So this is our first meeting of the winter quarter in the lecture series that David Meltzer and the chess group put together along with our program in the McLean Center, and the title of the overall program is Improving Value in the U.S. Health Care System. It's now my pleasure, real pleasure to introduce our speaker today, Dr. Douglas Dershal. Dr. Dershal is Professor of Orthopedic Surgery and Rehabilitation Medicine here at the University and also was the founding chair of the department. As orthopedics became a new department, Dr. Dershal became its chair. Since Dr. Dershal came to the University in 2013, our orthopedic program has tripled in size and has expanded to many off-campus locations. Prior to coming to Chicago, Dr. Dershal served for 10 years as chair of orthopedics at the University of North Carolina and previously had served as chair of orthopedics at Oregon Health Sciences University. Dr. Dershal has deep experience with health care system leadership, served as the 124th president of the American Orthopedic Association, and now is serving as president of the Foundation for Orthopedic Trauma. Dr. Dershal's research focuses on many factors that influence orthopedics. He's written also about the issue of value in health care, and much of his work has been NIH funded. He's the author of three books, many book chapters and peer-reviewed articles, and sits on the review board, the editorial board of many orthopedic journals. Today, as you can see behind me, Dr. Dershal's talk is entitled, The Law of Unintended Consequences in Surgical Care, The Next Shooter Drop, or The Next Great Opportunity. Please join me in giving a warm welcome to Douglas Dershal. Thank you so much. Thank you very much, Mark. Mike is working okay? I hear it really loud, but I don't know if you guys can or not. I don't know about you, but I don't like the sound of my own voice, except when I hear it through the echoing in the bones of my own head. I think it sounds really weird. It's a pleasure to be here. I was really grateful to have the invitation. Thank you so much. I'm going to speak for a little bit today about something that very few, if any, orthopedic surgeons would talk about. And I'm going to speak about it in ways that I'm sure no orthopedic surgeons would talk about. But I want you to think, as I talk through this, not of orthopedics, but of surgical care in general, because the examples I will give and the points I will attempt to make and the things I will attempt to convince you of are broader than orthopedics and cross all disciplines of surgical care and perhaps may cross all disciplines of procedural care outside of the operating room as well. And I've entitled this, the unintended consequences of surgical care. And then to be a little more provocative, I ask you the question, is this the next shoot-a-drop, meaning the next thing to nail us as surgeons and physicians and providers for something? Or is this actually our next great opportunity? And I hope, maybe it's obvious, but I hope I can convince you it's the latter. And I hope I can convince you to have a more robust discussion on the ethical implications of what I'll talk about. And maybe even more to convince you to convince, to help me convince other surgeons that this is the kind of thing they should be thinking about. But since most things, most points, most lectures, most persuasive arguments are better made through stories than through a lot of data, I want to begin with a few examples. And don't worry if you're not a clinician or if you're not an orthopedic surgeon, but just listen to these examples, then we'll come back to some commonalities between them and these broader points I want to make. So this was a 26-year-old male involved in a motor vehicle crash who broke his femur, or thigh bone. It was a frontal impact, so we had a little bit of trouble breathing when he was first into ER, but he did rather well. And we were able to take him to the operating room and do this. This is a retrograde femoral nail, make a little incision in the knee, put the nail in from the knee, it goes up and across the fracture and ends near the hip. Beautiful way to stabilize the femur. All the hardware is inside the bone, he can walk on it right away. Got to the recovery room, he did great. All night long, he did great. The next morning, he's getting a little short of breath. Later that day, he's had an arterial blood gas, he's not oxygenating very well. Day, things go on. Within two days, he is on a ventilator in Florida, a cured respiratory distress syndrome, ARDS. That's the first example. Second example is a 78-year-old woman who falls at home and breaks her hip. That's the hip fracture on the left side of your screen. It's her right hip that's broken. She has a few medical problems but not too many, receives clearance. We take her to the operating room and do what is common in a displaced femoral neck fracture in someone her age group. We do a hemiarthroplasty. We replace the femoral side, the ball side of the hip joint, leaving her native socket in place. She does well. She can walk the next day. She stays in the hospital a few more days than a bit at a subacute rehab facility and goes home and is doing great for one year. Almost exactly 12 months later, she's walking around the house, slips on a rug she has, and breaks her other hip. That's the second example. Third example is a 60-year-old female who has hip arthritis. And like so many people that have bad hip arthritis, she has a total hip replacement. That's the THA, total hip arthroplasty. This is her left side. This is what the x-rays look like post-op. And you can take my word for it. This is exactly what we want them to look like post-op. It may look weird to you, but it's exactly what we want to see. Looks great. She does even better than the hip fracture patient. She's younger. Her physiologic reserve is better. She goes home in a couple of days. After two nights in the hospital, immediately goes home, is walking, does wonderfully for 18 months. 18 months later, she is out in her garden, twists a bit, her leg snaps, and she has a broken bone just below the tip of that prosthesis. That's example three. Example four, we go outside of orthopedics.  That's a little cut from her mammogram to do that. She goes to surgery, has a mastectomy, has negative nodes. All is going well, we think. Until about two months after her mastectomy, they find a metastasis in her lung. That's the fourth example. Those are the four examples we're going to discuss as we go through the rest of this. And so that begs the question, where is the commonality in these cases? Three are orthopedic. One is non-orthopedic. Two are hip, but that's not why I chose them. What is the commonality? Now, if you were to look at this from through the lens of most surgeons, and since Dr. Angelos is here and a few other surgeons, I better say from the lens of an orthopedic surgeon, they would say this. They would say, in each case, a surgeon performed an intervention. And that intervention was medically appropriate, and the surgeon performed that intervention successfully following modern techniques, guidelines, and so forth. Basically, the surgeon did just what he or she was trained to do with the best training in the country and the most current techniques. And despite that, there was an outcome that was a bit unfavorable.  But, and here's the kicker, surgeon would say, that was unrelated to what I did. That was not related to my surgery. Now, my argument is that the commonality in these cases is actually slightly different, and that's where we're gonna go from here. I would say that in each case, the injury, but there wasn't an injury in any case. One was a, one was an elective total hip. So the surgery led to a physiologic response in the patient that was a contributing, and I would argue perhaps, causative factor to the unfavorable outcome. Yes, even the unfavorable outcome that occurred 18 months later. I wanna make a case to you that the surgery was a contributing or perhaps causative factor to that. And in fact, it's possible, I think it's actually more than possible, that these outcomes, these adverse outcomes that occurred are both predictable and preventable. But not if you only look at it the way I told you the orthopedic surgeon or the surgeon might. And in fact, thinking deeply about this, and understanding, developing, and taking preventative measures may be the next great opportunity for our profession, the surgical profession, the orthopedic profession, the medical profession, because we need to think about more than just the technical aspects of what we've done, but the physiologic aspects and the long lasting physiologic aspects and consequences for what we do. And in fact, if we continue as we are today to do nothing, even though we know these physiologic factors, forces, and outcomes exist, that could certainly have ethical implications. Have I convinced anyone? I convinced David, but probably not for most of you. So, well, I got one more slide before we get to the so, I'm sorry, but if I really wanna dig deep, I would say that our interventions actually induce this physiologic response. And the next frontier in improving patient outcomes will be to understand and predict this. That's where the opportunity is for us. If we choose not to follow it, then the next shoe drops, but the opportunity. So I would choose the opportunity. All right, in order to convince you, let's go back to these four examples and dig just a little deeper. And I promise I won't get too technical. So, this is a patient with ephemeral nail, young, healthy male, involved in a car crash, has ephemeral nail, three days later, is in the ICU and debated with a whiteout on his chest x-ray with ARDS. What happened? This is actually the easiest one for me to explain, but maybe for many of you. We've known for decades, probably 40 plus years about this phenomenon. It's called the second hit phenomenon. And imagine this graph. Don't worry about units or meters or anything, but if the y-axis here is some measure of systemic inflammation within the body and the x-axis is time. The blue curve is what happens when we get injured. We get injured, this car crash in this case, our body has this inflammatory response which builds and then slowly tapers off. When we do surgery, we cause another inflammatory response. We've known this for decades, which builds quickly and then tapers off. And if the sum of those two inflammatory responses crosses some threshold, that's the yellow line, it's a simplistic graph, I recognize that. And where that threshold is may