogate that area. And for some reason I was thinking about some other feature of the ablation looking at impedances and I don't know it just at a moment the thought came we'll if we could actually interrogate the impedance of the site where the you know vascular access is occurring could we at that point say would there be a difference and my thought was that there would be because you know blood has very low impedance very low resistance to electrical conduction. Muscle I would think still pretty low but probably a little bit more and then fat and bone and all those other things you know definitely much higher resistance to conduction. So if you could put electrodes on the outer surface of these sheets and then during the entire procedure you could emit a sub physiologic and by sub physiologic I mean a sub threshold so it doesn't capture the nerve or the muscle. Could a change in that if there's a sudden bleed could that be manifested in the change in the impedance. And so here's basically a scheme of that where you know again this is very introductory for everyone here but we start with a simple you know vascular access sheath placement and you know most of the patients are half calcific disease or or other types of comorbidities that increase the risk of having a bleed it doesn't necessarily need to be a posterior so it can be a trauma just from the mechanical manipulation of the artery. And the problem of course that we have typically is if it's an anterior bleed no big deal you know you put some pressure you can see it and everything is fine. The problem is if it goes back into this via the hunter's canal into the gutter and I'm going to show you what this concept was. And this is basically a rendition of having the sheath same sheath except for the four electrodes. The four electrodes are emitting this electrical current and they're connected to the hub of the sheath and the hub of that sheath in real time is analyzing the impedance. So once you put the sheath in the analysis starts it gives you say a green light it starts flickering the electrical impedance is shown here and let me just stop it here and this field then is being interrogated by the by the impedance it's actually this is a little bit incorrect actually just like a magnet if you have the north pole and the south pole of the magnet the magnets field vector field isn't like this it actually extends beyond the distal tip of the sheath in this case about five centimeters and why is that important because distal to this typically is into the hunter's canal and if you have bleeding or cumulation of fluid into the retro spare peritoneal space and that's the key feature that will allow you to detect the cumulation fluid as you'll see in a second very precisely soon as any blood is introduced into into space as I said within five centimeters distal to this to the tip so having said that one of the concerns was you know look you have a sheath in place and most bleeding actually doesn't occur when you have the sheath in place most bleeding occurs after you pull the sheath because if there's a bleed there may be a tiny leak but the sheath often is tamponading the artery and once you pull the artery the sheet from the artery you know an hour or two hours later you may have a precipitous blood draw hemoglobin drop or blood pressure drop and that's when you have trouble and by the by then you don't have a sheath to measure that and I think this is a very very real and legitimate concern so the the way that you know kind of we've decided to frame this and I think this is something that has been kind of not accepted but has been the interventionalists have been more enthusiastic about than actually having a sheath that once you take it out you lose all measurements is you take that same sheath and you go into the vein right next to it and in this case you can do it even with a five-friend sheet because many of these procedures from my understanding they do actually have patients who have a venous sheath they're either to measure pressures or have a temporary wire and what have you and in this situation what you can do is you have that the sheath with the electrodes is actually in the vein right next to it now as you pull the arterial sheath back and the bleed starts accumulating the impedance starts dropping drastically and at that point you have that monitoring to be able to pick it up at the moment it's happening and not only to pick up the onset but to pick up the propagation and extent of bleeding and I'll let this finish just one more time here's the venous sheath arterial sheath arterial sheath is removed you have a little bit of a leak here once you pull out the arterial sheath the bleed blood starts accumulating and this venous sheath basically starts picking up initially one level of an impedance change then a second and a third and these numbers are not are not arbitrary in a study that was done to as and was ultimately submitted to the FDA about a month ago per the FDA specific request 20 animals were studied and in that study what was done is the controlled amount of blood a fresh blood was introduced into the perivascular space so that way there was control knowing exactly how much blood has been introduced and what the timeframe is and after about you know initial just to check the specificity of the system once the sheath was inserted a lot of torquing and torsion and moving