So welcome back to Family History. We had a great foundational talk this morning from Marin Schooner, and we had a very lively breakout discussion yesterday on what was thought to be the sunny terrace room, but it wasn't quite that sunny. We had a very diverse and a group of experts that both may not all be listed here, and I apologize for any misspellings of anybody's names. And we essentially, over the course of the afternoon, arrived at six different topics or potential project areas for family history, validation of the information that's obtained in the course of obtaining a family history, the implementation science to integrate family history into the clinical workflow, to develop the user interface for both patients and providers for family history, to develop the outcomes research agenda that would enhance uptake and adoption and provide evidence for clinical utility. We discussed briefly a holy grail of integration of all data and the development of disease risk models. And lastly, to assemble a group to facilitate the incorporation of family history initiatives into large cohort studies. So let me just go through these in a little bit more detail. So in terms of validation of family history, probably some of the more age old questions for family history is how do you know that it's accurate? And particularly patient entered data has the accuracy of that can be questioned. And there's also the question of how often one should be obtaining family history as pedigrees, as families, and our lives evolve. How does family history data also evolve with it? And what's the frequency that it needs to be obtained? And we thought that this could be the basis for some very focused initiatives in small projects in practice environments that are currently doing these or others to develop sets of iterative questions that could be used in follow-up of an initial family history and to refine those questions to obtain the most valuable information. And also perhaps a core leverage to that is to develop adaptive patient questionnaires that would move them through some logic to obtain accurate family history information. Now, some of these already may have been developed or are in development, but I think we wanted to leverage from those and move forward. This is also discussed in the context of David Valley's program in Mendelian disease genetics, where it's absolutely essential to obtain adequate validated family history information. And OMIM is being used as the entry point for a lot of the ascertainment for that project. And so there's an opportunity to collaborate with that ongoing research that we talked briefly about how would we benchmark validity and, of course, obtaining information from living affected or other family members would be quite important. So to compare patient, single patient-oriented information with those obtained from the family more broadly would be important. And a side note was we recognize that there may be a myriad of cultural and ethnic differences that might prohibit one from actually divulging important family history information. The example that was used in our discussion yesterday was about psychiatric illnesses and how patients might be willing or not to talk about that as well as, I think, you can imagine other disorders that we may not understand best, how to elicit from a cultural framework. So the second topic was the best way to integrate family history into the clinical workflow. And at least one of the participants in our working group had done some analysis of their electronic medical records showing that only 1% had adequate family history data, and that was out of genetics clinics. So we discussed the notion of having small studies that would attempt to optimize the way of collecting this data and evaluate. So for example, a key question is patient-entered versus ancillary health provider-entered types of information. Can we do some comparative analysis between, let's say, information that's obtained from a nurse practitioner or physician's assistant versus what is obtained from a patient? And more broadly speaking, just the setting in which the information is obtained in the context of a clinical visit, what can be ascertained versus what can be obtained, perhaps, outside of the clinical visit? So these would be, I think, relatively simple initiatives to implement and understand better what best practices are. There was a lot of discussion about whether family history tools should be standalone versus ones that are fully integrated into electronic medical records. There are certainly pros and cons to each, and I think we have no idea really which is going to be best for facilitation of integration into the clinical workflow. There was a lot of animated discussion, I think, about using electronic media. I think Mark also mentioned social networking in our discussion yesterday about the possibility of developing a wiki-based type of model that would encourage family members all to contribute to developing a pedigree and a family history. There was also lots of animated discussion about Facebook applications, and I think Jonas overnight has done some additional work on finding out whether that could actually be easily implementable. The notion of an iPad app and also just comparing to the more standard genealogy web pages was we're all elements of potential projects that could be undertaken in this arena. The information interface and education of providers, and I should say patients. I think that the notion that the group seemed to be interested in was not just to deliver information, but also to deliver an educational platform as part of family history gathering. Marin mentioned this this morning, but also what is it that the primary care physicians want versus what specialists want, so I think the high hypothesis was that journalists just want red flags where specialists really want more detailed information about patient history as well as genetics and genomics. So could we just get that information as I think the VA has already begun to do and surveying providers in different settings and understanding what their needs are to optimize their use of family history, and probably a much more challenging aspect would be to create the informatics platform that translates in family history data appropriate for the audience that's seeing the data. So if a PCP environment only wants to see certain things, can you limit what the information content is for them versus for other recipients of the same types of information? And we thought that we could build around the existing tools rather than create something de novo, that we should emphasize the fact that pedigrees should not go away because they really can be informative and educational about the underlying genetics, that the tools should provide the most likely diagnosis, but also to suggest alternative diagnoses that the information should be targeted, brief, and actionable. In terms of the outcomes research agenda, we discussed the desired outcome of adherence to evidence-based guidelines, such as from the USP STF. And we should be able to measure provider behavior in terms of their compliance with these guidelines, and patient behavior in terms of their compliance with physician or provider-based recommendations. There was some discussion about, could this be done in a focused way? In retrospective analyses, knowing the caveats and the biases that might be associated with retrospective studies of looking at how, what happens to patients subsequent to inadequate family history in the chart versus those that don't have adequate family history information in the chart in