Happy Monday everybody. So it is a brand new week. It is Monday. It is 5 a.m. I will never get used to this time for placements. It's a brand new week. I'm in today. I'm off tomorrow. I've got our live Q&A vlog tomorrow. By the time you watch this it will be posted and up and have a look at that because I'm fingers crossed it's gonna be a good one. And then Wednesday, Thursday I'm back on placement and then I'm off Friday, Saturday, Sunday, Monday. Long weekend for the Easter holidays. I know. I've always worked the Easter holidays or I've been on placement so it's gonna be really nice to have four days off over the Easter holidays finally. So yeah, so it's gonna be really nice. So let's see how today goes and I shall see you all later on. So we are now on week four of placement and I've got five weeks left. This week has been really busy. So this week I've done my usual drug rounds. I've helped patients get ready. I've been assisting at mealtimes. I have done no wound dressings this time. I've done some catheters and fluid balances. I've done some assessments. I've done discharge forms. All the usual things that I've done before and mentioned previously in my previous vlogs but there's been a few things that have happened this week that I really want to talk about in this particular vlog. So this week on placement I've had a semi-newish mentor because my current mentor has been on holiday and then they've been off sick and this is something that might happen to you if you're out on placement. You might have a swap of mentor and you might get a little bit disheartened by it but please don't be. It's just one of those things that happen. So my new mentor is amazing. She's so fantastic. She's knowledgeable. She loves teaching students and you can see that. You can see the passion shining her when she's speaking and when she's teaching me things and when she's showing me things and she's always like come and do this, come and do that. She's just absolutely fantastic. I cannot fault her at all. She's amazing. So the first thing that I did was I actually helped fill out a DATEX incident report. Something happened on placement not with me but it was to do with the patient and the relatives and things and DATEX incident form had to be put in because of it and I've never actually done this before. I've heard people do it and some things have happened in past placements and we've had to do it but I've never actually helped fill it out so I sat with one of the nurses and I helped her fill it out because it was all on the computer system and I'm quite a fast type. She was like can you help me with this? I was like okay let's do it. So I did that and it was really interesting to see how you fill out a DATEX incident report and all of the information that goes on that and how important it is to be clear and concise and things like that on the reports and yeah so that was really interesting. That's one thing that I did and anything I do that's new is absolutely amazing and I love it. The next thing that happened so I can't go into too much detail about this particular incident because of confidentiality but I'm just going to try and work around it so that I'm not giving away confidentiality but I want to tell you the importance of what this is and raise some awareness around it just in case it happens to you when you're out in placement. So sometimes you will have patients or a patient or many patients. I think this is quite a common thing that happens across the board. I've seen that happen a few times but sometimes a patient will be under your care in the hospital setting or care home setting wherever you are wherever you're based and they need a higher level of care when they are discharged from your services. So they will put in a package of care referral form, they will get the social workers involved, they'll get the CCGs for continuing health care, they'll be involved all of that to try and get funding for this patient or to see if this patient is eligible for funding to get carers come home or if they need to go into a care home or something like that. So we had a patient who needed that extra level of care so the social workers did all the bits and things and they decided that okay this patient needs some help but it's not to the point where they need to go into a nursing home or a care home. So this patient needed just the extra level of care so they wanted to put a package of care in place so to increase carers to the house visits to help them in their own home and this is what the patient wanted. The patient didn't want to go into a care home. The patient wanted to stay at home in a own little home and the social workers, OTs, physios, everybody that's assessing this patient also agreed. So they just wanted some extra help to go into the home with their medications, things like that and that was fine. However, sometimes the relatives see a completely different side of things and they sort of worry and I think they get a bit anxious about this and they I mean they just want the best for their relative. So from their point of view, they might want whichever patient you've got that this might happen to. They might want this particular relative to go into a nursing home or to go into a care home and not because they want to sell a house or financial is nothing to do with that or anything. Sometimes they just want the best care possible because from their point of view they're seeing their relative deteriorate and they need that extra help and they're panicking because what if something happens when they're at home alone when the carers aren't there and there's nobody there to help. So they're worried about that side of things. So they will be sometimes very anxious, very angry. They will want answers. They'll want to know why you've made that decision. They will want to know every single detail or how you've come to that decision and no matter what you say, they're going to be angry and it's because they love their relative and they want that care. It's nothing else. I mean, sometimes there are safeguarding things involved and you have to get the safeguarding team because sometimes there is an ulterior motive behind it. So you have to watch out for those warning signs. But in this case, I don't think it was a safeguarding. So the relatives were just worried, I think, and understandably as well. And so we had to deal with that. We had to deal with the families and we had to calm down the family. We had to speak with the families. Make sure those communication skills that we've learned at university are in place to keep it calm, keep it relaxed and reassure that patient's family member. But unfortunately, in this particular instance, the family members really weren't happy. They're really angry about it. But everything that from what I could see from the nurses side, social workers, physios, OTs, assessment, everything has been done is been fantastic. So I'm not too sure where that's going to go. But just to make you aware, you might get that situation. So you might get families and relatives angry with the decision that you've made or the doctors made or anybody that's involved in that care of that patient has been made.  Luckily, I wasn't on the back end of it. I was just sat there and I sort of witnessed it. I had to do the reassuring the patient afterwards and stuff because the patient got quite upset about it afterwards. I had to reassure that patient and be there for them. And I did get a little bit worried about it because the patient was so upset about some things that had been said. I did get worried about it. So I had to report back to my mentor. I actually reported it to three different people because I wasn't happy with what was going on and I was really a little bit upset myself and I went home thinking about this particular patient. So I just wanted to clarify some things and put my sort of point across as well to see what they would say. But everything's fine and everything's been documented or everything in the notes has been documented. And luckily, it's all right. We're all right. Everything's settled and it's fine. But I just wanted to make you aware that sometimes you will have somebody upset and you're going to have to be that person that reassures them and sort of double checks everything out and make sure everything safe and sound and all of that jazz. I hope that makes sense. I'm trying to not say as much because of confidentiality like I said. So I hope it makes sense and I hope you can get something from that and just make you aware that you might deal with something like that whilst you're out on placement without even realizing it. If you have had a situation happen and you've dealt with it, comment below. Let me know. See what sort of things you did out in practice. It'd be really interesting to see what sort of things everybody else does. So let me know. And then the final thing I want to speak to you about is medication errors because yesterday, I'm going to say this because I am an open honest. That's the person I am. I am open and honest and I want people to be aware of what they're doing with medications because we are student nurses. We can still be thrown off this course for doing errors even though we are protected in a certain way. But if we make a big, big mistake, we're going to be off. So yesterday, I was doing a drug round with my mentor and I had in where I work is all paper based. There's no computer system. I've always worked on computer systems. So the whole paper system sort of threw me. So I had my paper, I went through the drugs for a particular patient, opened the meds cupboard because every patient on this particular ward has their own cupboard with their very own drugs in. Whereas on other wards, we've had a big trolley with every single drug and you just take whatever you need for each patient. But each patient has