around and all kinds of stuff mechanical stressors were applied to the sheath and you know the algorithm pretty clearly could pick up what was the real deal and what wasn't at the moment of bleed infusion and bleed infusion was 10 cc's per minute so you know it's it's not it's it's a leak maybe a robust leak but a leak nonetheless it's not a gusher the the device picked up every time that there was a drop in the impedance and there was a clear correlation then not only between the onset of bleed and thus alerting you that you have a bleed but also with the progression of the bleed which were defined as each of these lights and so this now provides a clinician with the potential to say number one I'm I have a leak I can do something about it I can not do something about it knowing that until that second light goes off in all probability we're looking at about 100 150 cc's of blood but probably not more once that second light goes off now you know you're a little bit more serious and you're going anywhere between 150 to about 250 and if that third light goes off you almost certainly have are dealing with more than 250 cc's of blood in that in that peri vascular space and so the correlation not only with the onset but with the progression so that's the first kind of problem again I'm sure every one of you in this room have had to deal with that just you know think about it try to you know try to not be hampered by what you have been taught in med school and in residency and I think that the best ideas you're in a phase in your training that you really are your mind is still open and you can come up with these solutions that I think can make a huge difference again this I will admit is not something that I deal with thankfully on a daily basis but the same component concept of impedance can be extended to other fluid accumulations in other spaces and again this audience is much more facile with the concept of indoleaks is a complication long-term complication of aortic graft repairs and and by extension of what I just said you know if you if the concern with an indoleak is that there's now going to be a communication that potentially will allow the introduction of blood or fresh blood into a space that up to now has been excluded and now has either clot or whatever have you but has been excluded from from the presence of fresh blood what impedances again be altered and well how would you check the impedance the most important thing I can tell you in this is location you have to be as close as possible that's where you get the most accurate readings and for a while we you know we were thinking go subcutaneous punch it in through you know behind their back or do something like that and then you know I remember you know putting up catheters in the EP lab and this happens to every one of us attendings fourth year second years when they put up those catheters and invariably as you're going up the right side you think you're going up and suddenly you know the catheter just buckles and you're like you know I wasn't there so you back it down and then you go back up and you try a couple of times and we keep saying torque this way and torque that way until you go into the main branch of the IVC and you go up well what is it that you're going in in those dead ends there's you know there's a lot of veins that I refer to as the inominate veins in the lower extremity but the IVC is sitting right next to the aorta especially at the abdominal limb and provides an excellent location these branches provide an excellent location they literally are hugging the aorta and so if you could put a catheter in there just like we do in the venous system it's going to be a dead end if you could again in the case of these veins I'm not talking about the IVC itself if you could embed it there then what would happen when you introduce blood into the area surrounding the aorta and that's what we did and as you can see and this I'll present the data in a second soon as blood is starting to be introduced into this area you see as expected an impedance drop and the challenge of this study is the mechanism in the model for having an endolyte that's a very tough model to create and you know I admit that this is this was not the prettiest model I just basically took a transeptal needle went up the aorta retro aortic access at the level of you know the abdominal aorta and with the transeptal needle it just started you know puncturing and and it wasn't that bad you know everything was fine and so then the impedance soon as you have that accumulation of blood which you can document just with a little puff of contrast the impedance drops and it dropped significantly and then after a while it tapered off and I think the aorta had sealed itself but again this was only one study we have not pursued this and this is the other I think the other motif you win some you lose some and you'll probably lose some more much more than you win but the chase is the fun part coming up with the idea testing it seeing that it works that you're not crazy and it gives you a level of confidence to you know the confidence to not be afraid to fail to fall on your backside and and so you know my backside's pretty resilient so it's I think it's really really important to to not be afraid of going for an idea that may not have been thought about before it's it's not because it's crazy it's just because you were