terms of certain outcomes using the rich data electronic records from places like Marshfield, Geisinger, and Intermountain Health. The idea of doing some prospective studies, a cluster randomization where some practices would practice usual care, others would practice family history-informed care, and measuring, again, the patient-provider outcomes. The notion of specifically collaborating with the VA or the Emerge Network to integrate family history in some areas, but not in others prospectively, and look at compliance with guidelines, behaviors of patients in terms of compliance with diet, exercise recommendations, medication compliance, or achievement of relevant preventer medicine goals around blood pressure control, blood sugar control, cholesterol, and so on. So I think these are all things, many of which can be readily implemented. So the holy grail in some ways is, OK, family history is certainly one type of data, genomic data, molecular information. I think we need to be prepared for a time when all of this data will be resident in some type of data warehouse. And the first thing is to think about initiatives to develop the methodology that assimilate these types of different complex data, all with their different formats and standards so that we can begin to approach what might be the most refined molecular models that can be aggregated to predict disease risk or drug response or whatever the predictive model is aiming to do. We also believe that this requires access to an incorporation of family history with ongoing population study initiatives. And we recommend that structured family history data be incorporated into as many NIH studies as possible, particularly ones that are collecting genotyping or sequencing data, and some of the places where that might happen are listed here. And then finally, we felt that maybe some of the esteemed colleagues in the room or on our working group could actually form some kind of advisory group on family history that could look across the opportunities and make some recommendations where family history information should and could be implemented into ongoing initiatives. And also to probably provide advice to study PIs and steering groups about family history where they may not have that information and be able to inform them about the best ways to collect it and also potentially even to recommend future research in the form of RFAs or the like. So I think that was it. And I hope I did justice to our discussion. If any of my colleagues want to make any comments, please do so. Jeff, a point of clarification. The Mendelian Centers that I mentioned is not my project. We have part of that project at Hopkins, but it's led up by Debbie at University of Washington and investigators at Yale with Rick Lifton as a third site, and we being Baylor Hopkins together. And just so I appreciate your clarification. And I think your press announcement is happening as we speak. Well, congratulations, all of you. I guess I was also curious as to where the OMIM piece is also across the entire, and I meant to spend a lot of time on this, but I think your point yesterday was also to integrate this with the OMIM portion of that. It will be one. So the group will go to and interact with the distributed to the centers based on capacity? So I think the point of our discussion was to potentially collaborate with you to obtain accurate family history data on those Mendelian families that you'll be looking at. So Jeff, yesterday when you gave your talk, to me the exciting parts of that was that primary care folks learned to value family history. And I didn't really see that coming out of the breakout session slides, where to me, I think generating the data that shows value to your target audience is something that's really missing. And if you have to go in and show everybody why it's valuable, then it's never gonna happen. And so another element would be getting some of those talking points with real metrics that could be shared across family medicine. So I think right now people think it's a good idea, but they don't know it's a good idea. And somehow that needs to be conveyed, or maybe it's not as good as we think and we need to just stop pushing it. Right, and I think your point is a good one. We didn't focus a great deal of our time on that point yesterday, but I think it was implicit that we really would like to develop both as part of the implementation science initiatives means to evaluate what provider see and patients see as the value of having this information and as well as also try to come up with some robust outcome measures that could actually be, or outcomes that could be measured in that regard so we can report it out in a way that's meaningful to health systems, to other providers so they really, so it can be translated to other environments where it's not being used. So thank you. I think the other thing that I would add, this is I think in your third project where you're looking at prioritization and how you can be actionable about family history. The thing that I didn't see there was patient control and patient centeredness in the sense that if you have a patient that completes a family history, there may be risk for several things that are identified. So perhaps there's cardiovascular risk, we look at and we say, gosh, we need to talk to this patient about their cardiovascular risk, but the patient may say, I'm really concerned about my family history of colorectal cancer. I think there's an opportunity to use this as a pre-visit negotiation tool about what are we gonna talk about in the 10 minutes we have together and the hypothesis I would have is if we prioritize based on what the patient's concerned about in their family history that we may in fact see a better movement on health behaviors, which some of the health behaviors relating to diet and exercise at lower colorectal risk also happen to impact cardiovascular risk. So I would really like to see a patient centered research focus with these tools. So great point, but not unique to family history as you know, when you see you're a provider and your provider has a list of 10 problems and you have your list of 10 problems and they go like this, you're probably not gonna have an effective interaction. So whether it's family history driven or not, but if your coin is well taken, it should be included. Other questions or comments? Thanks, Jeff. Thank you. Actually if I can ask all of the breakout group presenters to make sure they leave their presentations on the computer up there, it'll help us. Going forward. All right, so next is Alan Howard and Mark, I'm not sure it looks like Alan, pharmacogenetics, genomics.


We're going to treat you to just one more quick tune, and this is for our friends down in the southern half of the Western Hemisphere, and we're talking about you, Brazil. This is for you. This is by Antonio Carlos Jobim, who is the leading composer of Bossa Novas and Sambas. And this is a beautiful song he wrote called Cocuvado, Quiet Nights of Quiet Stars. This love, a song to make people happy, whoever it is. To have time to unify the window of your life, always like this, with you, close to me, of the old tea. I, who was sad, is great from the world. Você, o coni, si, fili, si, bejime, quiet nights of quiet stars. On the silence that surrounds quiet courts by quiet streams, and a window that looks out on the mountains and the sea. How lovely. This is where I, till the final flicker of was only a bitter, tragic joke, have found with you the existence of my yet-courge. But so close to me, till the final flicker of lost and lonely, be the existence of...