their own medications in their own cupboard and we just have the sheet to go by. So I was going through the sheet and I was like, okay, so this patient needs this, this, this, okay, open the cupboard. I was like, hang on. None of these drugs are in the cupboard. What's going on? This is really strange. So then I looked at the chart again. I was like, yeah, this drug, this drug, looked in the cupboard again. I was like, there's nothing here. And then I looked at my mentor's like, there's nothing here. I don't know what's going on. So then when I rechecked my drug charts, you know, the five R's, right patient, number one, was it the right patient? No. On my paper, it was a different patient. So I was looking at different patients drug charts, but in the cupboard, obviously it's not going to correspond because it's different medications, different patients. And I was just like, oh my God. And I was genuinely, genuinely mortified. Luckily nothing happened. I didn't give any medication. I didn't get any medication ready. But I went through my five R's to check, okay, right patient, let's check the drug chart. Name is a different name. Oh my God. So luckily, I think the way this set particular setting works well because the patient has her own drug cupboard and they have their own drug chart. So in this instance, it was alright. But imagine if I was on a hospital ward where you've got the big trolleys full of every medication, I would have been getting all those medications out the trolley ready to give to the patient. And then I've just dispensed those medications then. So technically that would have been a drug error if that was back on a ward because I've dispensed all of those medications and I would have had to chuck them because that wasn't for that patient. So luckily nothing happened. There was nothing that happened. I didn't give any medications. I've managed to save that drug error from actually happening. But I wanted to just be open and honest about it in a vlog and it's really opened my eyes to actually how simple it is to make a simple, simple drug error. And I wasn't even in a rush. We went in a rush. We were calm. It was quiet. There was no distractions and just something so simple like that. I just went over my head and it's maybe really panic now. So I am from next week onwards. I'm going to be going through my five hours. Okay. First patient documentation. Is it the right patient? Yes. Okay. Drugs. Drug chart. Is it the right patient? Yes. Check the wristband. I mean we check the wristbands anyway. And I think if something like that happened on the ward, naturally I would have dispensed the medication. I would have checked the patient's wristband and then I would have realised actually this isn't corresponding to the patient notes to the patient. And that's the point. So I think that would have been prevented. But I just wanted to make it aware to you that it's really, really easy to make a drug error.  I'm really organised and all of that. So if that can happen to me, it can happen to anybody. And it was, it felt horrendous. I mean nothing even happened. But it felt horrendous for me to even think that I could have made that mistake and that could have gone horribly, horribly wrong. And I could have been up against the NMC. I'm a pin could have been gone before I've even got it. I'm brief. So just learning from that and reflecting upon that I need to be more vigilant and I need to be checking, double checking, triple checking. And yeah, and be open and honest about it if something does happen in the future. But nothing's going to happen because I'm aware of it now. More aware of it than I was before. What else happened out on placement? I think that was it. That's the three main points that sort of come to light these three days. But it's been so, so busy. We've had admissions, we've had discharges, we've had all of the events go on that's happened. Or I did a social effort. I did a social worker referral form. I have never done a social worker referral before. So it was really interesting to do that social worker referral. And it was just a new thing again, a new piece of documentation that I haven't done that I can put in my book as an extra thing that I've done. I love it when I do something new as a student nurse. It's amazing. So that is it from me. I shall see you all next week. Have an amazing week. I hope you've had a great bank holiday and see you next week.


Hello and welcome back to the craft box my name is Brent and today we are doing some more stardew valley I found out that if you you can click these things and then you can make things happen apparently but we're not going to do that now let us jump right into where we left off last time which was in fact somewhere if it could load that'd be great um day 23 in fact 23 of spring high rows high sts welcome how are you today how's it going how's it going um what's this so we've got deep in the mine and raising animals okay um we're the report for tomorrow it is going to be flower dance that is correct we get to dance with people actually we probably won't because we have no friends it's too real way too real um i'm just gonna turn this down a bit i don't know if it's too loud but we're gonna turn it down anyway um you're good you woke up two hours ago oh my gosh what's our males dear Brent tomorrow we're getting together for the flower dance if you can find a partner you might want to even participate in the dance yourself there's a little clearing beyond the forest west of town where we hold the dance arrived between three a.m nine a.m sorry and two p.m if you're interested three a.m yeah let's just arrive at like three a.m that makes complete sense we got some deaf adults that's cute um let's put these in our gardening chest not this chest we will get this boy out um so we're not planting anything new at the moment just because um yeah it's nearly the end of the season we don't want things to die so we're kind of just going to let these things grow real quick here oh we got some strawberry some strawberry strawberry strawberry really good strawberry um and then the beans good there we go fantastic look at that okay um so what do we want to do today i don't know what i didn't check our luck so let's quickly go and do that that'll depend what we do today um fortune della uh mildly perturbed will not be on our side okay well let's do some clearing of the farm i think is probably the best idea this one is the random chest let's go for this this and probably also need a pickaxe probably a good idea let's um start clearing out some of these tree things because they're annoying and also what is good boop boop boop boop boop boop boop there we go fell down good job good job i love when it falls down it's just so great watching it fall down i don't know why but it just gives me so much satisfaction when it just falls like look look it's about to fall right now now it just pops everywhere i just love it i love it i love that so much it's so fun so cool so so cool um okay let's clear out some of this let's clear out some of these gotta make out farm tidy we've got to be tidy boys um we should probably kill our out some of this mess as well probably a good idea even though there's grass and grass is like kind of useful we're going to do it anyway because we need to make a clear clear path we just need to clear everything up just be clear here so much so much grass so much grass just everywhere just all the places okay okay we'll just do with that we'll destroy some of these rocks we need to go and water the cat as well we need to go and water kitty where's our watering can always forget to water kitty good job friend good job um we did get our bag upgrade which is great i was about to say we could probably go and do that if we didn't already but we did so that's always good let's not go into the house um good job hello kitty hello kitty um and well what are you what are you hi kitty hi hi they can't see you but hi um let's just clear this spot as well let kitty have a bit of space kitty's got to have a bit of space um we'll fill up this fill up the watering can and then we should be good how many crows have used to get away you haven't encountered any crows yet well that's good um should we go into town i think we should go into town let's quickly just drop off some of these boys um we'll bring our scythe just in case and we will do this um you're kind of glad you're playing this instead of was because it's obviously really like this game it's nice to see you enjoying yourself doing something different yeah i i do enjoy this game it's really fun and it's just i don't know i just enjoy playing something different for a bit i know not many people like me playing things differently but i enjoy playing this a bit sometimes only only sometimes it kind of just relaxes me a bit more you know just something nice to play that isn't whizz all the time because whizz all the time can get a bit boring all the time um let's see how want to joji cola oh my gosh we even have some of that eveline eveline's the grandma is that eveline i think that was eveline there we go and get out of joji cola we got a whole bunch of that we got a whole bunch of joji cola we got lots of joji cola at home because we love it we love it so much it gives so much energy even though it's apparently trash okay i think that's in this chest here correct we good we good whereas i think eveline is the old lady i'm pretty sure hi hailey how are you today that's cute good job um is she still in here no we do not want to drink joji cola oh is that joji cola i requested i really appreciate it let's see here's why are you good job look at that that was the probably the easiest one we've done 75 gold just for that fantastic fantastic look at that so so quick and easy um i think as a content creator with a somewhat specific audience expecting a certain