differ from patient to patient. Then the patient's inflammatory response wins out. It doesn't drop down and you start to have complications. If however, we wait until the patient's inflammatory response falls before we do the second intervention, the second hit, the surgery, then that secondary inflammatory response still occurs, but it doesn't cross that threshold and the patient does okay. So in this case, this was a case where we did, we attempted, or in the example, what's called early total care for a multiply injured trauma patient. We took them right to the operating room when we did the surgery they needed and we flipped them over, crossed that threshold to ARDS. Yes, and what would that data be? That data, yeah, it depends on the fracture. Here we're talking about a dramatically injured patient. So yes, on that femur fracture, I can get someone walking right away and if we're gonna look at days, it depends on what your lens is. If your lens is days off work, days to weight bearing, opioids taken or something, they're all different measures. But in this case, when someone, and the problem here was that it wasn't recognized that this patient was, had a major physiologic response to the injury and was still at the top of that phase when the second hit was given. And what happened here in the 1980s and into the mid-90s, early total care was the thing. That was the thing. And there was a lot of literature written in the 80s and 90s that said waiting is bad, waiting is bad, waiting is bad. And waiting was bad because they waited a long time. And during the waiting period, the patient, John Border, a famous general trauma surgery trauma surgeon, coined the term the horizontal crucifixion position, which he said that's how trauma patients are managed in the ICU until they get all their definitive surgery. And being supine arms out for as long as about the worst place for us. And that garnered in then early total care. We would operate right away to get patients chest upright in bed to try to get them out of bed as quickly as possible. And in doing that, and in doing that routinely, that was the mantra all across the world for orthopedic trauma for about a decade. We started then recognizing these things, the second hit, the higher rate of infection if we operated on a fracture when the limb swelling was pretty bad and things. And then what happened now is, and then that led to where we are, that led to then delayed definitive care, which also probably wasn't right for everybody. And where we are now and where we wanna be now is in that case of early appropriate care. Trying to recognize that this patient, whether we're measuring interleukins, measuring interleukins or lactate or something, recognize that this patient isn't quite ready for that femoral nail yet. And we delay it a couple of days. But maybe the next patient is. And that's where we wanna be. But the point of this example and the reason for this example was to bring out the fact from an example we've known about for decades that the patient's physiologic response, not only an injury, but to our intervention can be a contributing factor to kicking them over into adverse outcomes and complications. This one we've also known about for a while. This is a 78 year old hip fracture patient who about a year later broke her other hip. We've known about this for not since the 80s and 80s, but since the, well, mid 90s or so. And what we learned was that when I was an orthopedic resident, I started a prospective randomized series of hip fracture patients. Three hospitals we collected every hip fracture and we did something that had never been done before. We measured the bone density at their lumbar spine and the other hip. And what we discovered was in this cohort of hip fracture patients that their bone density was two standard deviations below age matched controls. This number's not a T score, which is how we think of bone density now. Back then we were measuring Z score. And so these patients have all had osteoporosis when they break their hips. And you know what? The younger they are, the worse it was. For the people in this cohort that were in their 50s, they were three standard deviations before below age matched norms. So here, this is the first time over 20 years ago now that someone had published that patients who have hip fractures have poor bone. But the story got even better. We followed these patients then for a year after their hip fracture and we measured their bone density again. And in that year, they lost 5% of their bone mineral on average. What you expect in a post-menopausal female for natural history studies is about 1%. So this is a bone loss that has accelerated five times over what we normally expect. And this is at the opposite hip. This is in the operative hip, the opposite hip. The only explanation for this is a physiologic effect of the injury and the surgery and the hospitalization on the patient's whole skeleton and whole body. And again, this is over 20 years ago, we learned this. We still aren't getting orthopedic surgeons to give hip fracture patients vitamin D or bisphosphonates or any of that stuff. We're beginning to scratch the surface, but we're not there yet. But we've known this a long time. And so what this research did was it gave us a data to describe a phenomenon we'd already known which we call the hip fracture cycle. People are the fragility fracture cycle. People enter that with low bone mineral density already. They sustain a fracture. They get the fracture cared for, they recover. And the question mark box means nothing else is done for their bone or bone mineral. And as they go around this cycle, their bone mass goes from yellow, which is not good to orange, which is worse to red, which is very bad. And they feed right back to the top of the cycle with another hip fracture. And we know that you're six to 12 times more likely to have a second fracture after you've had a first fragility fracture than you are. Now, there are things we can do about this, right? And in fact, we can. This data, I'll explain it, people don't. But if we were to modify, attempt to modify that physiologic response by just putting patients on any bone active substance, bisphosphonate, prolia, you name it, not counting calcium and vitamin D in this study, it makes a difference. This is a study we did out of claims data, where we took a cohort of patients who had their first fragility fracture, didn't have a diagnosis of osteoporosis, weren't on any bone active substances, and in the claims data, we followed them forward for three years. The incidence of a second fracture in that cohort in three years was about 12% higher than you'd think. But then we looked at the group and saw who got on bone active substances after their first fracture and who didn't. And those that did had a 40% relative risk reduction across all the fracture locations. So here we have a phenomenon where injury and surgery cause a physiologic response in the patient that washes out bone mineral at a rate much faster than it would otherwise. We do nothing. They have a pretty high incidence of secondary fracture. We do something simple, you know, they are these things, some of these are simple. You use something like the NOSAMab, it's a subcutaneous injection every six months. That's pretty easy. And we could reduce their risk of second fracture by 40%. But does this get done? In the US, the most recent data is less than one in five patients with fragility fracture get anything at all. So again, physiologic response, easy to mitigate, doesn't happen. Third example, the total hip replacement patient who you might recall, 18 months or so after their twisted inner garden and broker femur below this. Well, you might know where this is going. This too was related to the physiologic response of this and how it washes out the bone. Amazingly, the magnitude of the impact is higher in a hip replacement patient and a knee replacement patient than it is in the hip fracture patient. Not sure why, but the data shows almost a 18 to 20% bone loss from the contralateral lower extremity in the first 18 to 24 months after a knee replacement. And this is data compiled from a men analysis of 11 studies. So we take an elective patient with some arthritis, we do a hip replacement, their bone washes out or a knee replacement. Hip replacement is the same. About a 15 to 18% loss of bone, okay? But in this group of studies, they gave a bisphosphonate and it blunted the rate of loss, but it did more than that. It blunted the rate of bone loss. It also lowered the rate of revision. And I'll show you some data of multiple studies. And it improved the osteo integration of the prosthesis. And you know, the similar data, I didn't give you a spine example, but similar is true in spine. People with spine surgery, spine fusion lose bone mass.  By the way, the evidence that it does is pretty weak, but people are afraid of it. Spine fusion patients fuse faster, fuse at a higher rate or lower rate of nonunion, and they have a lower rate of loosening of their pedicle screws, their instrumentation. Simple thing done before surgery to help mitigate the post-surgery inflammatory response. This is just another study shown the same thing in hip replacement, and this isn't what I wanted to show you. When you give bisphosphonates, it reduced the rate of revision surgery in four studies. So it's a forest plot. You can see the 95% confidence intervals don't cross unity, seems to be good data. Simple things, things we could have done or could do, but most don't, to blunt a physiologic response. The final thing, and this gets out there a bit while we're on hip replacement, there is so much has gotten better with hip and knee replacement over the years, but there's still a gap. Results are 100% excellent. And what joint surgeons say today is they say, that's something we're calling adverse local tissue reaction. Somebody has pain, pain, pain, never quite goes away after their joint replacement. They just don't get well. They continue to have pain. It goes on for years. We can't see that we do, we work them up. They're not infected. Doesn't appear the implants are loose. Nothing's moving. They appear in the right place. It just must be adverse local tissue reaction. Well, I think adverse local tissue reaction is something else, okay? In the old days, we called it cement disease, polyethylene disease. In the days of metal on metal, hips, it was metallosis. Every one of those was the body's physiologic response to particulate matter in the joint. Macrophages that try to phagocytose the polyethylene, they