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All right, this case is another meniscally focused case. It's an adult man with a work-related injury. Lord knows what he was doing. But often underutilized is the axial projection. And when you scroll thin section axials, less than 2 millimeters, you can pick up a lot of information. For instance, you can see a problem with the bone on the lateral side, which correlates with this fracture, or osteocondrol fracture on the lateral side. You also see distention of the postural lateral menisco capsule reflection by fluid. So that already tells you that you probably have had some type of pivot shift related insult. And then when you go over to the medial meniscus side to the root, the area of the root attachment, which is right here, is interrupted vertically from anterior to posterior by this high signal area, which represents a radial injury. And a fairly large radial injury at that. So you can get a depth of that radial injury. You can get a width, which is a little more narrow here, but widens as it goes in. And now it's time to look at the meniscus and another projection, even though there's lots more information about what's happening with the ligaments and the axial projection. But that's a story for another day. So now let's look at the coronal since it's up. And we have extensive bone marrow edema, which tells us posteriorly in the tibia that we've had a pivot shift. We also have the typical terminal sulcus injury, again supporting the mechanism of injury of a pivot shift, which we will go over that mechanism when we focus on ligaments. But you should be dialed into the small character of the medial meniscus. It's got a little vertical signal in it, which is part of our tear. Let's follow our tear around. We can follow it into the posterior horn body junction region. So there is a vertical component. There's a horizontal or oblique component. So there's some complexity to this tear. But I'm primarily showing it for this. The radial gap that you saw in the axial projection. Let's go back to it. Here it is right here. Offed overlooked but never understated. And it's got some width to it. Obviously, that width changes from anterior to posterior. So it'll change as you scroll from front to back. And it is just medial to the root attachment. There is the root ligament attachment arcing down next to a small bundle of the PCL that courses along the inner wall of the femoral condyle. It's intact, but it is the meniscus immediately adjacent to the menisco tibial attachment that is torn. So functionally, you've lost your tether there. And that's going to allow, over time, with hoop stresses, the meniscus to start to migrate out. It has not done so yet. Let's look at the sagittal projection. We'll reaffirm our anterior cruciate ligament tear, although that's not why we're here. There is our fairly large tear. And here is our meniscus tear, which we said was rather complex. It had an oblique or horizontal component. And then it continues on with a little tiny vertical component, which is so common in these pivot shifts. This signal will be there forever. It is going to sit directly at top of the meniscal contusion. So you don't want to get too excited about these when you see them a year or two later. But I also wanted to show you the meniscal ghost. Here we are right through our radial tear. The meniscus is there. It's gone. It's back again. So you're missing that chopped segment right there. And meniscal ghosting or loss of meniscal signal can be seen with congenital absence of the meniscus, which is much more common laterally, although still a rare phenomenon. You can see it with auto digestion from rheumatoid arthritis.   You'll lose the meniscus. And even infiltrator processes like CPPD and gout may completely wipe out and obliterate the meniscus. So let's move on to another meniscal case.


Championship Saturday at the Birchmont never disappoints, and this year it was no different. The men's championship feature Nick Schaefer, who won the title in 2015, and Chris Curve, the Bemidji native who has made the semis twice, but has never won at all. They said it was the biggest crowd in memory for the match, and it was a good one. All-square headed into the 15th when things got good. Schaefer putting just off the green for Eagle from 40 feet away bottom of the cup. No time for celebration though, as Curve had this Eagle putt for his own. From 20 feet away had a good line, but it falls just short at the end. Schaefer takes a one-shot lead into 16. On the short par four now, Schaefer with the wedge sticks it to about 10 feet. Both players would make par on this hole, so he had to 17 with Schaefer leading by one. From the Schaefer, or excuse me, from the fairway Schaefer, calm, cool, and on the dance floor. Curve would go long on his approach, so he's off the back, needing it up and down to extend the match. The chip goes long. Couldn't make the comeback. Or Nick Schaefer is your 2018 men's champion. The perfect end to what Schaefer calls his favorite week of the summer. It's a fun week. My family comes here every year. My wife comes here every year. We enjoy ourselves all year all week, and it's just fun to put icing on the cake, but regardless, it's a good week, but it's definitely fun to win. Yeah, I was just trying to leg it up there. That green's pretty flat. I was just trying to get it within three or four feet for a gamey and move on to the next hole. Obviously, it's fortunate that it hit the pin and went in. I think it had a little too much pace on it, but I guess the hole was there.


Alex Smith is down. I remember doctors coming in and I'm wrapping my leg in the middle of the night. And literally, they were alarmed by something. It was black. I mean, the blisters were huge. I couldn't fathom seeing this. I'm like, oh, poor movie. They took him back into surgery, opened all that up. And I will never, ever forget this as those surgeons walked out and said, we're in life-saving mode now. And leg-saving mode, but it's in that order. This is the Michael K Show on 98.7 ESPN. All right, tonight at 7.30, E-60, Project 11. Alex Smith, obviously, is at the center of it. He had his leg broken when he was sacked in a game all with the Redskins. And it wasn't just another sports injury, but rather than have me go through it. And you'll see it tonight at 7.30. Let's bring in our very own Stefania Bell, who spearheaded this and takes us through the entire journey. Stefania, it's Michael Don and Peter. Hope you're doing well. I am, thank you so much for having me. Well, it's our pleasure. This looks like, I haven't seen the whole thing. I've seen the highlights. And we just heard at the top some of the audio highlights. It looks like it could be depressing and also uplifting. Which way is it? Well, I think it will be uplifting in the end. This is a happy story. As you've heard from the clips, Alex was in a touch-and-go situation. His life was in danger. There were some concerns about his leg, but we all have seen him. He's very much alive and walking around with two legs. So, you know, you will be uplisted at the end. But I think it's important to understand just how bad it got for him because it helps you appreciate that much more how intense the journey back has been. All right, tell us, Defanya, how bad did it get? Well, it got to, as you heard his mom say in that clip, it got to life-saving mode. You know, he developed an infection. It's always a risk when you have a compound fracture and that means essentially that he had, it was open, the bone pokes through the skin and you're on a football field where all kinds of things can be introduced, dirt, water, dirty uniform, sweat, et cetera. So, you get to the hospital as quickly as possible. They take you to surgery. They clean out the wound. They put the antibiotics in there. They flush it. They get you on antibiotic regimen and they repair the fractures. And at that point, they think everything's going well, but bacteria are microscopic and they're, you know, hearty and they can stick around. And apparently that's what happens. And within a couple of days, his temperature started to spike and things deteriorated for him from there. So for about a week, his life was in danger and obviously he survived it, but in order to do so, to remove the infection, the