game type of video stream or whatever can be exhausting because i imagine it gets boring easily i wouldn't say boring it just gets um i wouldn't say boring just a bit um kind of focused a bit too focused and i don't have a long focus my voice i don't have a long focus sometimes so it's kind of nice just to not play whiz all the time or pirate all the time um which is also why i play now boring because i don't people don't really watch that but i enjoy playing it so as long as i enjoy playing it i'm gonna keep doing it because at the end of the day this is technically still a hobby for me um and i only do it because i enjoy it what do you have today um i think really much do you know things are a bit boring in town today oh look let's let's look at the yoga we we should join some of this i think we should join the yoga class can we join the yoga class that'd be cool can we okay okay then we won't we won't join the yoga class that's fine um what do we want to do i don't even know what we want to do today i kind of just want to do nothing today um i think you should just do whatever makes you happy you can't please everyone right and at the end of the day as long as you're happy and enjoying yourself then people will support you exactly exactly the reason why i play this game exactly also because it's just such a good way to escape from everything hi hi kiddos hi kiddos who do you think do you think anybody's gonna want to dance with us at the flower dance tomorrow i don't think so i'm pretty sure we have like no friends but that's fun um what are our relationships that's a great question um not really good who's like who's like the best evergale is pretty good robin's pretty good i think we should maybe we should go for evergale who's evergale what does she like she surely loves surely she loves these dandelions i don't even know where everland i don't even know where um what am i evergale even loves it she she's pierced or isn't she she is good job good job brink you do know where she lives where she goes i don't know let's find out let's find out looks like your relationships are all yep pretty much pretty much me as well pretty much okay to be closer to what i don't think we did is she in here who's this that's caroline your ridden sweetie okay that's a bit weird where does evergale go whoa what is this why do we have like a i don't know this was here jeez peah you have such a big shop for such a small area jeez it's like the TARDIS you can fit so much more on the inside um louis you've just been there for like literally hours just standing there good job um where does evergale go quickly look up evergale i need to figure out where she is i want to give her a flower maybe she'll dance with us tomorrow i doubt it but you never know um evergale spring um what time is it it's like 4 20 um 4 30 she hits home so we'll catch her when she gets home we'll catch her when she gets home she's probably over here right over here yep this is hi evergale look we can no we don't want to eat we want a gift no i want to gift it to evergale you brought me a present thanks did it not really give her i didn't give it to her maybe she didn't like it maybe she didn't like it and it didn't even raise our hearts dammit dammit dammit you're in a competitive overwatch you won congrats congrats i'm winning she didn't like my present maybe hailey will hailey do you appreciate my present hailey hailey hailey hailey she appreciated my present she took it and she also gasped i'm sure that's a good sign right i think i think we're basically like married at this point where is she where do we even i had two flowers okay that makes sense i just thought we had one but i probably had two wouldn't be surprised i just don't look at numbers numbers are not even thing we're gonna go to the pub we're gonna go to the pub because pubs are great pubs are great we've gone enjoy our time before we get before we become desperately alone tomorrow at the flower dance because we we have no friends apparently hi everybody i'm here don't worry don't worry i have arrived um while Brent playing the field yep exactly um not this one let's see if i can actually do good at this journey of the prairie king um i'm not really good at this um at all i'm i really i suck i suck at this drink your sorrows away exactly um i tried okay i'm really bad at this like i'm not i if i'm using like arrow keys i want to move which is like really bad and it's not arrow keys to move it's a good job okay good job Brent we'll try one more time oh a game over okay well we'll quit i'm bad the walking noise is so cute it sounds like kiss good it it does it is great it is great hi shane how are you wow that's true fine we'll go away we need a beer we need a beer i'm sorry we just need a beer we we're gonna take a break and just drink our sorrows away everyone hates us actually let's change the music we can't drink to this music um don't don't don't what one's good i think i kind of like the what's this one one no no weird um playful no that one yeah that one's cool i like that one it's so relaxing um let's um head over here and drink let's go over to the games area because i can play pool and those games and i'm really good at it said no one ever and drink our drink our beer and yes oh look at us we're getting drunk tipsy minus one speed good job but we got how do we get energy i don't even understand that we get energy but we're also tipsy whatever um hi liz welcome how are you today how are you we're like blinking red i'm pretty sure that is not a side effect of drinking beer from experience pretty sure it isn't but you know what we're gonna go with it let's um walk home it might take us a while um yeah hi liz how are you today how is you going today we could like go for the slow slow walk home can we get any deaf adults that'll be cute that'll be fun no okay that's fine that's fine we won't you want to give way entire stream and you got a new mount congrats i saw that new mount i'm actually i actually think it looks kind of cool well i get it maybe not but um it looks really cool i might try and get it that'd be kind of cool um okay let's go to bed tomorrow is the fear tomorrow's the fear literally so happy i can imagine we got little three farming look at that we got one ho proficiency yep okay good job good job um and one watering can proficiency i don't know how what that means but sure thing um we can craft the beer house we can do speed grow and we can cook farmer's lunch that's a lot that's pretty luck that's pretty luck


We are going to turn over to our next presentation. I am particularly excited to welcome George Ashton III with LISC, and he is going to give us a presentation, and then after that we are going to do some Q&A with him. So please, as you are listening, drop your questions into the chat, and we will pull some of those forward and do a little bit of Q&A with him following his presentation. So I am going to turn it over to George. Thank you. Hello. My name is George Ashton. I am the President of LISC Fund Management. Here today to talk to you about a topic that I am very passionate about, leveraging private capital to create resilient BIPOC businesses. BIPOC businesses have struggled to close the racial wealth gap. We have seen a pretty impressive clip of new businesses start in black and brown communities over the last 10 years, 79% growth reaching 11.1 million between 2007 and 2017. So it is not the number of businesses that are the issue, but the question is, why aren't we seeing the outcomes that we want to see with respect to employment and economic opportunity that would close the racial wealth gap? In fact, the racial wealth gap has gotten worse over the last 10 years. And as we dig in deeper, we look at these businesses, we see that the number of jobs that they create, the revenue of the business and how often the businesses actually shudder are all signs that these businesses are not really being nurtured and growing in a scalable way to provide income and employment opportunities to their communities. And so how do we empower these businesses that do start, especially these entrepreneurs that have made it work for three to five years, how do we empower them to grow their businesses and to create the changes we want to see in their communities? If we can actually close this gap, the racial wealth gap, it means a lot of great things for the entire country, increases in GDP, millions of jobs, increases in revenue for the black businesses, increases in wealth for the black amount of communities. So the goal at the end of the rainbow is incredible, but the question is how do we get there? It's always nice that you talk about these sort of high-level theoretical problems that we have to actually zoom in and think about how real they are for entrepreneurs. And here we have an example of Zazz, which is a restaurant in the northeast. And it's a restaurant that's been around for nine years. And so you know that the entrepreneur has been battle-tested and is looking for capital to actually expand his business. And the fact of the matter is normally this capital would come from friends and family, so folks that have seen his success and believe in him. But what do you do if your friends and family network doesn't have that capital? And that's what's really hard for getting these businesses to get past the early growth stage. And we know Zazz is not alone. There are millions of BIPOC businesses that want to grow and help their communities, but struggle to find this capital. Grants are often too small to really make significant long-term business investments. And debt is an encumbrance on the entire business. And so many entrepreneurs, especially those who are risk-averse, will not take on growth opportunities with debt. So it's really a hole in the finance ecosystem that we need to fill. What does it mean to be resilient? How