the first one to think of it so I'll just kind of go through this a little bit more quickly so next is the concept of myocardial conduction disease myocardial dysfunction and ventricular arrhythmias so the reason that patients with the most common cause of ventricular arrhythmias in the post-infarct setting is re-entrant ventricular arrhythmias and what that is basically is anytime patients have heart attacks or for any other reason they have scar tissue what happens is the reason that they are predisposed to ventricular arrhythmias is because of delay in the electrical conduction and heterogeneity in the delay of electrical conduction in the heart now this is often through almost always through scar patchy scar in the case of non- ischemic cardiomyopathies and in case of ischemic cardiomyopathies more dense scar but it's an area really more so than scar it's in homogeneity of conduction that's the problem if everything was delayed together everything would be fine so if you look here you can see you know a conductive medium you have an area where there's a wave front you have an area where it's still refractory it's still resting and normally what you would get you know one wave would come then the second wave comes and everything is fine now if you create a situation where there is a little bit of a delay where there is and there's an inhomogeneity in that delay in other words if everything here was delayed equally this line would just move over here right and everything would be even but if there's inhomogeneity in the delay in other words there's an area that moves a little bit faster but there's an area that is just not able to keep up what that does is this area this medium that is excitable starts moving forward as it starts moving forward this area is still lagging behind so there's nothing to tell there's no rule that says you can't infringe on this tissue on this lower tissue from above so it actually starts moving forward and then it starts turning around you start turning around this wave front and as you start turning around this delay serves as an anchor and you have the initiation of a re-entrant beat a re-entrant basically a circle chasing ahead chasing its tail and in that situation you go from a normal rhythm to organized re-entry which we call ventricular tachycardia now when this wave when this re-entrant brick when this re-entrant wave front breaks down because again of those same inhomogeneities heterogeneities because of microscopic scar or what have you again smaller areas of delay here you know the water is coming you're standing in the pool you're the scar the wave front hits you you have little eddy currents form around your waist and now those eddy currents those little areas of wave block create newer eddy currents and those eddy currents cause what we call fibrillation chaos in the ventricle so you go from normal rhythm to ventricular tachycardia to ventricular fibrillation but the problem the crux of the problem is here the crux of the problem is the delay in ventricular depolarization that occurs again because of scar be it patchy non ischemic or denser scar so think about what is it that we do the drugs that we give amiodarone what does amiodarone do the conduction velocity it delays it what does Fleck and I do the conduction velocity it delays it what does so long due to conduction velocity doesn't delay it as much but still delays it is there any antiarhythmic that improves conduction velocity soon there will be you'll have these medicines that will be able to open the connection of the gap junctions the connects and 43 gap junctions but for now there isn't so this is why antiarhythmics can actually be profoundly pro-arhythmic by worsening this delay you actually can cause more more disease processes more arithmias and that's why some antiarhythmias are actually contraindicated in patients with myocardial infarctions what you want to do is you want to improve this conduction velocity and as far as we know right now there's no technology that does that to treat the underlying pathophysiologic mechanism of the number one cause of sudden death in this country and so with that thought and that background the the concept that we had and this was working with metopas quality at Rice University and Mark McCauley is intimately involved he's now at University of Illinois also our team with Brian Greene Matthews and and David Berkland and on and gonna put the I don't know they're they're all around here and and you know what the concept was let's take some conductive nanofibers and I won't get into the details of that but just suffice to say that conductive nanofibers think of them as thread-like physical properties with conductive properties of metal so they don't they're flex fatigue they're essentially resistant they won't fracture like metals will they have a contact impedance that is to say resistance to conduction and the ability to pick up current from tissue that's probably about about 10 times better than that of platinum or radio and so they have this remarkable ability to collect current conduct it and then dump it on the other end and so in this situation what you have is you start pacing this is the left ventricle of an animal you start pacing you have four decapolar electrodes sutured on the outer surface of the left ventricle and you look at the conduction velocities you start pacing here and you look