couldn't do it. They couldn't adjust them. They'd eventually burst in there. Their enzymes are everywhere in the joint there and it increases the inflammation. And we can see data that based on the, there are two, a couple, there are probably more than two, but there's a pro-inflammatory anti-inflammatory phenotype for macrophages. And if you can actually, if you look at the ratio of M1 to M2 in patients, you can see a differential in the rate of this adverse local tissue reaction. So I think what this actually represents is the patient's physiologic response to the hip replacement locally demonstrated. And as we've gotten better with better bearing service, lower particulate wear things, the rate of this still has remained about the same. And I think it might be related to looking at the patient's autoimmune status. There are other things we can look at about their immune system and such. All right, the last example, this is the most fun. And then we'll begin to put it all together and discuss the patient who had the mastectomy and a few months later had a lung mat. It turns out, if you look at both human and mouse data, that there are micrometastatic foci in the lungs in most patients who have breast cancer. And certainly in all the mice and experimental models they have. But the body's immune system has walled those off. I don't know if the immune cells, you know, actually gather in. But anyway, it's not, it's quiescent. And yet something happens at the time of surgery, probably something that causes inflammation, lowers the body's immune system, or the effectiveness of it, that allows these micrometastatic foci to grow up. So they're already there. You do this surgery, the body's inflammatory response kicks in, and then these things can grow. Happens in mouse models, happens in human models, but they exit from their dormant phase and they grow, and they grow large enough they can be detected. They were always there, but the body's physiologic, body's immune system was doing what it needed to do to keep them down. But the surgery pulls them up, allows them to grow. Well, what can you do about that? This is data from, that's what it was in the Harvard system now at Emory, where this is mouse model data, looking at these two peaks of the growth of these micrometastases in mouse breast cancer. And the dark curve is their natural history curve. The other curve is just giving these mice a couple shots of toroidal, catorilac, at the time of their mastectomy. Just a little bit of a non-steroidal anti-inflammatory seemed to do whatever, keep the body's immune system doing what it was supposed to do to keep these metastatic foci in the lungs from growing up. Pretty compelling data. But what about fish oils? That's anti-inflammatory. My wife makes me take them. I don't know about you guys, but an omega-3 fatty acids have been used and studied in a variety of places. Military medicine has done them for years and years. Trauma, colorectal surgery, I'll show you a little bit of data from that, and other things. And they seem to make a difference as well. Here's some data from a study of patients having major colon and rectal surgery. And this is interleukin-6 on the y-axis and time on the x-axis. And the black curve is those, the control subjects and the gray curve is those that just got omega-3 fatty acids, just got fish oil tablets post-operatively, blunted the inflammatory response at least as measured by interleukin-6. The same group, it also shortened staying in the ICU and in the hospital. Only difference between the two groups was the omega-3 fatty acid. Seemed to make a difference in that regard. Well, what about this breast cancer model? Well, and the red line here is mine because this is unpublished communication to me, but that same group now at Emory working on this added omega-3 fatty acids to the catorilac. They were giving these, the mouse breast cancer patients and they eliminated the growth of the micrometastatic foci in the lungs. The combination of catorilac and a little bit of omega-3 fatty acid just wiped it out, somehow taking control or at least blunting the body's physiologic response to that mastectomy. So I'll take us back to where's the commonality in these cases? I think, and I could bring up a lot more examples in other areas of surgery. I brought in a little bit of spine surgery. I could talk about sports, sports surgery. They're probably, if I looked hard I could find plenty of other examples in fields outside orthopedics. I believe this is a generalizable phenomenon. That the patient's physiologic response after surgery, and by the way, the patient's response is not always the same in every patient. It varies from patient to patient. But that response, our surgery leads to a physiologic response, which I believe can cause these adverse outcomes. I think it's probable that they're predictable and preventable and many cases pretty easily preventable or at least mitigated to some extent. And I think that understanding this and developing treatments and testing treatments and thinking about it more deeply is the next great opportunity for our profession. And doing nothing, in my view, with all of this we know, doing nothing at all, acting as, I can say it because I'm one, acting as a surgeon and thinking only about my technical performance, I think raises ethical issues that we're not really doing well for our patients. So as I sort of conclude, I think of where we are, and this is an orthopedic example, but it could probably, if I had more knowledge of other specialties in surgery, I could probably make the same case. I believe we're now reaching what I call the physiologic era in our profession. As we've gone on, and think about hip replacement, as we've gone on over time, our results have improved. But they're kind of reaching an asymptote. And with joints, we've mastered the technique, the surgical approaches, how to do the joint well and things. We've mastered how to fix the implants to the bone so they don't loosen quickly. And that's been improved. When I trained, we were having a lot of loosening. Now we don't. Med allergy has improved. We have better metals. They're not brittle. They don't break. They're closer to the elastic modulus of bone so they last longer. The bone reacts less well or less robustly to them and things. We've learned a lot more about the anatomy, how to approach it, and particularly the anatomy of the joint and how to position the prosthetic components so they're in the optimal functional position for that patient. Based on that, the amount of lumbar you'd load dorsus you have should influence how your hip cup, how your acetabular shell is placed. And we have better bearing surfaces through the polymers and things we do. But yet, we still have this gap. We're not yet at 100%. And I think that a lot of that gap is made up by our not understanding and our not thinking about and our not trying to intervene to understand and mitigate the patient's physiologic response to what we do. That's what I believe. So trying to bring this back to more ethics, although I think there's ethical things throughout it, you know, in the future, will surgeons choose to continue to act like surgeons and to continue to sharpen their focus on the technical aspects of what they do and only focus solely on those aspects? Or will they expand that focus? Will they be willing to listen and think more deeply and expand that focus to optimizing an even more, I think, exciting, individualizing what they do based on what the patient's physiologic response is or may be? Or will they do both? I don't really know. I can tell you, I talk to a lot of orthopedic surgeons. I've been a, I don't know, call it a world ambassador, if you will, for bone health and bone health treatment for a couple of decades. And I have a tough time breaking through to orthopedic surgeons that they ought to care a bit about the patient's bone health or that anything they do may impact negatively on their bone health. So I'm not ridiculously optimistic that the orthopedic profession is gonna turn and choose option two, but I'd love to be wrong. All right, I'd love to hear questions. I'd love to hear discussion, but mostly I thank you for listening to an orthopedic surgeon talk in ways that orthopedic surgeons don't typically talk and maybe try to convince you of something a little bit different. Thank you so much. Thank you for this nice presentation. I think one of the problem is that today physician, particularly surgeon, know very little, not very little, less know about the patient before they come to the hospital, after they go away from the hospital. The advancement of all technical thing has improved our ability to diagnose fast. So the patient comes with MRI without knowing the rest of it, the person goes to the operating room and within a day or two goes to rehab. Some people's sutures are taken out in the rehab, they come back, so inadvertently the physician have really lost the track of a patient or is someone else taking care of them rather than the physician. So the next shoe falls elsewhere and this thing. I give you a simple example about a decade ago, a family of mine was operated for hip fracture and the next day social worker says, where do you want her to go? I said, well, he's still is drowsy, the patient, no, we should plan. Insist to stay in the hospital, next day fever, next day a little bit more and 10 days later died. And so many of the thing is that it's not predicted and the pressure of financial thing from outside and from inside has taken that ability away from because anything you say here is not new, this has been in the past, but you discover it now because now patient go out and the fracture happens outside. We used to have our patient come in, we knew a lot about them, cheap them in there and then when a fracture got better they went home in there. So what, do you think any validity to what I said at the time? I think there's a great deal of validity what you say. You described kind of the journey and the path and the trajectory that surgical and hospital care has been on, so clearly that's valid. I would say that yes, we know less about patients than we used to and yes, perhaps, we see patients less postoperatively than we used to and the handoffs, if I can call them that, aren't always clean, pardon me, and don't always recognize everything that needs to be recognized. But the one thing I will point out is every one of these case examples occurs just the same way, whether I'm the most compassionate, caring surgeon who knows my patients and follows them carefully or not. This