do we get these businesses to actually solve the racial wealth gap? It means things like the following, growing in size and number of employees, revenue and customer base. It means diversifying into multiple business lines. In any business's lifespan, there are tough periods. What really helps businesses sustain through those periods is having multiple business lines so that when one is not doing well, another one may be doing very well. Also, entering industries with higher barriers to entry. And that creates more value in the company and more predictability of profits and profit margins going forward. These are all aspects of developing resilient businesses for any population. And what's critical to these is that growth capital that's missing from the ecosystem of black and brown businesses. A little bit about LISC. Really quickly, LISC is a national organization with 37 local offices around the country. We've been doing investing for 40 years, AA rated, and really invest in all parts of the community ecosystem. And so within small business in particular, our track record has been impressive as of late because of all of the response to COVID and the desires for racial equity investing as well. So a lot of lending and grants that we've done to businesses, really they either help them get through the COVID recovery or to help them sustain their operations for other issues. But in all of this, we now need to figure out how we go from helping these businesses sustain their current models to helping them grow and become more resilient. So here are the core elements of our program. So we have patient financing. We designed a product that we think is very equity-like and is patient and allows the entrepreneur to take risk and grow their business. We combine that with technical assistance to help the business with its professional needs, supply chain logistics, et cetera. And then of course, we design the product so that hopefully the success of the business creates an investor track record so that future investors will want to invest in this business and sort of help continue to scale. The product is a form of growth capital that we actually designed that takes recoverable grants and structures them as investments into the business. We don't take ownership of the business and the size of the investments are really tailored to the business plan that we're shown from the business. What's important about these business plans is they actually offer new employment opportunities for the community itself. So the product actually is the financing of a business plan that will grow the business and make it more resilient. And if the plan works out and does really well, then we actually end up, the businesses are paying back all of the money and potentially some upside. And if the business plan doesn't succeed, then we write off the investment. And this really looks like equity from a risk-sharing perspective. And so we think that entrepreneurs will take this money and utilize it to grow their businesses effectively and create the jobs we want to see in their communities. The types of businesses that we're going after, we're not necessarily going after start-ups, although it could be applied to that, but we're really looking for those businesses that have been around for two to five years, have a few employees, and have an idea for how they want to scale their business and grow it. We think these entrepreneurs are often overlooked because people think about entrepreneurship as starting new businesses. We also like community-based businesses because those are businesses that have a local presence, which is beneficial to the community, but also create local jobs and accessible jobs for the community as well. Some of the benefits we think of the business is that for this product, there are no payments until the business actually achieves its growth plan. Investors share that risk. The capital transaction creates a track record for the business, so they can show that to other investors. There's no collateral of personal guarantees required. We offer technical assistance, and then there's a finite repayment period. We don't take ownership in the company. We don't have to push the company to have some sort of sale or exit. It's really just paid back over time as the business succeeds. We also spend a lot of time thinking about how we help the business to succeed, so giving them money is a large part of that equation, but also making sure they have a support system around them. And all of the cities in which we're launching this concept, we are partnering with local TA networks through our economic development group to make sure that those businesses have the support they need to grow. So that was a short presentation on the topic of how to make resilient BIPOC businesses with private capital. We're excited about this journey and how it will evolve and what it will mean to these communities in the future. Thank you, George. I think we're going to have you pop on camera here with us at the moment, and I believe we have a few questions for you. Can you hear me? I can. Hi. Welcome. Great. How are you doing today? Great. Excellent. First question that I have for you is thinking about from multiple sides. You talked about multiple sides of the equations here from the investor side. What factors should investors consider when determining whether the investment is worth the risk and thinking about also risk? Risk can be defined in many ways. So what would you say about that? Yeah, I'd say it's a matching mechanism. So you need to match the risk of your investment with your expectations for getting your money back or end in some, right? So there are different types of investors in the marketplace from grant investors that are investing in the impact. So they have single bottom line, but it's all impact, right? And they don't want their money back all the way through the other single bottom line, which is people who just want the investment return. And so at risk we find from foundations and corporations and institutions and banks and insurance companies all the way through family offices that you can find differences in what folks are looking for. For this particular product, we are in the early stages of establishing an investment thesis and asset class and investing in community-based businesses this way. It's critical to changing the makeup of our country and fixing the problems in our country. So for me, it's not about whether or not we know what to do. It's whether we have the courage to do it. So we are raising mostly grant money for this first initial sort of go at it in terms of investing into this product and into this asset class with the hopes, of course, of finding the algorithm for performance that allows us to make the case for people who have less Chris tolerance to then begin to be a part of the investment and to scale it over time to make it a national solution for community-based businesses. But it's a great question. You have to match it to your expectations. Excellent. Thank you. And I think just a quick follow on question that's coming in through the chat, just where did you find the grant capital to fund those recoverable grants? Yeah, so we are finding it and have found it at corporate players, foundations, philanthropic-like capital is where we are right now in terms of finding that capital. I think I have let me kind of tack over to a different question. That is also coming in through the chat. The question is, are there certain industries, business stages, partnerships, and or structures that are non-concessional impact debt can finance to help BIPOC business help close the wealth gap? Absolutely. And we at LISC have done a ton of impact debt financing for businesses, whether it's in response to sort of the COVID crisis or even beyond that, we have the New York Fort Loan Fund, which is a fund that $100 million and it puts out low-cost debt and has been very successful in helping businesses sustain themselves through the pandemic and see the way out of it. We have a fund called the Black Economic Development Fund, which also does a lot of financing for larger black businesses that are trying to grow and scale. The major difference here is for entrepreneurs, debt is a good solution if you're scaling an existing operation. You have an understanding of how it's going to form, what it needs, and how you think it's going to grow as you really take the risk on of debt. What we need in many of our community-based businesses is we need to find resilience in those businesses through them having multiple business lines, which means they have to go beyond their current business. And so that's why they are hesitant to take on debt to do that. And so we need to come up with a new product. This exists in other communities, the Asian community, the Jewish community. They have all kinds of sort of informal networks where people can start businesses based off of friends and family sort of raising, not the case, and black and brown communities. So we're missing that and it's a key ingredient to getting growth. And I think when you, when we're thinking about that too, one of the questions that's also coming in here is about, is around the cities that you are targeting and where there might be extra growth there or ways to grow into different cities. Yeah, so from a city perspective, it's not surprising that there are certain cities around the U.S., large urban centers that have a majority of black and brown businesses. So this has been a BIPOC focused initiative, as I said before. So we're in those major cities and that's what we're looking at. So Atlanta, Chicago, LA, New York, D.C., it's not a surprise where we started. I would love to expand this to actually a rural application as well, because I think the rural community is the same issue. And so that would be sort of a future