at the conduction time from pacing in the middle here to each of these electrodes and for our purposes we're going to focus on these electrodes and at baseline before anything is done you see that okay everything is kind of you pace and you immediately capture it which makes sense because these are relatively close then you say okay I'm gonna make a deep lesion a deep RF lesion scar tissue in the shape of a horseshoe and I'm gonna keep pacing and I'm gonna see what does the conduction velocity do turns out the conduction velocity goes from about 26 it increases significantly as these things go again that's to be expected so then you say alright let me suture these fibers around this anchored scarf what then happens and you look again at the electrodes here and I'm going to show you what the other electrodes do in the next slide but when you start pacing again from here now with the fibers in position and looking at the electrodes that immediately oppose on the outer surface on the external surface of the scar these fibers and just again to be clear there is no direct contact between these fibers and the electrodes nor is there any direct contact with the pacing electrode what you see is that the conduction is pulled in the conduction velocity is reconstituted well maybe this is because of some mechanical feature you know you're thrown sutures and you're just approximating things turns out when you put a silk suture through as a control a non-conductive silk suture you don't see that phenomena the conduction velocities remain down and here's a video of that same here's the pacing electrode so you can see the good distance you can see there's a good distance here and here's the there's the horseshoe and you have the sutures so and the other point is if you it's only those electrodes remember four five six that were on the opposite side of those fibers that actually had them with the fibers had the normalization the reconstitution of that delay back to close to baseline again another feature suggesting that it is those fibers but probably the strongest feature that we have got to do tracing guys I'm sorry I can't give a talk without some intracardiac electrograms here but probably one of the most powerful suggestions for in a conduction over these fibers is if you put a catheter in the coronary sinus and the distal electrodes are labeled la1 and the proximal electrodes are five and so you have the lateral wall of the LV in the LA you have the septum and you're pacing from the ventricle so far so good so when you pace you're activating here and I'll tell you at baseline there was when you paste the ventricle at baseline there was no conduction so I'm gonna give you that right now and we're gonna show that in a second when you pace you notice on the coronary sinus catheters the coronary sinus catheter will pick up two signals it because it's hugging the left atrium and the left ventricle you will see the larger left ventricular signals and the smaller left atrial signals that's more magnified here the larger left ventricular signals and the smaller left atrial signals the reason that these are getting bigger is as you go distal the coronary sinus tends to hug more ventricular so as you are more proximal your relative size of the atrial to ventricular signal increases so the ventricular signal is going to be smaller relative to going more distal so you're pacing the ventricle everyone clear with this the big signals the ventricle you have activation and then you see for every ventricle here this is all this is time here and this is again location so a big signal a little signal big signal a little signal so VA VA VA but there's something else that you notice what is the earliest a you can see that the a here the atrial signal here is more separated than the atrial signal here but what's happening is that the impulse is coming up wrapping across this lateral aspect around LA one going to LA two then to LA three LA four and LA five and this happens with every beat at 480 milliseconds pacing one to one from the ventricle up to the atrium over this area where you had the fiber sutured now you remove the fiber and what happens you're still pacing the ventricle at 480 milliseconds so here's the ventricle remember the big signals V V V V what happens to these smaller atrial signals really there's no relation if you were looking at this if this was the a and this was the V you would say this is complete heart block and indeed it is except it's ventricular atrial heart block and soon as you remove the fiber that happens and so this is about as definitive as you know evidence as you can have that that conduction was indeed going up the fibers now I will also have to take a step back and say reproducing this in a sensed environment has been more challenging in larger animals in other words it seems at this point that in the larger animals we need for some reason to have a paced impulse to drive that current across in the smaller animals in rodents what we've seen that during normal rhythm spontaneously you will see that you can call it pre-excitation or that conduction from the atrium to the ventricle so there is a source sink mismatch issue that we need to work on so that the eight and during sinus rhythm and without pacing you have that conduction occurring to and so that's something that is a challenge at this point but we're working towards a solution