doctors had to remove his substantial amount of tissue. And that's really what left him with this leg that he's had to work his way back to being as functional as he is right now. Being a Redskins fan and I know a lot of people in Washington, I was hearing things at the time about it being really grave, but Stefania wasn't being reported that way. Even in the post, they didn't seem to have like a full awareness of just how bad things were. How did they manage to keep that so under wraps? And am I wrong in thinking that? It seemed like people didn't understand for quite a while how murky the whole thing was. You're absolutely right. And I think it's a credit to everyone who is in that immediate inner circle, Alex's immediate family and obviously the healthcare providers. These places take HIPAA violations seriously and they really gathered around and protected him. And one of the things Elizabeth, Alex's wife said to me that really struck me was, you know, they have three young kids and she was trying to keep their lives as normal as possible. So she's sending them to school with the help of family and friends who are getting the kids to school while she's in the hospital. And she didn't want the kids to hear from another kid whose parent might've read something that was speculative in the paper and so on. So she said, you know, we didn't even know what was happening, meaning her and Alex. And of course, Alex wasn't totally coherent because he was on so much pain medicine but her and the rest of his family, we didn't know what was happening from one minute to the next. We didn't want the kids to be hearing things that, you know, scared them quite frankly. And so in trying to keep everything as normal as possible, they really kept it on the need to know basis until they were ready to share the story. In real time, you go from, and you heard it in the clip where it's life or death and then it's about saving the leg. So was everything all at once or was it in a stage of, okay, he's out of the woods. He's gonna be all right. And now let's focus on saving the leg. It's a combination answer actually because they were trying to save his leg while they were also trying to save his life. The infection was sourced from the leg. So there was a question of, do you sacrifice the leg to in fact save his, and I think through the detail of telling the story, you're better able to appreciate that. But even after that decision is made because his leg is compromised, you're not guaranteed if you're Alex, but you are going to be able to keep that leg forever going forward. So the next couple of months in particular while he was still on antibiotics even after he left the hospital and the early work that he had to do, the additional surgeries he had to undergo to try and reconstruct his leg, those were, nothing was guaranteed through that. And in that regard, even though they had saved his leg initially, there was a question about whether he'd ultimately be able to keep it. And that's what made this journey for him so long and so intense. Is if on your bell is our guest here on the Michael K. Show E60 tonight. I just, I have to ask you this. You said he's up and walking around and that's amazing. Does he wanna play A and B? If he does, why? Well, you know, you'd have to ask him on the why.  I mean, I've gotten to know him after spending quite a bit of time around him. And it's interesting. First of all, I'm a physical therapist by training originally and you always set goals for your patients that you want them to achieve. So you set these smaller goals when you have a big injury like this because you don't wanna make the goal so distant that they get discouraged. When you have someone, and this happens a lot with professional athletes that just keeps meeting these goals, you have to keep making them bigger and bigger for them to stay motivated and engaged. And Alex could feel as he was making progress that he was now starting to think, hey, I'm doing pretty well. I'm doing better than maybe I even expected. Is there, maybe there's a chance that I can play. And so I think he sees it as a challenge. I think he sees it as nobody's ever done this before. Maybe I can be the first. And that's a real motivator. I also think he's got amazing perspective and if football was not a part of his future, Alex Smith will be just fine. But right now I think it provides this challenge for him that he enjoys quite frankly. And after seeing what he's overcome so far, far be it from me to suggest that he would not be able to do this if that's what he desires. Back to this team that this happened to. I'm sorry, I'm sort of hung up on this. Is, does the, how bad things got? Does it have anything to do with the Redskins decision making, medical staff, et cetera at all? And furthermore, did Alex Smith ever communicate with Trent Williams? Because there's obviously a period that crossed over where both a quarterback and his starting left tackle were in grave danger physically. I wonder if they ever communicated. I can't speak to the latter. I really honestly don't know. But what I can tell you is that one of Alex and Elizabeth's goals in doing this documentary style piece was that they wanted to show just how much gratitude and appreciation they have for the medical staff. They are incredibly close with not only the head team physician, Dr. Robin West, but all the surgeons, two trauma surgeons, a plastic surgeon, physical therapist, the athletic trainers, the folks, everybody who had a hand in Alex's care, they believe they got the best care possible and that Alex isn't here without them. So contrary to things that have been floating around, that's straight from the people who lived it. And I think if you watch the piece, you wouldn't need me to tell you this, you know? And so, but it wasn't very, it was very important to them. And I also think that's why rather than address things that were speculative as they came out, they really wanted to present the story in its entirety and present it to people in that way. And they reached out to you, Stefania, right? Because they wanted you to tell the story. They did. You know, I think when they were having initial conversations about documenting this with Dr. West, as soon as Alex realized it really wasn't anybody who'd been through something like this before, she mentioned my name. Dr. West and I have known each other professionally through Sports Medicine World for a number of years. And I think she thought with my medical background and obviously my current role at ESPN that I would be a good fit with them. And so we all had a phone conversation and Alex and Elizabeth and I talked at length and they decided that they wanted me to do it. And I'm so grateful that they did. Because of your extensive background, you've seen a lot. Anything with Alex's recovery and the things you had to see that actually made you a bit squeamish? Was it that bad? You know, I don't get squeamish on these things. So I may not be the best person to ask, but startling, sure. Because even though in my technical brain, I understood the technicality of the injuries he'd suffered. You know, when I first met him, I didn't see his leg. It was wrapped. He had just been home from the hospital for a few weeks. He was on a walker. He was in that external fixer device. You see the circular cage, which is there to hold the bones in place. But I hadn't seen the images from when he had the surgeries and when the leg was unwrapped. So by the time I saw those images, which was, you know, weeks or even a couple months later, I was already seeing what he was doing.  Not squeamish, but definitely startled at just how significant the loss of tissue was. And I think that's why it's so important to share that because it's hard to wrap your head around just how much he's had to overcome.  So I'm really looking forward to watching this tonight at 7.30. It doesn't sound like it would be fun, but it could be uplifting because as you said, he's up and about and certainly had a scare. So we thank you for spending part of your Friday with us. Thank you so much for having me. And I really hope everyone enjoys the program. Thank you, Stefania. That's Stefania Bell. Boy, it's a man. And Peter was telling us, you know, when it was not out there that he was hearing that this was pretty bad stuff.