effect, the physiologic effect, is independent of whether I'm the classic orthopedist who doesn't like to see people back in the office or whether I know them well. So I think what you're saying is great and I think in these handoffs and care coordination, that's the big challenge for us going forward. We can do better, no question, but I think these are, we need to figure out if we're gonna do this, how to do these things. David, and then here. You were the doctor who could understand where they are and are not. You might very well have a much greater likelihood of appropriately managing expectations about the plans for treatment happening, so I'm not disagreeing. I think it's sort of a physiological response as an adaptive response. In other words, it's something the body does, presumably for a reason, and I pushed you a little bit to ask why in this case we should interfere with that physiology. Reminded of this by something I saw on TV last night, favorite TV show, which is the American experience and the most recent episode was the protagonist. And it was about the draining of the attributes and sort of all the sequelae of Florida has developed that have been disasters and one form or another because they didn't understand the ecosystem. And so my question for you is, do you have a conceptual model for why in this case a physiological, or in these cases a physiological response is not adaptive? And what are the things we should worry about the extent to? I think that's a great point, and it clearly is adaptive, but I think what we have done throughout surgical care is try to change the natural history of things. And this is too. And so, well, yeah, I mean, that was Sir Ashley Cooper. You enter the world through the brim of the pelvis and you exit through the neck of the femur. That was a quote from the late 1800s, yeah. But I think, yeah, but I mean, I think the philosophic and academic discussion that would be so interesting would be, we intervene in natural history with everything we do. At what point is enough enough or what point do we no longer, I don't know? Yeah, I guess. Yeah, all right.  You said through the orthopedist. Maybe you're talking to the wrong audience. Maybe you should be talking to internists.  No, you're exactly right. And in bone health, that's actually what we've done. We've been talking to internists. We've been talking, interestingly, we haven't been, I hope I'm not offending anyone in the room. Well, I'm sure I'm offending someone in the room, but just because I always offend someone in every room I enter. But we've had the toughest time getting in front of the national group of family physicians. They really have not been interested in, and maybe they're interested in engaging in bone health, just not in engaging with an orthopedic society. I've done this on behalf of the American Orthopedic Association. But I think you make a great point that I think that part of me, and I've given versions of this talk to a few different groups. And I tell you, the reception from the non-orthopedist is always more, is always friendlier than from the orthopedist. But maybe it's, maybe it's a Quixotean thing, but I want orthopedists to change their thinking. I really, really want that. And maybe it'll never happen. But I should, up here. So I'm a neurosurgery resident up in Madison, and I see this all through the spine and the fragility fractures through the spine. Yeah, so you're in a place where they're actually doing. Yes, exactly. So Paul Anderson up there always talks a lot about this. Yeah, exactly. So I think in Madison, the patients are then sent to a bone health clinic. And that allows for surgeons to continue to be comfortable in focusing on the technical aspects of things and then consulting out more of the medical management. I think it actually is a very good way of, I don't know if they've published anything in terms of outcomes. There's some data on bone loss. And some of the data that I sort of quoted on fusion rates and pedicle screw loosening was Madison, University of Wisconsin, participated in those multi-center studies, some of them. But I think your point's very good. But I think give me your thoughts as a budding neurosurgeon on how boldly you draw the line between what the surgeon does, knows, and says, and maybe even cares about, and what someone else, in this case, the bone health clinic does. It's in that, that's the gap that I think we ought to try to close a bridge or something. And I think it comes down to culture of your training actually. So for instance, in minor surgical training, we do the majority of the hospice or medical management of our patients. We do all the ICU work. So that comes down from the perspective of my chairman. I think in, for instance, in some of their residencies in our institution, the perioperative management of the operative patient is all hospice or intensivus. So I think maybe it comes down to more of a training culture and how you come out of your residency. I mean, again, neurosurgeons, I'm sure, are kinder than gentler than orthopedists. But you know, you have many orthopedic surgeons who say, yeah, well, we have a bone health clinic here in our department. And yeah, well, they can go to bone health clinic, sure.  No, no, I don't want to do that because I just focus on this, just somebody tell them they can go to bone health clinic if they want. We get a lot of that. Yeah, right here. You're given really nice data about the consequence of not treating fragile bones. So have the national orthopedic organizations provided guidelines that are then disseminated to the residents and to the practicing orthopedic surgeons to do that following surgery.  And guidelines, I mean, we've got guidelines in cardiac surgery that after coronary bypass, you've got to be on aspirin, statins, and beta blockers, and everyone's doing it. I mean, so as you say, it's also the culture and leadership, but it's also, I think, a national leadership as far as guidelines. That's one of the quests we're still on. The American Orthopedic Association certainly does this, but our larger orthopedic organization, I call them a trade organization more than a professional society, the American Academy of Orthopedic Surgeons, won't go there because they really want surgery. They prefer surgeons thinking about surgery rather than these other things. So we haven't been fully successful with the Academy yet. Yeah, I understand that the bone looks better. You didn't show any data on refractures of those patients, but I'm assuming that it's much lower in those treated with. Yeah, I kind of zipped through the, and we have other studies on this too, but the relative risk reduction was 40%. That's a 40% reduction in the relative risk of having a second fracture within the first three years after your first fracture. It varied a little bit by location in the body of the index fracture, but it was not too variable. Yeah, so in terms of just elective replacements, just from a sort of ethics informed consent point of view, I don't think patients are being told that this is a big risk factor in terms of losing bone density around newly replaced bones, and that seems to be an area where you could enforce them to sort of be more conscious about this if they have to disclose it to patients before they have surgery, because I don't think patients are aware of that at all. I don't think anyone's putting that in their surgery. So that's a good point. Yeah, and I think also the criteria for doing these replacements seems to be really changing a lot is I'm seeing much older and frailer patients undergoing elective joint replacements as the need to keep up numbers, increasing pressure to keep up the numbers in large programs. The numbers of the joint replacements in patients under 55 is also going up very rapidly. Yeah. When someone back here, and then I think David had another comment too. The power was with the microphone. Because they need to record it for the thing. So great, great talk. I feel that in some ways we've only heard part one of the talk in that you framed it all as a very individual clinician decision, but we all know that even when it's good, population based evidence, it takes years, 17 years is the number of people tend to quote for things to disseminate. So you're right that of course you gotta change people's individual minds and there's a role for the professional associations in terms of that. But I don't know if it's not enough. So I'd like to hear like your part two of the talk of like giving your extensive experience dealing with this and other orthopedic issues as a chief and national leader. What do you suggest as ways to basically increase the uptake of what you're proposing? Well, don't get me started. There was more to this lecture. I took out some of the possibilities because I thought that got outside what this group would discuss and things. But so let me tell another story. So the American Heart Association has a get with the guidelines program. And that started number of years ago, a few decades ago. How long you suppose it took for the get with the guidelines of program to have 60% penetrance? The American Heart Association would say it took them 17 years. It was a slow, slow process. And that's a program that all of us think has been immensely successful. And so when we started the own the bone program at the American Orthopedic Association, our desire was to try to beat that curve. I don't know if we're gonna do it. We're a decade in now and I don't know that we're gonna do well. But I think changing behaviors is really hard. And changing behaviors in healthcare is even harder. With our current healthcare environment, because we have so many individuals that touch a patient.  