evolution of the program. But that's where we are for now, given the focus. Let's see. I have another great question that's coming in from Meg. She asks, how do you think about measuring the impact of these vehicles and what key metrics do you look at and are you looking for? I think there are lots of creative metrics. My number one is jobs. I think that the number one way that entrepreneurship can help close the racial wealth gap is through creating financial stability that comes with jobs in the community. And I think it's a next generation effect. I think the kids of those families get educated and make significant jumps in terms of family wealth in the next generation. So yes, you could have a community-based business that gets the right kind of money and all of a sudden becomes a national brand or whatever. But that's very unusual in this space. I think it's about providing jobs and financial stability. So when we look at the business plans that we are looking to sort of finance or to invest in, we're looking for business plans that require local jobs, ideally local accessible jobs. So I think maybe kind of going from that local piece to looking more broadly universally, there have been a number of corporate commitments and racial justice commitments that are starting to come out in different ways that organizations are following through or not. When you think about this in relationship to funding BIPOC founders and ensuring that communities have funding and generational wealth, what do we have to do more here in order to really make those commitments turn into significant actions? Yeah, so I think it's a really big question. Yeah, sorry. No, it's fine. We've actually been to the benefactor of some of those large commitments. I would love to say that, typically, the Black Economic Development Fund, the investors in that fund have been really incredible in lowering the cost of that capital so that we can do really interesting and creative things with it. So I would put those in the bucket of earnest commitments. I think for a lot of corporations, A, they do want a headline, right? So they have to get to a big number. And then to get to a big number, the question is, where's that capital coming from within the corporation? Right? And then that drives, again, this matching mechanism of risk versus what they can invest in. And so we saw a lot of big announcements with people we're talking about putting deposits in black banks, for example, right, which is and is not probably helpful to the system and is a very safe way to sort of make those investments. And so I think it runs the gamut. And I have gone away from trying to control that because I don't think you can. What I think we can do as an industry is continue to go to our our dearest friends, which are the foundations and philanthropy and do things like this, where we sort of see new investment opportunities, figure them out, make them more investment grade like and then go to those folks and say, hey, listen, we have something that has a proven track record, would you consider this as a proven less risky investment? I think that's got to be our crosswalk to some of those bigger commitments, but it's there's no panacea. But the right and I know that you are doing a lot of work on on that and in that side of the house. I think that it's also we need to really help people meet them where they're at, but then also help them see where they can go to. And I think that that's one of the things that I'm really tracking and noticing with some of the commitments and actions and others in the ecosystem that are trying to push that work as well. And speaking of big questions, I have another kind of big question for you. Within Spectrum and SoCAP, we have started conversations with in coordination with the community around reparations. And I'm curious to hear your thoughts on reparations and how can reparations play a role in supporting resilient, BIPOC led businesses? Yeah, I think it goes back to a question you asked me earlier about sort of figuring out how to work our way out of the hole we built ourselves into historically, right? And so the best explanation I heard was sort of a mathematical one, which was if you look at the well documented differences and let's say mortgage rates and mortgage approvals and home appraisals. Let's take that as a real life example.  Though not the fault of the white family who received a better rate and better appraisal, it has acted as a historic subsidy for that population, just economically, generation over generation. So for me, reparations is mathematical. It's documented and there's, you know, not a perfect way, but there are definitely some quantitative pillars to stand on and thinking about why it makes sense that you've had a population that's been disadvantaged in a recorded fashion mathematically for years. And how do you think about the amount of resources that should be utilized to help rectify that? And then the next step is then how do you deploy those resources? Right. And so that is the work that we're a lot in already, which is if we had money and the money we do have, we figure out how to deploy to fix some of those wrongs. But I do think that that would that should be a non-emotional, logical, quantitative conversation about the real math behind what's happened in documented policies in the history of this country and how we might acquire some resources to really make it better. And I think not just for the benefit of black and brown communities, this is a short sightedness of so many, but to the benefit of the entire country, like if we can get our entire team on the field and not have 30 percent of it sitting on the bench, then we're going to perform better as a country. And all of us are going to do better. But people are too short-sighted sometimes to see that. So I'm a big fan of the conversation and the link to potential resources. And then the longer conversation about how to deploy them. Thank you. As you were speaking, a quote actually came up and I looked for it really quickly. But from Taha Nishi Coates that he says, until we reckon with our compounding moral debts, America will never be whole. And I it's I think that's exactly we have to figure out how we can make ourselves whole. We are we're just about time. I know these lightning bolts go lightning fast. So I I'm curious if you have anything closing that you'd like to mention that you haven't covered yet and specifically maybe looking toward how do we as a community, as individuals, help to sustain action?  My closing thoughts are this and it's probably a call to action for the CFI community, impact investors and foundations as well. There's so much trendiness and novelty that is such a big part of what people want to invest in in this space. You know, the latest idea that sounds cool. What's the next thing that, you know, might be interesting or sounds cool? And this maybe goes all the way to like family offices and where the money comes from. Right. But at the end of the day, the the challenge I have is the scoreboard, which to me is the macroeconomic data about what's happening in the country. So that's not taking away anything from, you know, the long history of community development, et cetera. But if we're not winning on the scoreboard, then there is an issue and it can't always be about novelty. Sometimes it needs to be about finding a good solution and then scaling it and sticking to it for a long period of time. And it's not sexy. But if you really are concerned about making the country better and not just doing interesting things, that's what you should be focused on. George, thank you so much for being with us today. And thank you for not just that call to action, but all of the work that you're doing. Look forward to keeping the conversation going with you. Thank you. It's been great. Take care.


October is here and falling temperatures are bringing big savings. Get the phone you want with free activation all month long on post-paid service. That's up to a $30 savings per line. Better service, bigger savings. That's today's Appalachian Wireless. Two years ago, Cindy Moore celebrated a victory when she convinced Food City in Pikeville to order a special cart for her special needs child, Lily. Next, it was the Pikeville Walmart who ordered a Carolines cart. But she initially hit a wall when she talked to Lowe's, but she didn't give up. And this past weekend, the Pikeville Lowe's unveiled their new Carolines cart. The next thing I knew, there was a cart at the Lowe's in Pikeville, which, may I add, is the first in the nation. This is a big thing for Lowe's. We are, you know, I think the first one in the Lowe's store, the company that has it. So we were able to write it for our community, which that really just, that gives you that feeling of, wow, we can do that at our level. Cindy's ability to convince Lowe's to purchase a Carolines cart has reached the woman behind the cart, Drew Ann Long, who invented the Carolines cart for her own special needs daughter, Caroline. Long, who has Carolines carts all over the U.S. and in several other countries, had never been able to get a single cart in a Lowe's store. And it wasn't until Cindy reached out to the CEO of Lowe's and said, I want an explanation of why you have every other cart helping every other people group, yet you refuse to help the special needs community. It was not until she sent that letter to the CEO did we get some action. And with every victory, Cindy Moore becomes more and more determined to get Caroline's cart in retail stores throughout eastern Kentucky. I'm not stopping. There's going to be other stores soon. Hopefully real soon we'll be seeing some more coming at Pike County. This is a mission for me to help not just my child or my family, but everybody. And like you said, not just the children, but the elderly as well.