Suspense, and the producer of radio's outstanding theatre of thrills, the master of mystery and adventure, William M. Robson. Motorists are constantly being warned against giving lifts to hitchhikers. But all hitchhikers are not dangerous characters, and all motorists are not angels and wheels. Let the hitchhiker beware, lest he accept the ride from a citizen like J. Stuart Belden, it might be his last. Listen, listen then, as Elliot Reed stars in Four of a Kind, which begins in just a minute. And now, for Elliot Reed, a tale well calculated to keep you in suspense. Want a ride, young fella? You bet! I met J. Stuart Belden and his 1959 fish tale special. That's how I took the ride I nearly didn't get back from. He looked to be about 45. He wasn't bad looking for a guy that old. He was well built, about my size, no grin was there, and that coat he was wearing. Boy, I'll bet plenty of camels went under the clippers for that one. What's the name, son? Rich Fowler. Married? Not me.  Oh, no, it's not that. It's just, well, I have enough trouble feeding myself. I said the same thing years ago. You'd change your mind with it. 9B-1863. What? A dud. Huh? Oh, did you ever play license plate poker? License plate poker? I never heard of it. Just like regular poker, except instead of drawing cards, you draw license plates. Now, I drew that hand. There was nothing in it. Next car we see will be your hand. Come on now. What's the license plate? 14-34. Two pairs, three's and four's. You beat me. Hey, that's a good game. What are the stakes? Oh, make it easy on yourself. Shall we say a hundred thousand dollars a half? Oh, sure. A good joke.   And when we got hungry, he stopped not at a drive-in, but at a real fancy restaurant where he picked up the check. Boy, what a meal. The trouble is, they give you too much food in there. I've got to quit eating like that. My clothes are getting tight, especially this coat. Hey, that coat sure is a beauty. Yeah, but I'm getting to be too much for it. Oh. Say, I've got an idea. Why don't you try it on? Oh, no, Mr. Bell, then I didn't mean it. Go ahead.  Well, gosh, I...  Try it on. Well, it does seem to fit okay. Why, it looks like it was made for you. It feels like it, too. Son, you just got yourself a coat. There weren't many cars on the road now, and Belden didn't seem interested in license plate poker anymore. So I just sat there, wrapped up in my new coat, and thinking what a lucky guy I was. We were hooping along a road full of treacherous curves when I turned to thank him again, and the word stuck in my throat. He changed. He was no longer the smiling host. Instead, he was fastened to the wheel like a hawk. That's what I looked like, a hawk. Ready to strike. Then suddenly, he threw open his door, twisted the wheel, So long, sonny. and jumped clear. When the car hurtled into space, I was alone in it. In a moment, we continue with the second act of, and now... It came to hurting bad. The wind knocked out of me. But at least I hadn't gone to the bottom of the gully with the car. After a minute, I started to climb back toward the road. I was only a few feet from the top of the bank, and I looked up, and there was Belden. A gun in his hand. I ducked behind a rock, and the bullets whirred off into the gully. He wanted me dead, that was for sure. But why? I waited a minute longer, and then I heard the horn. I came out from behind the rocks and crawled up to the road, in time to see Belden make his getaway in that car. I couldn't tell what kind of a car it was, but I did get the license. 4L5555. It beat my straight. Head throbbed, I ached all over. And there wasn't any traffic on this back road, so I walked all the way to the next town. I got there, found the police station, and something else. But there he is. Belden. That's him, officer.  Just look at the side pocket of that coat. You'll find my wallet. What? Well, young man, when you get to say for yourself... You don't understand. You see, he gave me the coat. I didn't know about the wallet. Not the best you can do. But I tell you, he picked me up when I was hitchhiking. He tried to kill me. He drove off the road and jumped out. And when that didn't work, he shot at me. Sergeant, let the boy go. Mr. Belden. I've changed my mind. I don't intend to press charges. No, no. Lock me up. Please don't believe him. He wants to kill me. Well, it's up to you, Mr. Belden. If you don't think he'll cause you any more trouble, I am positive that after tonight, this young man will be no trouble for anyone. No trouble for anyone. After tonight, I had to get away from here. I had to run. Hey! Hey, come back here! You were the third act of... I didn't know where I was, except that the town was behind me. And then I saw a bright glaring neon sign. Max and Al's. Wayside rest. Trucks welcome. Just a dinky service station and a lunch wagon. But it was sanctuary to me. Hey, what's the matter, bud? Nothing. You sure look messed up. You've been in an accident? Look, uh... Mr., I've got to get a ride, South. Do you mind if I hang around and wait until a truck comes through? No, no, I don't mind. Won't do any good, though. Ain't allowed to pick up riders and company rules. Might be lucky and catch a wildcatter, but I doubt it. Thanks. See, you sure you're all right?  