If any person who's caring for that patient, therapist, nurse, doctor, doesn't matter, gives them tacit permission to remain in denial, our chances of changing their minds is pretty small. So it makes the task very complex on how to actually get these messages across and make them stick. And I know we've got people in the room that have probably been much more successful in that. We know with bone health that it's only these more intense programs, true bone health programs that really seem to tip the scales. What we don't know yet is how you get surgeons to change. Now the best examples I know of in orthopedics, there may be others about bone. And I know we're supposed to be a generalizable discussion but we're talking about bone. The Southern California group in Kaiser Permanente has been very good at this, probably the best in the country. And they just took their electronic medical record and put a bunch of hard stops in. You can't go anywhere unless you've answered the bone health questions and done these things and stuff. And most other people have been reluctant to do that. The second best example I know is Geisinger. They didn't do quite as many hard stops but they've been a little better at it than most. I'm an otolaryngologist in University of Michigan and I'm thinking about the follow up care, orthopedic surgeon with a total hip patient, even the most conscientious patient-centered orthopedic surgeon. I'm guessing you don't see your total hips a year after they had an operation, they're well healed. Yeah, the most conscientious would probably be two weeks, six weeks, three months, 12 months. Those would be the post-op visits. So the idea that engaging primary care, not because you're shirking your responsibility but because the reality of your interface with the patient is more limited than the person's gonna be with them longitudinally. It makes complete sense to engage primary care. You can be the trigger, the person that raises the issue and mentioning the electronic health record, you know, love-hate relationship with it but flags in it, you know, this person's had a hip fracture and you need to look at bone density would seem logical. Another thing that occurred to me on the total hip patient that fractured below her femoral component, at whatever time point post, in addition to physiologic response, I wonder about how this, maybe there's more octogenarians having total hips. Well, the rest of their body is 80-something and you've created this hip that's fabulous so maybe it's in the counseling too. Undetended consequence is that person's more active than they would have been with a 80-year-old hip that wasn't fractured, maybe in the first place and I wonder about that as a intervention too. Yeah, clearly multifactorial, no question. Hi, Doug. Hi, Emily. I just wanna join in solidarity with you as someone who's working on trying to improve hand hygiene with 150 years of people trying to improve hand hygiene behind me and yet we're still at about 50%. I don't mean to be a downer but I really think this idea about changing behaviors in healthcare providers is the next big frontier of what we need to do in medicine. We've hard stopped our way to a lot of great solutions in medicine and systems-based solutions are all around us and we harness, everyone harnesses the power of the team with the primary care doctor and the social worker that comes and makes the arrangements for you instead of just saying, get out of here. But there's still a lot to be learned and we're all gonna benefit from a lot of cross-platform and interdisciplinary understanding about how to change behaviors and what actually works in changing behaviors and how to sort of control cultures in medicine with our physicians or with everybody involved in order to make it so that what's the right thing to do is just what we do. And I think that you present eloquently about the challenge of doing that. And it's not just about, but I agree, it's not just about breaking through people's hearts and minds. It's about creating an environment that will make people just do the right thing because it's just what we do. So I'd love to hear your thoughts on this. I'll put it a little product. No, we've got EMRs, we can put hard stops in them. But if we do that and people remain tightly entrenched in their subspecialty silos, I operate on the left knee and that's all I do. Don't talk to me about anything. How successful will we be? We won't. I think you might be able to change the way people behave in certain circumstances, but it doesn't change the way people think and it doesn't change the culture of how we approach our jobs that we do. We have to create, I personally think that we have to shift the culture in every, and it's like literally every single orthopedic surgery area or three Southwest in Mitchell, we gotta get them to see that hand hygiene is possible and then they need to start doing it a little bit more and a little bit more and a little bit more. And you gotta get, and this is like, it's like a piece by piece, every single pod or group of community of physicians has to get on board with the right way of doing things. Then the hard stops are just there as backup to help save you if you're gonna make a mistake one day. But you have to, they won't think of the next thing to do. You're in danger of somebody not thinking about the next thing to do if we don't start changing the way that we behave and we culturally think about things. So I don't think hard stop, I think hard stopping is great as a backup, but I don't think it's the way to change people's, you don't change people's minds or behaviors with a hard stop. Okay.  I've been successful because I've intended to turn this into a free for all somehow and I might be getting closer now, bye. The time-honored tradition of incentivizing the desired behaviors is good for now. How you define incentive is pretty broad. This is why we were told, the American Orthopedic Association was told that the American Academy of Family Physicians wouldn't be interested in the on the bone program at Bone Health. They said, our physicians are so enmeshed in meeting the requirements. Most of them are sticks rather than carrots, maybe they're your point, that they can't do something else. We're not gonna ask them and advocate for them to do something more. So incentives can be either direction, but sometimes maybe they're adding or inhibiting things rather than helping things. I think it's a matter of the right audience again. I mean, who's got the most incentive for things to change? The patients and if you get patients demanding better care, then they would get it. I wanna also follow up on incentives. I'm interested in particular in the response of the Orthopedic Association. They think people should be in the operating room and they probably don't think they should be doing this and I think we all know the economics of that. And some of the earlier talks in this series, including one that I gave highlighted how the efficiency in American medicine is heavily focused in specialty care. Specialty care is heavily oriented towards the things that are well reimbursed and orthopedics is actually probably the prime example of that, where you guys make infinitely more money doing interventions than doing the follow-up related to them and also, I mean, almost unprecedentedly high salaries among surgeons even. And so I'm curious how within the profession people think about that. Is this just how it is when we live with it and we don't ask those questions? Is it what you talk about through the end of a long night of drinking after a conference? How much understanding is there? I think it's an awesome question. So I'm gonna give you my bias on part of it and then try to answer a little bit more of it. But I will say I am not speaking for the American Academy of Orthopedic Surgeons when I say this. And I'm on record as I focus my work on the American Orthopedic Association, which is a smaller group of mostly academic orthopedists who care about, who really try to function as a professional society. The Academy, as I said, functions as a trade organization. But the Academy, the reason they don't want docs thinking more about bone health is because they want docs doing that. They wanna keep their focus about how do we preserve the ability, my words, not theirs, for an orthopedic surgeon to do whatever he or she damn well pleases and get paid well for it. And I disagree with that philosophy. I don't think it's healthy for profession. It's certainly not healthy for patients and it's not healthy for our healthcare system. Every orthopedic surgeon who is board certified in this country is a member of the American Academy. Unless there are a few that have eloped at some point. But their membership is in the 40, 50,000 range and that's probably how many. In which decision making? Well, again, I'm giving you my bias. So I haven't sit, obviously, they're not gonna elect me to their board of counselors and I'm not gonna, if I'm gonna speak the way I speak and have it for a decade or so. But so I don't know what deliberations they have, but I do know their actions and what they prioritize and things make it pretty clear that whenever anyone comes to them for a more holistic purpose, the answer is usually a, it's a politicized, no thanks, but it's a no thanks. Alan. I wanna thank you for an extraordinary talk. There are more questions. So far it's been one of the most extraordinary exchanges that we've had in the series between the speaker and the audience. I just thought that what was emerging from some of the questions was a notion that the orthopedic profession should exert its power and control where it had the best opportunity to do so. I'm thinking now of elective surgery rather than trauma and emergencies. And that would be in the preoperative period before taking a patient to the elective surgery. And there, total control would rest in the hands of the surgeon himself or herself. That would be the time to exert as much of the prophylactic and preventive interventions. Even requiring bone mineral densities and the like. The way Geisinger is doing and the way it's going on in California. Whereas once you finish the surgery, then it becomes a free for all. Now you're absolutely right. And I think that's a great point. I think what's going on at Wisconsin and within the North American Spine Society, they're probably the closest to making, for example, pre-op bisphosphonates before slumbar spine fusion, more of a guideline type thing. We've certainly have communicated those for fragility fractures, but I wouldn't say the adoption has been great. I'm Linda Waters. I'm a hand surgeon from California, from Kaiser San Jose, so in the North part. And I just thought it was an excellent talk and very compelling. And we'd be exciting to see more patient outcomes data based on some of the early work that's been shown. And I would just give you my thoughts with the more introduction of URAS, of sending patients home often on the same day with we now feed them Gatorade or something like that the day of surgery, which it would have been unheard of. And we have the physical therapist in the PACU, in the post anesthesia area, actually teaching them how to walk with their new hip and or their new knee. And that, I think a heart stop does change a culture. So just to say that you roll this into the computer, although it's really our foe, it can also be our friend. So I just wanted to give a shout out for that. Thank you. Thank you so much, Douglas, for coming. My pleasure. We're so delighted. Thank you. Thank you.