Hello everyone, my name is Max Meneri, I used to work at Toronto General Hospital and now I'm at Leipzig-Herzentrum, I'd like to thank the organizer for giving me the opportunity to present the 19th Annual Toronto Perioperative TE Symposium and before I start I'd like to congratulate everyone involved in the organization for doing a phenomenal job in a very difficult time. I'll be talking about tricuspid regurgitation and unfortunately I couldn't connect live because I'm actually Covid positive, fortunately with minimal symptoms both my kids at home so it was going to be difficult to keep them quiet during the whole time I was going to be presenting. I don't have any competing interests with the only exception that I'm work at Leipzig-Herzentrum that's a reference centre for Philips and I'm part of the writing committee for the basic TE exam at the National Board of Echocardiography. I'll be presenting two cases, the first case is a 74 years old female that presented for a elective surgery in our operating room with chronic chronic atrial fibrillation, diabetes, left ventricle ejection fraction 60% and a pulmonary arterial pressure of 48 plus CVP. The preoperative echo showed severe matter regurgitation and it was the main reason the patient came to the operating room and moderate tricuspid regurgitation. Now the surgeon in this case as in most of the cases at our centre wanted to do a minimally invasive approach and we would normally don't place a superior vena keva canula or a jugular bypass canula unless we do a tricuspid valve repair so for microvalval alone we would not place a canula we would if we do the tricuspid valve alone. So the patient comes in the and as soon as the patient is intubated my junior would start doing the echo and as he does the echo then he asks the nurse to come and to give me a call and so I come in and I look at the echoes and as you can see in this four chamber view the both atria seems to be predilated there is definitely dilated left ventricle but as we look at the tricuspid valve annulus it doesn't look so big or at least not as big as I would expect it and there's not much of a tricuspid regurgitation and I start looking around and looking around I hold the probe now and in this modified four chamber sort of something between four chamber and RV inflow outflow view I could get a regurgitan jet that wasn't even big enough to actually measure a vina contracta and now my junior had already measured the tricuspid annulus and in this first measurement the annulus is 3.2 actually looking at this picture this is not like sort of an ideal sort of cut to measure the annulus and that's why I decided to remeasure it again and as I remeasure it again then maybe trying to be generous I could find an annulus of 44 millimeters so here we have very little tricuspid regurgitation and we also have a dilated annulus more than four but not that dilated so now the question is yeah what shall we do so I'm gonna give the surgeon a call and I'm gonna let him know and then we said I'm on my way and in the mean we used 3d technology to get some extra pictures and here is the four chamber so from the modified four chamber view I got a 3d block and then with color now we can actually see in the center of the valve on the right that there is a little bit more tricuspid regurgitation with sort of tracing and multi-planar reconstruction we actually found a vina contracta area of 0.66 and a vina contracta width of 0.6 here on 3d when we look at the guidelines actually this qualifies for vina contracta width which is not necessarily validated to be measured on 3d but sort of for moderate tricuspid regurgitation and actually for vina contracta area with 3d we can only define severe and nothing that's less than severe so if more than 10 centimeter square is severe if it's less than 10 then it's not severe so in this case it's definitely less than 10 is not severe and we sort of now sort of probably agree that there is a there is tricuspid regurgitation probably moderate and there is a slightly so now in terms of surgical decision making here is where it becomes tricky because like we have preoperative data we have interoperative data preoperative data are based on trans thoracic interoperative data are based on trans esophageal echo and these are just a few information within a much bigger sort of picture which is sort of a patient with comorbidities with sort of a whole clinical history atrial fibrillation the latest atria so what would sort of the literature yeah so we know that and this is so now i'm working germany so i'm glad to present german data but it's sort of from the from the sort of the equivalent of the sts database from germany we know that tricuspid valve surgery alone yeah regardless is definitely 10 times higher risk of mortality than any other surgery so definitely operating the tricuspid valve alone eventually in the future it's probably not a good option what we actually know is from this key sort of paper from dracus from 2005 is that if you repair the tricuspid valve at the time of mitral valve repair the mortality doesn't change and what does change is that the patients who had mitral and tricuspid valve at the same time they won't develop tricuspid valve regurgitation in the future when those where we didn't repair the tricuspid valve they would then develop tricuspid valve regurgitation in the future probably the reason for the guidelines from AHA ACC from 2014 suggests that in case of tricuspid regurgitation if you have a severe tricuspid regurgitation and you do left heart surgery you definitely need to do something to the tricuspid valve when it becomes a little bit tricky is you have mild or moderate tricuspid regurgitation and then you need to decide whether the annulus is dilated or not and the cut off for dilated annulus is four centimeters measure in a four chamber view and in this case our case for 4.2 and if there is only tricuspid if there is tricuspid valve annular dilatation it's a class one indication place 2a indication and if there is a not tricuspid valve dilatation but there is pulmonary hypertension then it's a class 2b indication in our case we actually probably can classify although sort of on borderline this patient for class 2a so with left heart surgery moderate tricuspid regurgitation the european guidelines are not very different and again with severe tricuspid regurgitation left heart surgery there's a category one mild moderate tricuspid regurgitation if the annulus is dilated or there is a pulmonary arterial pressure systolic more than 60 then it's a class 2a indication so that's definitely the case for so the surgeon said you know what max i'm sorry i got your point but really in this patient knowing her history and looking at the dilated atria although i know it's not part of the decision making process but still i decided i think you should just put a superior vena keva canula through the internal jugular vein and then i'll do a mitral valve uh i'll do the tricuspid valve together with the mitral and this was sort of for chamber view with x plane offer repair mitral valve that was successful through a smart or economy and at the same time you can see here we also place a nice ring on the tricuspid valve and there's no regurgitation so the sort of key point and take on message from this first case is that as we know tricuspid valve alone uh surgery carries a high mortality and and sometimes we play a significant role in making the decision and i think i based on that and based on the fact that the surgeons are having more and more um confidence in repairing tricuspid valve then there is a tendency um to um have a lower threshold to repair the tricuspid valve nowadays than there there was probably a few years ago and especially because there is no significant increase in um in mortality now the other problem is that we typically assess the patients pre-operatively in in in determined physiological circumstances and now the patient is assessed again intraoperatively in a completely different physiological circumstances so it's difficult to compare the two type or the two time points and is and it's uh as as for other valvular lesions ideally this type of discussions or this type of decision should be made based on the pre-operative echo instead of uh waiting for the intraoperative echo a different story is when the patient comes and there's no known tricuspid regurgitation and now suddenly we find tricuspid regurgitation that is probably where our uh intraoperative finding can definitely make a difference and when we do do an intraoperative assessment using all the tools uh that are available to us actually in our case with 2d images alone we could barely see any regurgit and jet and then when we actually use 3d we could actually see a jet it was sort of after a few minutes and I mean the physiological hemodynamics may have changed but uh still use all the tools you have in order to better define your tricuspid jet uh now as a technical uh discussion uh this is functional tricuspid regurgitation it's due to the distortion of the relationship of not just the annulus or the leaflet but the whole tricuspival complex which includes the atrium the annulus the leaflet the cordae the popular muscle and the right ventricle so changing any of these components then can lead to um tricuspid regurgitation now in case of functional tricuspid regurgitation the mechanism is the annulus dilation and because the septal leaflet is attached to the interectrial septum more than the other leaflet to this to the lateral wall then there is a tendency for the septal leaflet to not to adjust to an annular dilatation and leave a gap in the center with a uh um regurgitan jet that typically it's directed against the interectrial septum so as a technical um sort of uh sketch here to display the different options for tricuspid valve repair there is the typical um there's a few techniques so one is to put a bend and put a ring and just make the annulus smaller another option is the so called the vega technique where instead of putting a ring we just run a suture along the annulus and then we um we pull it and and that would sort of do it and then the third option is this so-called big cuspidization of the valve where basically one uh commissure is basically uh uh suture together so then we basically have like a three cuspid tricuspid valve we can make it a bi- valve what's a bit tricky about the tricuspid valve is that um there is a funny triangle that's called the triangle of Koch and it is defined by the so-called tendon of Todaro that goes from the top of the coronary sinus to the um uh commissure between septal