You sure look like you could use one. Yeah, that's a good idea. For ride turns up, I'll call you. Thanks, Mac. Oh, I'm not Mac. I'm Al. Mac works days. Halfway decent when I came out of the lunch wagon. I had cleaned myself up and reduced my capital to 15 cents. Al had a customer. Yes. Oh, Al, that'll be 480. Oh, hey, bud. I got you a ride, South. You have? Uh, who with? Little lady here. She's been driving all day. Got an awful headache. She's going straight through. Uh, here's a fellow I was telling you about, ma'am. The one that's going South. Oh, well, I'm afraid you misunderstood. I just said I wished I had somebody to drive me. Oh, well, I don't blame you for not wanting to take a ride, or, ma'am, but I'd appreciate it if you'd change your mind. I'm in an awful big hurry. Well, I-I am tired. Well, go ahead and miss. He's a nice fellow. Oh, if you'll vouch for him. Oh, now, wait a minute, lady. I don't vouch for nobody. Oh, I guess it'll be all right. It was a pleasure to drive for her. She didn't say much. And I didn't feel like talking. She just sat beside me. Her eyes closed, resting. Once in a while, I snatched a quick look at her. Long, dark eyelashes resting on her marble-like cheeks. Maybe this terrifying day would end up all right. Feel better? Much better.  I'm afraid I'm over-cautious. Oh, I wouldn't say that. Can't be too careful. One reads of such awful things happening on the road. Awful things. I hadn't thought of Belden since we left Al's gas station.  And unconsciously, I tramped on the gas pedal. You're going awfully fast. These curves are treacherous. I'm sorry. I swiped him. I'm sorry. I...  What about it? I thought I'd heard it before. Before? Look, maybe I'd better drive. No, no, I... I mean, I'll be all right. I'm sorry. Pull over and stop. Huh? Pull over. I'm going to drive. It drove about a mile, I guess. Neither one of us said anything. And then, without any warning, she took an abrupt turn off the highway and down a rutted dirt road. What's the idea? We better stop a while. You don't look so well. I'm all right now. You don't look it. Better have a drink. Reach in the glove compartment and find some scotch. No, really. I'm all right. Maybe I need a drink. Maybe it was a drink. Maybe it was a girl. Maybe it was just relief. But I felt calm for the first time that night. I watched her as the glow from her cigarette led her high cheekbones.  What's your name? Ridge. Mine's Virginia. Hi.  It's all right. Things like that happened to everybody. Yeah, I guess so. Well, look, I'm all right now. I could drive. What's your hurry? Well, I thought... What's the matter?  No, it's just... Well, I thought you were in a hurry. I'm not now. Are you? No hurry at all. It was so gradual. I caught a trace of warm perfume in her hair. She smiled at me, one of those... one of those elusive smiles. Half innocent, half... had touched my shoulder. I accepted the invitation. Like you, Ridge. Like you a lot. You know, tonight back in the... filling station when I first saw you, I... What's the matter, Ridge? That miniature license tag on your keyring. Yeah. 4L5555. Four of a kind. Four of it. Four of it. You play license plate poker? Mm-hmm. It's fine. Four fives. The license of the car that picked Belden up after he tried to kill me. That's right, Ridge. We're in it with him. That's right, sonny. Oh! In a moment, we continue with the fourth act of... starring Elliot Reed, act four of... four of a kind. Fell out of the car. Hard. I didn't black out. I could see in here. Took your time getting here? I couldn't help it. You were supposed to be here waiting. What if I hadn't been able to keep him? Oh, I knew I could depend on you, darling, to detain him. What's that supposed to mean? Did you have to go as far as you did? Did you have to let him kiss you? Do you know a better way to keep a man on ice? The perfect wife. A little help me.   Sure no one's discovered the car yet. Of course not. The way it's lying, nobody will see it until daylight. And then J. Stuart Belden will be found dead, burned to an unrecognizable crisp. And we can shake this place. Go to South America. You can go. I have to stick around, remember? Collect the insurance. Pretend I'm heartbroken. You're dead. Is that going to be so hard? Don't be silly. Come on, hurry. Gotta work fast. Give me a hand with it. No. Wait. Here comes the car. Do you have your wallet? I'll put it in his pocket as soon as I can get him out of the car. All clear? Yes. I tried to move my arms just a little. Then my legs. They hurt like they'd been asleep for a long time. I'd only have one chance, one chance, if my muscles coordinated. I'd wait until he dragged me out of the car, and then I'd do the best I could. Virginia, get the gasoline can out. I felt him grab me under the arms. I opened my eyes just in time to see a murderous wrench in the girl's hand. As she brought it down, I closed my eyes. Something hit me hard, but it wasn't the wrench. It was Belden. The wrench had folded him up, and he collapsed on top of me. She didn't know I was watching her. She was too busy dragging Belden over to the rim of the cliff. Well, Stuart, this is how you planned it. Accidental death. And then she pushed him, and he disappeared over the edge. I didn't wait to see any more. I crawled out of that car, and I started to run right down the middle of the road. Then she saw me. Wait. But I kept on going. I heard the car starting. She was coming right at me. First, I thought she was just trying to catch up to me. Then I realized she was trying to run me down. She was trying to kill me. It was just a question of seconds, and suddenly, around the bend, a big truck. I was sandwiched between them, stunned with horror, her scream ringing through my head, and the picture of her in the car squirming off into space into the canyon below. Hey, hey, bud. You all right? Yeah. Oh, what happened? She went off the road. Crazy woman driver. Who are you staring at? Our license plate. CM 1111. Oh, look here. My fault. You saw how it happened. Four aces. I'd won. Turn off, poker. License plate, poker. The stakes can be too high. Women robes since production of Four of a Kind, written by John Bagney and Gwen Bagney Gielgud. In just a moment, the names of the supporting players are about next week's story of suspense. Supporting Elliot Reed in Four of a Kind were Joan Tompkins, Alan Reed, Jack Krushen, and Barney Phillips. Listen. Listen again next week when we return with another tale well calculated to keep you in. Suspense.