What's going on, everyone? Sam here with Layton Sportsguards, Rippin' 23. Top Star Wars, Finest Hobby, 8-Box Case Break, number 3, random mini-box style. So what I'm going to do first is open the case and just say which mini-box is which. So I'm going to open it. Label is facing us. So here we go. Box is facing us. Yes, it is. So you can see up top. The front row is going to be boxes 1, 1, 2, 3, 4, 5, 6, 7, 8, back row, 9, 10, 11, 12, 13, 14, 15, 16. So I'll take them out. You can see that's going to be 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16. So there you go. Empty case. See that's what I was saying. It is good value. It is good value. Oh, we're doing Star Wars. Alright, let's do the random now. Bring you guys over to the random. We have our 16 participants and then 16 numbers 1 through 16 representing which number mini-box you're going to get. Roll the dice and go 10 times. 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. Paul M. down to Andy C. 10 times on your boxes. 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. 4 down to 10. Paul M. with 4. Arturo V. with 15. Socrates J. 16. Arturo V. 2. Jeremy B. 8. Paul B. 14. Daryl M. 1. Michael J. 3. Paul B. 9 and 13. Kerry M. 12. John B. 7. That is Paul B. with 6. Jonathan L. 11. Troy H. 5 and Andy C. with 10. So we get these copied over to the randomizer. Thank you, Abdo, for picking up a spot in Pinini 1 Mixer. It's time to 15 to go now. Over halfway sold out on that. Over halfway sold out on the Pinini 1 Mixer. So thank you all there. That's 2020 and 2022. Five boxes each. So there's your random, or your random results. Let's get started on the break, everybody. Here we go. Boxes 1 and 2. Empty. Animes of the Empire on Channel 2.  Let's go. Box number 1. That's number 1. 16. Yes, 16 of them. Alright, mini box number 1. This is Daryl M. Good luck, Daryl. That is a Tales of the Jedi, Hanel. An auto to 199. It's going to be Karen Fukahara as F. Nice one there. Congrats on that. It's Kanata. Task number 2. Yes. Finest Warriors. Yoda, Shibaka, and Beast. What's up? No, I'm just going to give them a bonus together. I got you. Luke Skywalker on the Refractor. That is Zoribless to 199 for On the Aqua. Enfis Nest and Kino Lloyd. Drop of the Hut. That is Finest Moments of Pads Vizsla and Yoda. Finn. Finest Warriors. General Grievous, my guy. And Director Krennic and Dryden Voss. That is Kylo Ren. Nice one there on the Refractor. Green to 99. It's going to be a Snap Wexley and Admiral Ress. Alright, so that'll do it for box 1. Mini box 1, I should say. On to mini box 2 now. DJ Khaled, don't it? What'd she say? Anakin Skywalker. Baylor Ghana and Babu Frick. That is a Finest Warriors of Boba Fett. That is a Gallon Urso Refractor. Fifth Brother and Luke. Got a Finest Moments of Riva. Refractor, Kylo Ren, and Gallon Urso. That is a Finest Warriors, Ken and Jarrus. That is a Purple Auto. Debra Wilson as Sarri Jr. Nice one there. 275. Purple Wave. And General John Doadonna. Enemies of the Empire. Luke Skywalker on the case hit. Nice one there. Congrats Arturo. That's nasty, man. So nasty. Let's go. Congrats on that one. Enemies of the Empire. General John Doadonna. Weasel and Grogu. Alright, thank you Scott. Taking two spots in the next one. Daniel taking a couple of spots on Friday as well. We're down to six to go. On the next, everyone. Six to go. Three and four now. Three and four. Alright, dude. I love Star Wars Finest. This is like, in my opinion, the Star Wars product. Other than master work, maybe? What I look forward to the most every time. Sommage on the Tales of the Jedi. Nice. The Mandalorians. 199 on the teal. Take that all day. Love the big characters with the color. That is huge. That is huge. That is huge. That is huge. That is a Finest Warriors. Qui-Gon. Qui-Gon Jinn. Very cool. Admiral Rattus and Vail Organa. Bo-Katan. Hey. Fiona Shaw as Marva Andor. Nice one there to 199 on the teal auto. Grats on that. Yeah, this is Michael J at number three. I meant to say that. Michael J. This is a Unduly Ezra Bridger Finest moments. It's Cassian Andor. That is going to be to 75 Purple Ray Wave of Melchie. Congrats on that one. Nice one there. Andor's mom. That's cool, man. Base and Luke, of course. That is a refractor of Talodirth. Kylo Ren and Gallon Erso. And number four, we've got um, number four, Paula. Good luck here, Paul. Let's go, Jay Blazin. It's fun, man. Star Wars, this product particularly is awesome. Brian with two spots and Finest and Mr. The Other Brian with a spot down to five. Five to go on the next Star Wars, ladies and gents. Five to go. Thanks, Jay Blazin. Appreciate you, brother. Appreciate you. Mace Windu, Tales of the Jetta. That is a Mark Boone Jr. as Anzar Mulk. Nice one there. Grats on that. Paul M. Finest Warriors. Luke Skywalker. Weasel and Grogu. No sketch yet. We got to hit a sketch here. Oh, is that a gold? I think it's gold. Princess Leoragana. Gold Qui-Gon Jinn. Nice. 49 to 50. God, the gold's a clean this year. 49 to 50 Qui-Gon Jinn. Congrats, Paul. Nice one there, buddy. Take gold all day. Gold of a good character. That is a Finest Moments of Mon Mothma. I love how they incorporated the moments in this year as well. It looks so good. Very similar to a Finest Baseball moments as well, which I really do like. Poe Dameron, Finest Warriors, Crescenton, and Vicks Kelly. That is a Commander Diossi and IG-88. Nice one there. That might be Extended Base right there. Yes, Extended Base, 22. Nice one there. Congrats on that. Paul, very good box for you there, buddy. All right, on to five and six now. Five and six. Ehla Secura, Captain Rex. Captain Rex. Nice one there. Vader, Finest Warriors, Anakin Skywalker, on the Refractor. Gran-Ameril Tarkin. What's up? They sell out all their names over there. Who does? Arkansas. Oh yeah, for sure. We got an Orange. That is Ray. Orange to 25 is Ned B. Nice one there. Congrats on that. Number five is Troy H. Good stuff, Troy. Grats on that, buddy. R2-G2 and John. Hey, thanks, Shane. Picking up a spot. We are down to four to go on the next one, everybody. Four to go. It's got it sold out. We'll rip it next. If it sells out, let's do it. Four to go. Four to go. 80 bucks a spot. Gets you a mini box. Been pretty solid so far. Has been pretty solid. Leet. That is Aerosendula on the Finest Moments. K2SO and Rio de Rens. Finest Warriors, a Bo-Katan. That is Myrna Velasco. It's Torre Doza. Nice one there on the auto. Congrats on that, Troy. Good stuff, buddy. And the Mandalorian. Snap Wexley. The Grand Inquisitor. Nice one there on the Refractor. Armorer and Zorobolis. All right, Paul B. Coming in at number six. First crack out of here, Paul. Let's do it. First crack at this break. Good luck, buddy. That is a Qui-Gon Jinn. Tales of the Jedi Refractor. Finest Warriors of Darth Maul. We've got Aqua of K2SO. 2199. Nice one there, buddy. Congrats on that. 21989, Kylo Ren. Count Dooku, Refractor. T.J. Kelly is a loser, too. We got a gold Kira. Gold Paul of Mary Elizabeth McGlynn as Governor Price. 350 Gold Wave. Nice one there, Paul. Congrats, buddy. Lowest number at auto we've hit so far. Not too shabby. Not too shabby. Weasel and Grogu. Finest Warriors of Kylo Ren. Gold is gold, for sure. What we want, Kenobi. Luminara and Dually Refractor. That is Cassian Endor. Extended Base. Nice one there. So a little shorter printed on the extended base. Kind of how Finest always does it in all sports as well. Troy with spot number four. We are down to three. Three to go, everyone. Three to go in the next Star Wars. Thank you all. That's awesome. Hell yeah. All right. Seven and eight. Seven. John B. Eight is Jeremy B. So John and Jeremy. And before I go on as well, I'm going to do it uniformly. So I'm going to turn them like this because this was the one that was facing us, was not the front. So I'm just going to do it uniformly again. So it's just going to be like that right there. So it'll be, that's how it'll go. So everything's still in order. All the same boxes just flipped around. So good luck. Here we go. That is Padme Amidala. The next one I will flip it around to make sure it is the front. That was my mistake. But same thing basically anyway. I just want to make sure that they're the same. Chewbacca. That is Bo-Katan on the extended base. Nice one there. Make sure that it is fair. Jedi Master Dooku. We've got R2. R2-D2 to 199. Nice one there for the seven spot. John B. Ned B. And Obi-Wan Kanubi. Fisto. Finest Warriors. General Grievous. C-3PO and Han Solo. Finest Warriors with Boba Fett. R2 and Janna. Jabba the Hutt. That is Nazine Contractor as Sinara San. Nice one there. Congrats on that. Number seven. Again, that is John B. K2SO and Rio Durant. Very nice. Very nice. Very nice. On to the next one. Again, three to go in the next one now. Three to go. To go on the next Star Wars. Number eight. I think that was Jeremy if I'm not mistaken. Jeremy B. Yes, Jeremy B. Good luck here Jeremy. So no sketch out of this here. I usually get like one a case. What I've noticed. Gantica. Nice one there. Mandalorian and the Armourer. That is a Finest Warriors of Canon Jarrus. We've got a Green Molly Miller as Agira, 25 of 99. Grats on that one. On the Green Auto. Very solid and Zordi Bliss. Shrulaar's Refractor. Rosteco, Poe Dameron. Moments of the Emperor. Finest Warriors of Finn, Harrison Dula, and Mace Windu. Another gold coming up. That's Luke Skywalker. Gold General Grievous. Nice one there. 47 to 50. That's awesome Jeremy. Congrats buddy. Nice hit for the number eight spot. One of my probably my favorite Star Wars character of all time right there. Love me some General Grievous. Trying to get him on the the thumbnail but I couldn't find like a really good picture that would work so. Come on. Yeah oh well. It's really really nice one there. Congrats on that buddy. Number nine is Paul B and 10 is Andy C. So good luck again Paul and Andy. Good luck again Paul and Andy. Again just doing it uniformly. How we did throughout the last ones. So number nine is Paul. Good luck here Paul. Refractor of Nakil Tana. R2 and Jeanne. There's Finest Warriors, the Mandalorian. What are your thoughts on Matt ordering your kid's meal? Kid Fisto Refractor.  Still do it. Moments of R2-D2. He definitely doesn't feel like he's a man yet. If he's still ordering off the kids menu. 68 of 99 is Riva. That tells you a lot about him. Nice one there on the green. Congrats Paul. Take that. Green Riva.  