and anterior uh leaflet of the tricuspid valve and that with the um uh edge of the septal end of the annulus of the tricuspid valve constituted triangle and at the apex of this triangle comes the AV node so and that's the reason for the annular eye that are typically used this is a so-called physio ring um they are not a full ring but they are open ring and this open ring is left open in order to sort of try to stay away from the um AV node that's uh sits just right there at the apex of this triangle here we go with ship ears and i'm in good time 15 minutes so far this is a slightly sicker patient so 86 years old female chronicator of fibrillation she has a permanent pacemaker for complete block uh diabetes COPD normal left ventricular ejection fraction elevated pulmonary artery pressure memory current asides and admissions with right heart failure the patient was by multiple echo pre-op and uh this is the trans thoracic echo that shows that mild tricuspid regurgitation sorry mild mitragurgitation and severe tricuspid regurgitation and that's um given her picture and the isolated tricuspid problem then they decided to use a percutaneous technique we have two types of percutaneous techniques that we use at our center for a tricuspid valve uh one is the triclip and the other one is the Pascal system both work in a very similar way these are clips that basically grasp the leaflet both now can grasp the leaflet uh independently so one independent from the other uh the the clip is the leaflet are grasped then the clip is closed then we assess for the results if you're happy then we can decide to release the clip if we're not happy then we can reopen and then we can we can re-grasp yeah so very similar to what we do for the mitral valve with the difference that here we are going to we're not going to re-accept this is the baseline assessment of this patient uh as expected for chamber view in the left on the left side we have a very dilated right side of the heart uh there's a dilated tricuspid annulus and on the right side we can see that there's a bright broad base uh tricuspid annulus here is inflow outflow view with x-plane and we can see this broad base jet and we can on the right side uh from the color x-plane we can see the pacemaker wire there and we can see that the the gurgian jet comes right next to the pacemaker wire to the right is the transcastric short axis view of the tricuspid valve where we can see that there is a large jet that comes from the anterior and septal leaflet and then extends a bit more posterior also with the origin of the jet between the posterior and the septal leaflet and we can clearly appreciate there the um pacemaker wire that's against the inter uh against the septal leaflet of the valve this is in four in in 3d to the left we have a 3d and to the right is 3d with use the 3d with color again to better quantify the tricuspid regurgitation and here it there's no doubt this is a severe tricuspid regurgitation with a vina contracta cross-sectional area of one square so then this is the view this transcastric view is what we typically use for planning our uh procedure and here what we plan was to start with one clip between anterior and septal leaflet uh towards the anterior commissure and a second clip more towards the center of the and here we have fluoroscopy that sort of guide us and we're lucky at the health center leipzig we have a screen that shows the fluoroscopy that's just above our tea machine and here you see that there's the introducer that comes to the right uh atrium so we need to follow the clip the clip comes out of the introducer here the clip is actually uh getting close to the interatrial septum we need to tell the cardiologist i mean they usually look at the screen as as they do this but although we know that also there's uh uh typically this patient come with a very dilated right atrium so there's quite a lot of room for movement for the clip and the delivery catheter but still we need to be very careful because there's a lot of critical structure that can be eventually perforated here the clips come closer now to the superior vina cava and rotate close to the aortic valve and now the clip is now diving going down into the tracastrid valve and this is uh the clip above the tracastrid valve and now with the x-plane we can tell the cardiologist the correct orientation of the clip to the left we can see in the inflow outflow view we see the clip in its long axis which is non-correct and it rotated the clip 90 degrees and now it's in the right orientation it's uh now in the short axis uh in the um RV inflow outflow view and then in long axis in the derived sort of here uh perpendicular uh kind of uh reversed or mirror view uh tracastric view now we look at the clip and for the and we look at the position and the orientation so for this procedure we keep going constantly back and forth from tracastric short axis and RV inflow outflow view with x-plane and we can help ourselves with the fluoroscopy as you can see here to see where your probe is in respect to the clip especially for the tracastric view to align and be with your scanning plane just perfectly parallel or as parallel as possible to the clip and try to remember this picture so then if when you go back into the esophagus and then when you go back into the stomach then you remember where you are where you were and you can maybe that helps you find and sometimes when we are lost our cardiologist they just press the fluoroscopy button and then we can actually get a better picture so as we said uh uh tracastric short axis view we can see where the clip is and the orientation and the RV inflow outflow view with the derived mirror four chamber view give us a better um alignment of the clip with the scanning plane and we can see the clip arms and we will use these to uh monitor the uh how we grab the leaflet and we orient ourselves with posterior anterior uh on the left on the inflow outflow view and media lateral on the right in the four chamber view so here we come down we position the clip we close the clip we look at the leaflet the leaflet are both inside the clip with the clip is closed and here with the tracastric view you can see how the leaflet come right into the clip as I showed in this tiny little dive so we're we're pretty happy um and we look with color there's still a little bit there's still a little bit of regurgitan jet which is expected this was just one of two clips and now we come in with the second clip so you can see the first clip is to the right so closer to the arctic valve and the second clips come behind it and here on the right is the tracastric short axis view and that's where the clip is placed yeah for clip guidance then what do we use uh uh we use a a number of uh two basically two views one view is the tracastric uh midisophage tracastric short axis and the other one is midisophageal rv inflow view with the x-plane rv inflow outflow view with jacksplane unfortunately it doesn't allow us to always know exactly what leaflet we look at so on the left what we have is posterior but on the right can be septal or anterior uh our experience is as as you have this inflow outflow view then as you move towards the arctic valve you're cutting more towards the anterior leaflet then in the center and moving the probe a little bit then you cut more towards the septal leaflet but with certainty we don't that is the reason why for precise positioning of this clip we rely almost entirely on this trans gastric short axis view where we know for sure what leaflet there are and we and we can clearly position the clip and then we go back to midisophageal for the 3d helps a little bit we don't use it as much and if we want to use it then we can correlate our view with the anatomy by trying to include in your 3d block a little bit of the arctic valve and as you position the arctic valve at about 11 o'clock the arctic valve helps you identify the commissure between septal and anterior leaflet and what we often do is we take this block and we just rotate it upside down because that would allow align well with what we normally see in the trans gastric short axis view and that's what our cardiologists really like to see all the time and they help them better orient something that's a bit tricky is is decide whether we can clip or we cannot clip and we obviously always want to clip so one way to clip is if the gap between the leaflet is more than one millimeter which is which was actually remains a relative contraindication for this procedure but something that we can do is we can actually try and increase the peep and then we look at the at the same picture so this is to the left you can see or maybe you can convince yourself that if with peep there there the leaflet come a little bit close together and and this is something that usually we do when we grasp so when we actually have the clip in position and we're ready to actually grasp the leaflet we stop the ventilation we just increase the peep to 30 sometimes even 40 if the patient can tolerate it and then we stop the the ventilation for the time it takes to grasp the leaflet sometimes through three minutes the patient can tolerate if we've well if we've had them well pre-oxygenated the other trick about this procedure is that this trans gastric short axis view it's not always in the same at the same angle and sometimes it's very tricky to find and this is just an example where we were completely lost because the actually took us a while to figure out the anatomy for this patient and on the right side you can see this view we could only find it at 120 degrees so my advice is don't have a fixed number in your head but have sort of the anatomical correlation in your head and that's what you need to know you want so here is going back to our case we've deployed the second clip and regurgitant jet there's basically regurgitation the only problem was that as we look at these two clips like the one clip second clip was in was good and stable the first clip we found it was a little bit moving a little bit too much but because we couldn't get a good cut through this second clip now with multi-views we could actually get our cursor on the second on the first clip and as you can see this first clip is a little bit maybe too mobile or a little bit mobile but the leaflets are actually still going into the clip so we were sort of and we decided not to do anything a particular problem and a gradient also sort of guide for success gradient obviously we wouldn't accept anything more than three millimeters of mercury mean gradient but for the tracaspid valve it's rarely a problem so as a technical