I am going to focus now very specifically on the classroom situation, classes and laboratories and this goes back to what I mentioned in the beginning about two things. Recognizing the equal worth of all individuals and secondly, recognizing everybody is learning and it is to ensure that everybody is learning and that nobody drops out. The reason why a lot of people began to do research on STEM and STEM communication is because it was felt that how we communicate, how we exclude current issues affects the progress of different people to scientific careers. So if women or if people of certain backgrounds were doing very well in school but do not progress on to careers in science and engineering technology felt it is partly due to what happens in the classroom whether we encourage or discourage people of different backgrounds. So here we are going to discuss some of the best practices relating to this. So it is felt that inadvertently without us consciously having a bias some it encourages so a lot of studies have shown that progressively as you grow from school to tertiary education to college university higher education the number of women keeps decreasing likewise with many other groups as well. How do we ensure students who perform exceedingly well very well who are interested in science engineering technology mathematics are able to pursue those interests let us forget about parents and society and so on us as teachers what can we do. So this here we are saying that there is socialization that happens in the classroom that is there are certain kinds of teaching habits that affect how students decide about their careers. What kind of careers they can go on to it depends on what we teach how we teach what kind of examples we do in the classroom all of those kind of things. So some general guidelines are given in this way and that is why the STEM approach is very important if instead of focusing very narrowly only on mathematics or only on biology only on physics if you can make it much more interdisciplinary and focus on problems it is found that more children will be interested of all backgrounds in going in for careers in science and engineering. So why for example is that you know in India we have a very large number of teams spending crores of rupees on smokeless chulas most of them have not been adopted in India most of them are worthless all that money has gone down the drain could it be because women themselves who are involved in cooking are less involved in the actual research. So you need to deal with expertise in cooking so many of the smokeless chulas the cook stoves go wrong because they are not adapted to the different cooking needs they can cook rice they cannot cook chapati they cannot cook dal they can cook something else. So bringing different skills together to understand a problem will ensure that people retain interest in science engineering math. If you teach the subject in an abstract way through textbooks only in terms of very narrowly focused problems then maybe people may not be very interested there is this very famous textbook in physics I think it is called Resnick and Halliday isn't it? Some of the principles of physics are taught only through weapons missiles and rifles and all that if I am not interested in military hardware then I lose interest in physics instead if you can show how physics is useful in daily life some people may retain interest. It is important we include involved more women so beyond scientific research outside of science how are these areas how are these concepts and theories useful incorporate personal experiences very interesting examples have been carried out by this Ekulavya group in Madhya Pradesh it is called the Hoshangabad Science Education Project. So biology for example if instead of teaching through textbooks you actually take them out and tease them with real plants they learn it better. If you are interested in learning about soil and geology take them and teach them about actual instead of teaching them only through textbooks. So using personal experiences of children outside of their houses makes them much more interested in science education and here we find women's experiences in the house especially left out while designing education textbooks examples and so on. Simple example is kitchen in Hindi Rasaian Shastra and Rasoi have the same root and all over the world chemistry first started in the kitchen because what do you do in the kitchen distilling and mixing and all of those kind of things isn't it. But how many of the how many people actually think of what we do in the kitchen as chemistry and how many of us use examples from the kitchen in the laboratory very few of us. So there is a disconnect between what happens in real life and what happens there. So that's why we are saying here Professor Fatak who started this initiative always keeps talking about silos avoid silos. What silos means is that we split up different branches of knowledge and teach them separately whereas bringing the different branches together understand means that more people get interested in science technology and mathematics and especially women and other marginalized groups the dropout rate from higher education decreases. Of course as we have said language should be gender neutral or neutral towards other communities and so on don't use models which are only reductionist or dualistic it's not only either or black and white one and two many things are gray. So how can we understand problems as having multiple causes so it is possible for example that a tsunami causes flooding in a coastal area but it's important that we go beyond tsunami to look at the structure of houses to look at environmental degradation which is causing flooding. So understanding multiple causes means that more people can relate to the concepts and theories or disease we are only taught about germ theory of disease. But germs occur because of hygiene because of sanitation issues because of diet some people who are malnourished get affected by diseases more. So exposing students to all of these means that they understand grasped concepts better that's why this STEM approach is very important discuss practical uses much more. And this ensures that more students retain interest in science as opposed to only using hypothetical problems examples which don't have everyday usage. Some specific kinds of instructions in the classroom one encouraging all of these generally in every classroom you all will know when you ask a question some people will raise their hand some people will never raise their hand the front benches will always have something to say back benches will not say anything but that because inhibitions. So do you always call upon only the person who is raising the hand that's what I did here okay that was I could you couldn't help it there may be people who may be shy who may be timid you have to identify them in smaller you can do that in students you can't do it identify them and encourage them to speak. So if you only identify those who raise their hands then other people get discouraged thinking teacher is not interested in me that's one way of encouraging you have to establish class norms that if some students ask questions others should not ridicule them cheer at them then they get discouraged forever this especially happens with boys and girls waiting time sometimes we because we are we know everything we think students also know everything we ask a question then nobody responds I give the answer but some people take time to formulate the question to formulate the answer some people are waiting for somebody else to raise the hand before I can say something nobody wants to be the first so waiting time is very important so that you encourage more people who are shy diffident timid to also participate in classes these are some ways in which you can encourage more people especially girls to participate more in class and get an interest in science subjects when you have large classes there are some classes here in IT where we teach 350 students in such cases you have to divide them up into smaller groups give more writing exercises some people are not always good at speaking they are better at writing so I have noticed also that some people do better when I make them present in class others do better when I give them writing so having more varied kind of assessment and exercises means that more people do better in class if you're teaching undergraduate students we have started this experiment in IIT now the teaching assistants who help us teaching in the classroom learning in the classroom some students have doubts I only have one hour so we have extra tutorials we find that for undergraduate students they are intimidated if they have senior PhD students who are acting as tutors if we can identify their friends to help them then they are more willing to come forward and accept that I don't understand something please help me to understand in laboratories also generally if you don't intervene at all what happens is they will divide themselves into groups of girls groups of