Finest Warriors of Mace Windu. Rosteco Poe Dameron. Oh Black to 10. That is Dentromiro. Black to 10 is Cary Jones as Cersantin. Nice one there. Congrats on that Paul. Take that all day. Seven of 10 Cersantin. Four is Fortnite skin right there. Yeah. Nice one there Cary Jones. And base. Alright number 10 we've got uh that was Andy. Look Andy. Yeah that'll work for sure Paul. I'm in Yaddle and director Krennic extended base. Yeah I did. That is Darth Vader. What? That is Mon Mothma. Got Otto Harrison Davis as Pommet Warwick. Nice one there. He's got a nice auto. Congrats on that one Andy. Count Dooku. You know what I mean? He's a baby. Finest Warriors of Chewbacca. 2199 is the armor. Nice one there. The armor. He was sleeping in there. What are we doing? Taking a nap. Just taking a nap on camera. That is the fifth brother refractor and base. Alright. What'd you say? Brother. Richard with a spot in number four. Let's go Richard. Down to two. Two to go everyone. Two more spots left on the next one. Two to go. Right on to number uh 11 and 12. Yeah the dust is real in here today. Yeah dude. I'm already clogged up. There we go. Alright number 11. Jonathan Elf. They love Jonathan. Bad. What'd you say? They're just bad. There's Ahsoka Tano. It's on dude. It's over there. No it's still. It's on. It's still going yeah. That thing dude. We need like a five ton unit in here for that. Per santan. This room is just better. We have it running every day dude. Uh body rook. I need it like right under my nose. That's what I should do is put it right below me. That's all that. I should put it right below me. True. It's not a bad idea. Dietra Mira. We got a gold finest warrior. Asajj Ventress 24 of 50. These look really good with color. These look really good with color. Yeah I'll check it out a little bit. It's probably caked. That is finest warriors of array. Tobias Beckett. That is Otto Debra Wilson as Saria Junda or Junda Junda. And nice one there. Not too shabby for you. 11 with Jonathan Elf. Number 12. Karrion. We love Karrion. So we get there right? Yeah. I got this filter. We just can't find the filter. Bale Argana. Green IG 11 and 99.  I'm like where's your air handler? I'm like you know we got this thing. I'm like what's this in the garage right here? It's finest warriors Lay Argana. The air handler and the heater. It's like oh yeah yeah. I'm like well here it is. Oh but where there's no place. I'm like see this little knob right here? Lift that up. What's that right there? He's like oh dude listen to me. Oh god. Lando Count Rizzi and I can imagine dude. Dogs in there. It was just costing. I saw one there on the teal. Harrison Dula. And then you know of course who's walking in there old Mr. Algy himself. Dylan. Char Char Binks. Bro he was destroyed in the house bro. It's miserable. It's miserable all week. That's finest warriors Obi-Wan Calvi. It was unbelievable. I have personally never seen the AC filter. Like there was no air going through that whatsoever. Right. Just winding up. Ooh sketch let's go baby. Here we go. Ochi of Vista and let's go. It's uh what is that? Clone Trooper. Nice one there congrats on that one. That Shaw Strong I believe. Sean Strong. That's sick man. I like that name. So cool on the sketch congrats on that one. Carrie good stuff Carrie we'll get that into a mag. I love the sketches. That's why I that's why you buy Star Wars right there man. Stuff like that. Okay so Greg just returned home from dinner meeting one of the largest commercial insurance companies in the world. One of the top brass was from Texas and a Rangers fan. Okay so 13 and 14 is Paul Paul this is essentially a personal. Brought him a 91 PSA 9 of Pudge that led to grading that lead to grading was and eventually breaks and I took him took over their AV system and pulled you guys live while breaking. Let's go dude. Let's go.  Let's go Greg. Uh Senator Son that is a Christopher Sean as uh Kazuda Siona. Hell yeah Greg appreciate that man. They're probably like who are those two studs?  I told you yeah yeah he was sleeping full on. Vel Sartha. Dueling. General Grievous extended base nice one there Paul. Yep got him. Finest moments of Cyril Karn. Shaka Karn. Finest warriors of Hunter. Oh now look at this look who's coming out here. Oh sure. Don't come in here not on caps. That is a Sabin Wren and 275 that is um Garseff Whip. Nice one there too. 75 purple ray wave and the story is that I didn't have to listen to corporate BS had a great meal didn't have to talk insurance and got what I need and got the hell out of there. That a boy.  That's how you do it right. Feel that man. All right good luck Paul see if you can get you something big in this next one. Tonight in breaks we are all winners absolutely. Senator Lark. And green Moff Gideon 99 of 99 last one stamped nice one there buddy. Assage Ventress. Shorts what up brother. What's up shorts. Refractor of Finn that is John Otsu 199 on the teal. Read it. Read it. Imagine the scene all corporate suits trying to figure out what the Yeah quite the quite the duo you introduced into breaking forward to. Like just knuckleheads. There's the armor. You're sitting there pointing at that mat after you just to watch this and do something God. Some of the faces were priceless. I can imagine. Yeah. Funnest Warriors is so katano. That is a Tim Rose. Admiral Ackbar to 75. Nice one there congrats Paul. Greg next time just have us come to dinner with you. Absolutely. Yeah. There's Fennec Shand and base. Let's go. Kyle got you a sketch. Let's go. Chase. It's a trap. It's a trap. Let's go. William G. Selling us out on the next one. Let's go William. Come on baby. 11 to go rich to go on the last Star Wars everyone. 11 to go on the last Star Wars. All right. Number 15 we have Arturo V and 16 Socrates J. No way. Wait. Refresh real quick. Are you are we live or not? I thought so. Oh no. Oh. He had a super Sabine Ren. Nice. Let's go dude. Damn. Try something new with their kids this weekend. Hell yeah. Appreciate that Greg. Refresher. Go Greg.  Thank you buddy. That is Mace Windu purple to 75 of Poe Dameron. Congrats on that. Yeah Sabine Ren. That's sick man. But I think that was for Jonathan L right there. So congrats Jonathan. That is a the fourth sister. Carl we need some tats down there. Oh yeah. It's not bad actually Jace. It's a pretty good box. Moments BB-8. Loop to 99. Yeah. Loop to 99 is really solid. Yeet yeet. Finest Warriors of Darth Vader. 2199 is Grand Admiral Thrawn. Yeah buddy.  Hell yeah. I can't wait Carl. Yeah it's gonna be dope. Cannot wait dude. Niannup and Otto of Vivian Leroblar as Princess Leo Organa. Nice one there. Congrats on that. Arturo and Socrates J at number 16 rounding us out. We got a gold. Tales of the Jedi path. T-Tano gold Qui-Gon Jinn. Tales of the Jedi 4450. Nice one there. When I showed them the party RPA and what it sold for made them all believers. I guarantee guarantee that made them believers for sure Greg. Donna Warriors Chewbacca. I was gonna say what was it flawless or yeah I thought it was flawless. Yeah something all clear from the docks. My wife told me to go alone and enjoy myself. That's nice of her. That's awesome. General Hux. Oh let's go. Be raging with Carl. Let's go. I'm down. I'm down. Oh man Sabine Red. Let's go. Two more here Socrates. Good luck buddy. That is a Finest Warriors of Yoda. A Grant Feely. Young Luke Skywalker. 83 of 99. Nice one there. Congrats. We should have him come in here one night. We're breaking it. Absolutely. Yeah. Hang out. Unless he's got something else to do. That is a trio of two tubes. Nice one there. Rogue one and base. That will do it for the break. Everybody can't really do a recap. Everything's already packaged up. So thank you all for selling this out. Next one is sold out. So we'll get right into that. Appreciate y'all.


Hi, I'm Matthew coast head dating coach and founder at commitment connection calm and today We're going to talk about how to tell if he likes you So how do you tell if a guy likes you? So let's let's talk about it right now So the first way that you can tell is that he'll keep looking at you So if a guy like looks at you a lot guys look at women that they like and so if he looks at you a lot That's a telltale sign that he likes you The second one is that he'll stand close to you and so a lot of guys will They'll do this totally subconsciously and they'll they'll come over and get near women that they like and They'll want to be near them or around them and and sometimes they aren't even consciously they'll be like Oh, I did that I didn't realize I was doing that and so um because I've I've asked I've talked to guys about this like hey, why'd you get so closer? Oh, I didn't even realize that you like her Don't you? Oh, yeah, I guess I do okay So anyway, the third one is that he'll come up with reasons to talk to you and sometimes these are stupid reasons so if you like a guy and He comes over and starts talking to you Just let him talk to you about whatever stupid thing that he comes up to talk to you about or you know If it's not stupid or whatever just just talk to him, you know have a conversation with him and If you like him then That's a good sign is that he will come over and start talking to you about things So the fourth sign is that he'll want to know more about you so Guys get curious about women that they like and they want to know everything about them They'll want to know about your past they want to know about what you're interested in what your favorite color is, you know Whatever, you know and anything about you though. They'll want to find out. They'll want to know about you They'll just ask you questions about yourself. It's a great indication that a guy likes you The next thing is that He'll talk about the two of you in the future together or he'll make some type of hint at it So a guy that likes a woman will think about them together Like both of them together in the future and so if he's making hints At things that he wants to do with you in the future He might even talk about things that he wants to do And he won't mention you but he'll see like he'll try to gauge what your interest is and so that he can ask you out to those types of things so if you want to go out with him and You know just listen to what he's saying and if he starts talking about something cool I'll be like, oh that sounds really awesome. I'd love to go and do something like that or you know, maybe You know just give him some kind of indication that it's exciting to you and that's interesting to you The next one is he'll seem really happy around you for absolutely no reason and then this this is kind of a funny one But he might just smile, you know, and you'll be like, what are you smiling about?