vignette and to conclude again we know a functional tracaspid regurgitation involves annular dilatation and leaflets there's been many percutaneous approaches that's been proposed then starting from addressing the annulus addressing the gap with the former device that we've had some experience in toronto before I moved here to leitzig and here with the clip we are only addressing really one problem in within these the tracaspid valve and and and so this that we actually need to know and basically all of our clinical work is based on the largest trial the one of our cardiologists philip lurtz was involved with whose senior author is rebecca han and this was the triluminate trial where 88 patients in a prospective multicenter single arm trial patients with tracaspid regurgitation there was at least moderate in a gap less than one millimeter where we're actually treated and as you as you can see although this is a little bit more it's a little bit sort of not so easy to read but there was a good success in the great majority of cases there was significant improvement of a tracaspid degree of tracaspid regurgitation and right ventricular dimensions and in terms of clinical improvement all of the patients had a significant improvement from as you can see 75 percent the baseline had either new york heart association class three or four and that actually decreased drastically at 30 days to 20 percent in a six months to 12 to 13 percent with a very low complication rate with nine percent of the patient had the tracaspid stenosis we unfortunately haven't had any so far and with the attachment of the clip from one of the leaflet in seven percent of the cases and this is something that unfortunately we've seen a few times and we've basically just dealt with like sometimes placing an extra clip or just leave it alone what is critical and what is important here and what we've learned from this from this study is that in order to have an improve in clinical outcome and the way the patient feel we don't necessarily need to resolve the tracaspid regurgitation and that's why this new classification of tracaspid regurgitation has been proposed by Rebecca and Zamorano where we have within severe we have three different levels of severity of how severe they are so severe massive and torrential where actually if we have an improvement from any of these points to the lowest one so say from torrential to massive or massive from severe at the end of the procedure the patient would still have severe tracaspid regurgitation but they will actually definitely get a significant clinical benefit and they will eventually better I remain available for any question per email I thank you once again and I'm sorry I couldn't connect live and it's a honor and I'm extremely proud to see how some of my younger colleagues have been taking this conference to the next level and they are doing phenomenal phenomenal job at Toronto General Hospital and contributing to the world of perioperative transophageal ecocardiography thank you very much


So as Sergio said, we're live from a vaccinated room in Santa Clara and again I want to thank Federico for being with us. We were talking before about this being the 50th anniversary of microprocessor and you being the pioneer of that. I was wondering if you could take us through from your hometown of the Chesa and your studies in Padua. How you ended up the coming to SGS Fairchild, right? So I was born in 1941, wartime. After a year and a half. My father decided to move to a small to a village. Isola Vicentina because the Allied forces were coming through Sicily and they were soon to be in the north. So I spent my first six years after that after, you know, so from from one and a half to seven and a half. In a rural village where basically in many homes there were not even electricity. You know, farmers were still using plows with, you know, pulled by by hawks. I mean just unbelievable, you know, unbelievable when you think about it with the eyes of today. But so anyway, so I I experience. How people live 200 years ago and my first language was the Venetian dialect, so which I still speak very well. And also with English, yeah, but not next was Italian. But in fact, the first the first day of school. I understood half of what the teacher was talking because everybody speak dialect in the village. So, you know, Italian was a new language for me. So I have to learn that one first. Anyway, so I grew, you know, then we moved back to Vicenza where I was born, where my father was a professor of philosophy and history at the classical and also University of Padua scholar. My father wrote about 40 books, translated the Enneads of Plutus and wrote about many philosophers, especially idealist philosophers like Schopenhauer, Meisterrecker, so on. So I grew up in a in a home that was quite culture. My mother was elementary school teacher. But I didn't care about that stuff. I really my first love was model planes and I decided to I saw one when I was 11 and that's it was love at first sight. So I had to build myself one and then two and then three. And so I still build them and fly them. And but I had no money. So I had to figure out how to design them and make them and I bought a book, first book I bought with my money. And and I was self taught essentially, except for the book. And that was a fundamental experience because he essentially gave me a 12 an experience of how you actually build a product because the product you first imagine it, then you have to draw it, figure out a plan, you make a plan, then you buy the material, then you construct it, then you assemble it, and then you fly it from A to Z at 12. In fact, I never had any trouble designing anything because that experience gave me the entire 360 view of how you build products. You have to manage every aspect of that. You have to master it. But it all comes from the mind. It all comes from that moment of imagination where you now then it becomes the first transfer from consciousness into drawing, which is some memory on paper. And then from there it becomes physical. So that process is the process of invention. I went to a technical high school to the chagrin of my father, who of course wanted me to study classical IC, but I couldn't care less about Latin. So and even less about Greek in those days. And so I graduated the best of the Institute by long shot. But the point is that right after I went to work for Olivetti, when Olivetti was a major force in office systems and computers, they had announced in 1959, they announced their first transistorized computer. At the same time as IBM had the first transistorized computer. So they were fairly advanced for those days compared to the US. In a work in Borgo Lombardo, I started in 1960 toward the end of 1960, and I spent the entire 1961. And I was lucky enough to be given a project that eventually became my project to design and build a small experimental computer about the size of, say, the 2004 and all the memories around it and so on. So about that much. And I did that. I did about 60% of the design and build the entire thing. I had four technicians working for me, all older than me. So instead of a plane, it became a mini computer. It became basically it was the equivalent of a much faster calculator, programmable calculator really. But it was a general purpose computer. But the intention was to have a fast calculating machine and to see how that would work. So anyway, after that project, I decided that it was time for me to go back and study physics. And you were 19 or 20? So 1961. And in the end of 1961, I left. I just turned 20 in December. So I decided to go back to go to university, University of Padua. And I wanted to study physics because I study vacuum tubes at the Technical High School. Transistors were fairly new in 1960. And these tools are all this 5, 5, or 10 years late in terms of what they teach with respect to what is the forefront of technology. And of course, transistors in those days were still very slow compared to vacuum tubes. Germanium transistors, they had a carol frequency of about megahertz. That or a few megahertz. So it took silicon to really go the next leg. And so I decided, though, that that was the future. It was very clear to me that was the future. So I wanted to understand quantum physics, understand how the transistors really work, not just using it, but how does it work? And so I did physics instead of engineering, which would have been the more natural thing for me to do. And I never regretted having done that because that was really gave me some solid foundation of mathematics and physics that I could do anything after that of technical nature. So after graduation, I went to work for a small company for less than a year. And then I ended up in 1967 at SGS Churchill. So it was May of 1967 when I started. And with the earlier company called Charest, they sent me in Silicon Valley in the summer of 66 to learn MOS transistors because this company had the rap. They were a rap of general microelectronics. It was the first MOS company in the world, starting I think in 65 or early 66. And they had developed a 100-bit shift register. Can you imagine? They couldn't build it, but they were. Yeah, this was the vision. Yeah, that was. And so I spent a week here with a course on MOS and the products of this company. And then I went back. But then GME was purchased by Philco 4 that they disappear. And so my job there disappeared. So I went to SGS. And SGS Churchill had just started an R&D facility. In those days, SGS was the European licensee of bipolar transistors and integrated circuits from Fertial. Fertial had about 30% ownership of the company. But they were dependent on products from Fertial. And so they decided in early 67 or early 66 to start an R&D facility. I joined them. In my first job, since I knew everything about MOS, right course, was to develop their first MOS process technology, which I did. I did in about four months. And then I designed two integrated circuits before the end of the year. One was a 16-bit static shift register, which takes a lot more transistors than a dynamic one. And then it's sort of a gate array with metal that you could decide your own. Of course, there were only a few gates. I don't know. They were probably the equivalent of 20 gates or something. Maybe 40 gates. But that kind of thing. And that was the that takes us to the end of 67. And then I was sent here in an exchange of engineers in early February of 68. Here in Silicon Valley. Here in Silicon Valley to work in the R&D facility of Fertial.  Yeah, exactly. Life in Italy. And now we are at the beginning of my second life.