I'm gonna do two more very quickly and then spend a couple minutes on the last one so pericardial access again most of you have been in those procedures we dread pericardial access unless you're dr. Rasek who seems to have an unusual interest and enjoyment with them and and so what you know what the dread is of course is that needle when you're trying to get access that can go anywhere you know that it's happening even in the liver we all read about stuff that happened goes into the lungs you know you put a wire and you think you're in the RV you put a in the pericardium you put a sheath in and you know you just poked a hole in the body of the right ventricle so again across the this is my last impedance based moment or impedance based concept but could there be that same needle that you use could there be a signature impedance that could help you differentiate between the anterior mediastinum the pericardial space and the right ventricle and the answer is yes that there is a clear difference in near field impedance between the anterior mediastinum you go under the under the sternum that's that tissue the diaphragm things of that nature and you start pushing in and versus the mediastinum itself versus the right ventricle very clear demarcations and I always say that I'm I get a little embarrassed to show this ROC curve but this is at least the data that we had this is the way that analysis look so with this data in mind with at least the so this was a catheter that we placed and we would go into different spaces and looking at the near field impedances this was not the needle itself so but with this knowledge now we said okay let's see if we can take a needle put embed electrodes this is a regular old you know 18 gauge needle embed electrodes on the distal tip and make sure those electrodes again you have to have they have to be insulated from each other because the relative impedance delta that you're looking at is between these electrodes okay so we have these electrodes here we have the wiring in the body of the needle and then that but this wiring is connected to our impedance meter for lack of a better term and so I bet you guys can tell who this is and also who this is but so downstairs we said okay let's do it let's go advance the needle just like you would fluoroscopically with the same guidance and everything else and let's see what happens and here is Dr. Berkland and you can see that he's positioning there's a sternum he's going sub-ernal and he's I don't think you're going to see the advancing of the needle I doubt it yeah so he's advancing it but so this is this is what you do every day now every time that you're trying to get a dry tap this is this is a technique that should be familiar to everyone and what and what you see is that there is a dip this is the raw data that at the anterior metastinal space as your again impedance is on the y-axis this is on the time is on the x-axis as you transition from the anterior metastinal space to the pericardial space you have a drop in the impedance again it's reproducible we've done two studies so far and it's multiple attempts at each and it's very very clear cut and so the concept then is so in this case what we did is we introduced it Dr. Berkland then went and what we noticed is the diaphragm actually causes a drop in the impedance too when you go through the diaphragm that's the first drop in impedance that you see and why because it's muscle muscle has blood muscle has tissue so you would expect that that tissue versus the fat and the bone of the anterior metastinum would have a lower impedance and indeed that's what you find so this is Dr. Berkland on purpose going back into the anterior metastinum so anterior metastinum or it shouldn't be it's still in and right behind the sternal entrance the diaphragm again back diaphragm back diaphragm back now he decides to go all the way he goes through the diaphragm into the anterior metastinal space and soon as he goes in to the pericardial space and he confirms it by contrast the impedance drops again and so you now have a means of that needle tip actually telling you where you where you are of course it requires a lot of a lot more work but at least the initial data looks looks pretty promising two more things and then we'll be done here the dreaded esophageal fistula complication so many of you who've done the ep rotation are familiar with this scary and unpleasant situation in the lab here you have a three-dimensional map of the pulmonary veins you're actually looking at the left atrium from the back so a posterior view of the left atrium the pulmonary vein this is the right inferior pulmonary vein just looking at it from slightly different angles and so we're looking at the back going in and how we create this map don't worry about it there's catheter there's catheter that we use that looks at voltage creates a gps-based rendition in 3d and so you create a voltage electro anatomic map of the left atrium and this is a spiral catheter it's got 20 pulls on it we call it a lasso that goes at the opening at the osse of the pulmonary vein so this is right now kissing right at that tip of that pulmonary vein and you know the the thing that you can appreciate is is really this is fine what's the problem well this catheter is in the esophagus so this is a catheter that is hugging a temperature probe it's again a mapping catheter and this allows