Hi everyone, welcome to the D5 Render Tips and Tricks series. In this episode, we'll show you how to create an animated LED light strip. Let's first take a look at the final result. Creating an animated LED light strip is actually quite simple, for which the key is in the video material. We need to prepare the video required for the light strip beforehand. We got two videos for you. Here is how they look. Next, open the D5 Scene file for this tutorial. Press the hotkey I to select the material of the light strip, choose video as its material template, and import the prepared video. Once it's loaded, adjust the intensity accordingly. Since we want to create an orange light strip, set the emissive color to orange. Finally, adjust the UV of the video material to a proper value. That's it. That's all for this D5 Tips and Tricks tutorial. Thanks for watching. See you in the next video.


Hello, welcome back to yet another revision video now when it comes to English language paper two Which is going to be your final set of exams in terms of this exam The main challenging aspect is you basically need to do double the work in exactly the same amount of time that you've got for Language paper one you've got read two extracts You've got to compare both extracts of question two and four and of course you also have a fairly challenging question number five We've either got to write a letter speech or articles So mr. Saleh's and I will be presenting our own approaches when it comes to language paper two because we know that Different students have different learning styles and then it's down to you to select which one you prefer So let's go over the language paper two structure now I think question number one is actually quite straightforward It's a multiple choice question and you're asked to usually look at Source aid now from my perspective I think when you are answering this multiple choice question where you're simply shading in the circles You simply just make sure you don't look at the wrong line numbers Keep your answer to just five minutes before you move on. I completely agree with all of that I thought I don't ever stress about question one because just like in paper one the average mark is 3.5 everybody gets nearly all the marks. So just settle into the exam Relax and enjoy Now for question number two, which is your first comparison question So the level of difficulty goes up significantly This question is worth eight marks But you've got work pretty hard for these eight marks because you've got to write a summary of either similarities or differences Between the two texts that you are presented now for question number two, which is a summary My suggestion is aimed to write at least two pill paragraphs where within each paragraph You were comparing both source a and source b either are they similar or are they different? However, given this is a summary question. It's not where you need to talk about language or structure Keep it simple. So you say text one and text two. This is either similar to a difference evidence to support that Then you explain it and link it back and you just do it two times So my channel as you probably know is aimed at people getting the top grade. So my advice is slightly different You have to make your comparisons But I try to train my students to write in P sentences rather than p paragraphs So you'll give the writers perspective and some evidence in the same sentence That means you can make four comparisons instead of two and I recommend four comparisons for all eight marks However, it's only worth eight marks and you have to read both texts for it So there isn't the universe where I would want to do question two before question three because question three You only have to read one text and there are 12 marks So I'm going to go in with question three after question one because I know I'm going to get more marks And there's less reading to do and then when I do question two, I'll already know one text really well Okay, and that leads us to question three now with question number three You only need to look at one extract. It comes as a little bit of a relief Usually you're asked to look at the modern source However, there have been some past paper questions that have asked you to look at language use in the Victorian source Whichever it is just remember that question number three tests your awareness of language things like alliteration Metaposimilies and so on my suggestion for this question as it's worth 12 marks is right three pill paragraphs mentioning within each paragraph a language observation so Again, it's 12 marks. How are you going to school the points? Most students will really like the idea of writing people paragraphs was really familiar to you But when I read exam answers, they often don't get really high grades because students just don't write enough They tend to think a paragraph is like a massive effort and so they don't write many and so instead I reckon I recommend thinking of this as points I need to make 12 separate points in order to get 12 marks You don't need 12 quotations because you might have two interpretations of the same quote, but you need 12 explanations and however many quotations to get to those explanations It's a tough one because you just got a right like crazy In fact, most of my revision would be can I write really fast? I know that sounds mad because it's an English exam, but that's the way it is Now for question number four This is I would argue the most challenging question Yeah, primarily because you've got to compare two sources also talk about writers perspectives and Equally make sure you are mixing in some language and structure points Okay, so this is the question relating to writers perspectives. Are they similar? Are they different now for this question? My suggestion would be aim to write Three comparison pill paragraphs where in your opening point you're talking about both sources in your evidence You're adding evidence from both sources in your explanation You're talking about either language or structural observations from both sources before you link back to the question referring back to both sources You do this times three So that is super advice and again, I think that's More easy to follow than the advice I'm going to give you so if you are after the very top grades You've got to think well, there are 16 marks here. How am I going to get all 16 marks? You you need to come up with all those explanations again, and that's really really hard When I pulled my YouTube viewers I gave them an exam answer that has already been marked and I asked them to give it a mark between nine ten Eleven and twelve marks.  It's because it's really difficult to mark So if only fourteen percent of viewers can work out what's going to get the marks You really need a method and I've racked my brains to find a method and I'm embarrassed I am embarrassed by this method, but it's this On average, whatever grade you're writing You'll get one mark for every 26 words you write and I've tested that with loads of answers And so if I got 16 marks, I've got to write 26 words 16 times try to put my explanations into each 26 words It's mad, but the more you write the more points you get So on balance, it's probably easier to think about just doing it in paragraphs Now for question number five, which is worth half of the overall papers marks You were asked to write a piece of non-fiction writing It's either going to be a letter, an article or a speech Of course, in addition to making sure you allocate half of the exam time to this Okay, so minimum 45 to 50 minutes on this My approach is firstly make sure you're clear on the form of each When it comes to letter, make sure you start with your address, date, dare You write your main points, right? So make sure you write three main points in support of your perspective Two counterarguments before you finish off by concluding your discussion And then ending with kind regards, your name and surname When it comes to an article, start off with a headline Then your opening paragraph should be setting out your argument Then you have your first upheading, which introduces your main points So at least three main points for your perspective Then the second stopheading with two points against your perspective So counterarguments before you have your concluding discussion That's for an article However, for a speech, when it comes to speech, make sure you show an awareness of your audience Start them off with either ladies and gentlemen If it's just a general grown-up audience or fellow students If you're writing your speech for other students' new year group Then a speech is actually quite simple Because you just have your first paragraph setting up your discussion Then your three main points in support of your perspective Two counterpoints while people disagree with you Before you finish off by thanking your audience Now, of course, within all three, so letter, article, speech Make sure you include anecdotes, made-up examples And statistics I'm exhausted with that So I agree with all of that But I know I do... This is genuine I know if I go into the exam, I'll forget that And so I have to come up with a simpler method It's not necessarily a better method, but The kind of learner I am I know I need something simple that's just going to help me So Whatever the style of writing is Almost doesn't matter The examiners don't really care Because the mark scheme is the same, whichever one of those you do So you only need to think about getting the right form of A genre here, really in your first line Your first line will tell you whether it's a speech or a letter And that's the only kind of decoration you need to do To your writing to say, I'm doing this particular genre The rest of it is just I'm just going to persuade you I'm just going to try and persuade you as best as possible So, I've got Mad Fathers Crotch These are 15 different persuasive techniques That top persuasive writers use Metaphor Alliteration Direct Address Facts Anecdote Triplets Hyperbole Emotive language Repetition Similarly Contrasting pairs Where one thing is like this, but the other thing is like that Rhetorical question Opinion Contrasting pairs Well, I've done that already Creating an enemy And humour I practice this in 15 minutes Because there are only 15 of those So I sit down with the title And I'll go, right, first minute I'm going to write as much as I can I must include Metaphor Next minute I'm going to write as much as I can But I must include Alliteration And so on After 15 minutes I've got something that's packed Full of persuasive techniques First time I do that It's not so awesome Because It's difficult to write about the same thing In this artificial order But once I've done that like three times Using these techniques just becomes second nature And three times is 45 minutes revision That 45 minutes revision Will add at least one grade Probably two Get cracking Check out your mad vultures CROCHE We done Yeah, man That was just so hard What a day, man You are so stressy I just don't know how I cope with this But, hang on What? In a real pleasure You can't hear it Thank you for watching, guys And I hope you enjoyed this video Now, if you are curious To see the video that Mrs. Halle's and I made Looking at English language Paper one Make sure you head over to his channel Where we're going to be going over that together