us to localize and since it's hugging the temperature probe by taping it to it you see where the temperature what the temperature is but also where the location of the esophagus is and i did this because i wanted to make the point that this isn't just one view when you rotate you can see that this esophagus is right on the pulmonary vein and by frame of reference this distance is five millimeters so you are very close to the esophagus and why is that a problem well one of the biggest well not the biggest but the most dreaded complication of aphiboblation is atrial esophageal fistulas the mortality approaches 80 percent it is a devastating complication patients die and they die a terrible death and really for a procedure that at its core remains even you know in the worst of situations a semi elective procedure and so you know what was the solution in that case i had to use cryo because and even cryo has been reported to have atrial esophageal fistulas but certainly a fraction if that of what you would see with with rf application so this is the cryo pro balloon setup so so the thought was is there a way to move the esophagus away and that's not anything that's new people have thought about it they looked into it you know you you take a stylet and you try to push it one way or another the studies that have done that though when they've looked endoscopically they've actually seen an increased incidence of ulcerations and the thought is that probably just the mechanical trauma of trying to push the esophagus in one direction so you have a leading edge and you're pushing against that leading edge that trauma may be as worse as anything else the other problem is you have a leading edge but what about your trailing edge are you moving the entire esophagus you know along and so some studies have shown that you can do that um but the thought i had is is there a more a traumatic way of doing this in the thought that we and why not try to suck the esophagus does that make even sense is the esophagus well the the reason that i kind of we thought about this was in the beginning we used to give contrast to these patients oral contrast back in the day where not everyone was under general anesthesia you would have them swallow a little bit of contrast you would see that bolus of contrast and you really would see the esophagus is a pretty dilated uh organ now and then you'd have a peristaltic wave front and it was such that sometimes i would wait to time my ablation around a vein waiting for that peristaltic wave front to come because when it would come the esophagus would contract and as it's contracting it would go away from the vein that i was trying to blade around so you're waiting there you know peristalsis comes let's burn let's burn then the next peristalsis comes so why not try to do a suction and so suction straightforward again you have a regular temperature probe it's got some fenestrations some openings in this plastic tube there's a balloon distal a balloon proximal and when you're in the esophagus you're ablating you're doing your thing the balloon is down everything is everything is fine but now let's say you're getting close to ablating say this vein in that case all you need to do and you want that peristalsis you know you want to have that contraction all you do is you open up this balloon on either side and you apply suction this is an open chest demonstration here's the esophagus again we're not inflating and deflating this is the baseline size of the suffix i gotta be real clear about that when you when we put when you introduce to the box it's it's a low profile so the esophagus is not you know you're not pushing away the esophagus the balloons are on one end and another end and then when you apply the suction you can see that this dilation comes it kind of sucks it in and so it's a very straightforward you know nothing and then you have the temperature probes on it too so here are the fenestrations balloon distal balloon proximal what does this you look under x-ray this is what it looks like you're applying the suction and it basically creates that peristalsis but the esophagus kind of collapsing now clear cut limitation if my pulmonary vein is right on the middle of this esophagus the collapsing it is not going to do anything i mean that is that's for sure but you know it it's it's still pretty nice to know that you can decrease the the caliber of the esophagus by you know something like 80 or so because in those situations every millimeter really does matter you may say well who cares it's you know the incidence is one in 2000 it's the same thing what is the incidence of retroperitoneal bleeds and guess what this is much more lethal than any retroperitoneal bleed what it does is it makes the ablations longer the success rates probably a little bit lower it makes gives me a lot of gray hairs and frankly you know it's something that is a major obstacle that we have to deal with pretty much in 50 60 70 percent of procedures so the reason that you're not we're not seeing the complication rate is because we are spending so much time dealing with it to prevent it in the lab and that's the that's the issue and so now i'm gonna end spend a few minutes on the concept of defibrillation so just to be clear this this pacing based defibrillation we have not in any studies done ventricular arrhythmias and cause pacing defibrillation i'm going to give you a little bit of background into what's going on and then kind of what the hope is to to go moving forward so defibrillators are you know we don't need to discuss those we all know what they do they shock and we know what their problems can be you know lead malfunctions lead fractures patients who have no vascular access etc etc and now there are actually leadless pacemakers one of them has actually been FDA approved the other one i expect that within a calendar year will be but suffice to say that those pacemakers now do not are leadless but at this time at least they're also a single chamber device that is quite large and and you know you use i think it's a 24 french venus sheath to to insert them again forget about the names but these are not small devices but more importantly with regards to the defibrillators the subcutaneous defibrillators have the opportunity and now commonly used with them you also avoid vascular access but in the case of the subcutaneous defibrillator you tunnel the leads under the skin here's the defibrillator can under the left uh castle region and you tunnel the leads you go across the breastbone across the sternum and the vector is the left ventricle so it's sandwiched between the can and the lead and it delivers a shock uh it's an 80 jewel shock and for those of us who may not be familiar typically most devices not all but most devices intracardiac devices the maximum icd output is 32 to 35 jewels some devices 41 but these devices can be 60 to 80 jewels and you have the issue therefore of pain defibrillators when they shock can give you a major major uh complication a major major issue with regards to post-traumatic stress disorder severe anxiety morbidity um in these patients that is is really sometimes often remarkable i had a patient who was saying that he was in vietnam and this was like vietnam was nothing compared to getting these incessant shocks and so so is there a way to shock the heart without shocking the heart to defibrillate the heart without shocking the heart and so let's take a step back and remember what why do we have to defibrillate fibrillation how does fibrillation defibrillation work the way that defibrillation works is it creates uniform simultaneous transient absolute refractoriness of myocardial tissue okay so simultaneous refractoriness of myocardial tissue if at one you have with fibrillation you have little areas we can call them wave fronts we can call them re-entrant areas we can call them however the mechanism is but think of it as electrical chaos all over the place and these regions of chaos basically feed on themselves there are little circuits that are going around and around the head catching the tail and again i showed you that image earlier it's literally that same you know the the little ripples the eddy currents of myocardial activation well myocardial tissue has a property of being absolutely refractory for about a hundred milliseconds as the sodium channel slams shut and during that period of time no matter how much activity how much electrical stimulation you provided it will not be active so how defibrillation works is by delivering that shock energy it simultaneously depolarizes the entire tissue when it depolarizes the entire tissue now you have reset the refractory period too everyone now goes on the same clock so for 100 milliseconds probably even less 50 to 70 perhaps in some situations you have absolute refractoriness nothing can get activated nothing can be stimulated and all those little re-entrant currents everywhere are annihilated they extinguish and so now nothing can feed on itself because nothing exists to feed the head no longer exists to feed the tail and so the arrhythmia comes to an end the reason the pacing doesn't work is when you pace the heart you are not achieving that depolarization diffusely at all areas it's not that you need to have that myocardium a cell a given cell cares if you shock it with 40 joules or if you activate it with five volts what it cares about is it needs to be depolarized at the same time that it's neighbor two centimeters three centimeters four centimeters is away is depolarized and pacing can't do that pacing when you pace from a site that site becomes the origin and from there the electrical activation spreads so you can't have simultaneous deep depolarization across all locations that's why you need to shock shocking does that involve so but what if you had the ability to pace from say 20 30 40 spots in the myocardium what if you had a situation where every cell was just maybe half a centimeter at most away from a pacing lead that was synchronized to pace with all other 25 electrodes in the left ventricle would that make a difference well the data the animal data says yes it would absolutely it would and there's very very strong data especially in atria but even in the ventricular fibrillation so here is and you know Igor FM off has been the pioneer in this field at wash you in st louis but here's a kind of a very nice study where you have a situation where you have ventricular arrhythmia and what's happening in each one of these is you're having pacing trains delivered followed by a shock okay so as you can tell here these pacing trains are getting more and more rapid right you can see the cycle lengths are shortening so here you have pacing and you give a one jewel shock and no success here the pacing is more rapid for more sites also and once you deliver the shock you have what we call typically a type 2 conversion there's a few beats of ET and then you convert back to sinus 1.1 joule fails here 0.24 joules gives you a type 2 success now you're pacing with five monopoles so five poles at a faster rate so again more sites at a faster rate shock 0.16 joules again it's type 2 but it converts lower energy so you went from one jewel 1.1 failing 0.24 0.16 okay here seven monopoles and you're pacing at a faster rate and you deliver 0.2 joule shock still type 2 but a much cleaner maybe type 1.5 uh conversion but it's a clean it breaks at an energy of 0.2 joules so a clinical's abstract by the same author was presented last year at heart rhythm uh taking patients who had paroxysmal aphib and they were getting ready to be ablated they took the coronary sinus catheter and with coronary sinus catheter they started pacing in multiple all all those areas at the same time and then again the same thing would happen they would either convert or the shock that they would receive was low enough that at least in the in the abstract it was said that the thresholds were sub sub uh they did not have pain but again we had you know where the patients already sedated because they were having an invasive procedure already done but nonetheless this concept is has been you know worked out by fm off in great detail there's also rabbit models of ventricular fibrillation the problem with ventricular fibrillation is the ventricle is a thicker tissue and what happens is and they know this actually from from extensive mapping the reason that defibrillation fails is typically because the mid myocardium the mid myocardial cells are not exposed to enough of the current and when that happens those little rotors everything else might be extinguished and be quiet but the little rotors kind of continue in the septum and in the mid myocardium and immediately cause immediate reconstitution of the fibrillation so again if so in these rabbit models what they did they still needed to do about four jewels to shock the ventricular for ventricular defibrillation a bigger hurdle but in humans if you could have a pacing chip that would be small enough to place say in a epicardial branch vein just like we do five french venus leads right in the for lv pacing if you had something that could be as small as a one and a half to two french catheter system that introduces a lead with multiple pacing chips on it and you place that in different areas around the ventricle you now have the ability now you have the tools to finally deliver multiple pacing impulses from everywhere but what's critical they have to be small and they have to be able to be commanded to pace simultaneously with adequate outputs and so here is where the technology actually pretend has the potential to rescue the day because what you can do is you can create a situation and again this was work with idin babakani at rice and he is now at ucla you can create these chips or nodes that are powered and commanded via electromagnetic induction emi and what happens is here is kind of one of our first studies that we did and you can see the circuit there's an antenna here so you're basically this antenna is powering the chip and or the the node and communicating with it not only commanding it but powering it and here's a kind of a rendition of the size of these chips the antenna is still you know is is going to be that right now is the biggest impediment to making these small enough to not only place and say the anterior interventricular vein but in the septal perforator until we get into the septal perforator pacing induced defibrillation will not work that is where the recurrent sources that's that's kind of the holy grail and so here you see a situation you have the chest open you can see the the coils the current iterations are much less bulky than this but you see the coils here you have two chips on the atria two chips on the right ventricle two chips on the left ventricle the led is basically a marker that it's received the signal and it's putting out electrical current and what we've done is there's an onset of a hundred milliseconds so you have a atrio ventricular synchronization and ventriculo ventricular synchronization in this pacing and this is again with six electrodes wirelessly you know again it's a big big magnet but the key thing here is we did the same with the chest closed so now what the holy grail here will be and what we are hoping and what is going to be our efforts is to be able to have a system where you can take those nodes have these be small enough that you can now introduce them into those epicardial vessels and branch vessels say put 15 20 of them especially around the left ventricle and then a system which we already have that is significantly smaller than this but nonetheless obviously and then you power these in the time of fibrillation you power these simultaneous outputs that have been as high as about two volts per node right now that's what we have at this point and then with that you create the ability to defibrillate or to depolarize simultaneously the bulk of the left ventricle and we shall see whether or not that will enable us to finally achieve what we call imperceptible defibrillation and so I started seven minutes late I uh I'm on time thank you guys very much and that's it this is the team