boys so it's important that the group is mixed that the also it should not happen that only those students who get very high marks form themselves into groups and those who get low marks form themselves into groups so if you have more mixed groups they can learn from each other and what happens in the lab has to be connected to the research topics otherwise it just becomes mechanical kind of activities and students don't develop an interest in science provide role models so when you're referring to scientific work or I've visited a lot of engineering colleges and mostly they have pictures of male scientists hanging in all the classrooms and the libraries and the computer rooms provide role models try to increase the proportion of women faculty or if you don't have at least invite guest lecturers so that they understand that women also are a significant part of science and acknowledge women's contribution to science using these role models there are plenty of them in India itself ok of course make sure that your language is gender sensitive as we have learned earlier use examples all can empathize with so if for example you always use examples only relating to the military relating to weapons or arms or relating to astronomy and so on or high technology mission Mars not everybody will be interested some may be interested in other kinds of projects so one student here he mentioned to me came over very poor family from a from a village he explained that in civil engineering they only talk about all high-end luxury apartments and stadiums and planetariums they don't talk about low-cost housing and therefore he completely lost interest in civil engineering even though there are real problems to solve in India in general you should have all of these kinds of things in the classroom discussion debate it's okay for some people to disagree learning in groups and learning through consensus building that is trying to arrive at a common way of understanding things the first one is it true or false true B is false C false true D false okay these are things that you should try yourselves in your classroom so try to find out which kind of students have what kind of learning problems is it because of language so we say for example that subjects in humanities and social sciences because they are much more conceptual theoretical they require more language skills is it because of that or even in other subjects physics for example which is the lot of theory so a lot of students have difficulties even in IIT in understanding lectures because their English is not good enough is it because of their educational background family background is it because some concepts theories are very difficult to understand so which kind of issue do students have problem with and try to address those in the classroom how many of you make it a point to a give a chance to everybody in the classroom you do that okay what roughly 30% okay so and sometimes it's not possible because there is too much pressure on us I have to finish the syllabus I don't have time for discussions okay but in such cases what you can do is to spread out in this class I will ask these students next class I will give a chance to somebody else but also through tutorials through smaller groups and so on does the how often does this happen in the classroom the third point happens it happens but what happens is sometimes irrespective of the right or wrong answer if it's a girl who is saying it they start lapping okay or sometimes they in IIT they use a term called Magoo this guy is called like in English they use the term nerd any ad you know this person is very bookish therefore he doesn't play or she doesn't play the rest of the students don't like him or her and therefore when that person answers everybody starts clapping okay so there are these targets for some students so students can be very insensitive they're not mature okay so we have to ensure that it doesn't because in some cases some students can get very depressed it can have lifelong consequences for them okay it's very important that in the classroom there is encouraging kind of clapping but not the discouraging kind of counseling is very important so students have to be told that this is not acceptable again is something you can do in the classroom or the laboratory so with your own colleagues for as part of MOOCs or further workshops I suggest that you can do this but focus on these kind of issues teaching teacher-student relationship interaction between students in the classroom or in the laboratory how can you change the classroom dynamics so that learning happens for everybody and not only for a few people okay so I think I'll stop here


Hi, my name is Bala Ambadi. I'm an ophthalmologist at the University of Utah, and today I'd like to spend a few minutes with you discussing endophthalmitis, or infection inside the eye after cataract surgery. The main risk factors for endophthalmitis are elderly age, more than 80, immunocompromise, such as HIV or other immune deficiency disorders, severe bluffritis, or poor lid hygiene, if there's a lot of matter and crud on the eyelashes and eyelid margins. If there's a poor construction of the wound, if the wound at the end of cataract surgery is leaky or doesn't seal well, that's a huge risk factor for infection inside the eye. And then very importantly, if there's any intraoperative complications, such as posterior capsule tear or vitreous loss. This is what endophthalmitis can look like. As you can see on the left picture, there's a hypopian at the bottom of the anterior chamber, as well as fibrin within the anterior chamber, resulting in an irregular pupil due to synechia formation. There's also loss of the red reflex, indicating vitreosopacification. B-scan ultrasound can show these vitreosopacifications and fluid collections or abscess formation within the eye. And if you don't have a good view of the back of the eye, a B-scan is mandatory to look for endophthalmitis in any patient who you suspect of it. The signs and symptoms that lead you to suspect endophthalmitis are pain that is unresolved with topical anesthetic or redness of the eye, especially around the limbus, which is called ciliary flush. If there's in severe injection or ciliary flush that's not resolved with dilating drops, that can also be a clue that there's endophthalmitis. Of course, decreased vision, loss of the red reflex, and everything I showed you on those slides before, fibrin formation in the anterior chamber, hypopian, vitreosopacities, all of those can point you towards a diagnosis of endophthalmitis. The main causes of postoperative endophthalmitis are skin flora such as staph aureus or staph epidermidis. Streptococcal infections can also occur such as strep pyogenes or strep agilactae. Pneumococcus tends to occur in the context of cataract surgery in patients who have had previous glaucoma surgery such as blebs with trabeculectomy or tube shunts. Bacillus can infect a traumatized eye and Bacillus is typically found in endophthalmitis after some sort of penetrating trauma that's not surgical. Why is endophthalmitis important? Well, you can lose vision permanently or you can lose your eye. This is a very serious devastating complication of cataract surgery. It's very feared by cataract surgeons and patients and so it should be made clear to the patient that anytime you do surgery there is a risk for infection that you could even lose your eye with. It's a very low risk but it's not zero. Even if you save the eye there can be complications inside the eye such as scar tissue formation on the retina or other intraocular structures, retinal detachment or long-term glaucoma. How can we prevent and reduce the risk of endophthalmitis after cataract surgery or other intraocular surgeries? First, treat the patient's eyelids and skin. If they don't have good hygiene, talk with them about what you want them to do to optimize their eyelids and facial hygiene before surgery and phrase it in a context of not accusing the patient.  Tell them to reduce the risk for infection after surgery. You want them to do X, Y and Z and so that will go into the conversation of blufferitis management, facial hygiene and so on. Make sure they have an access to clean water in this discussion. Then during surgery, of course avoid hitting the posterior capsule. Avoid losing vitreous but if you do have those complications, if you do encounter vitreous make sure you have a clean vitrectomy so that you don't leave vitreous adherent to the wound. Adherent vitreous strands can cause CME but they can also be a wick for bacteria to get into the posterior segment of the eye. About two years ago, I switched to using intracameral antibiotics on all of my cataract surgery and this has been very helpful. I use intracameral moxifloxacin on every single feco emulsification procedure that I perform. Alternatives to moxifloxacin include intracameral suffuroxium and intracameral vancomycin. The reason I prefer moxifloxacin more than the others even though it's a bit more expensive is that at least in the United States context there is no suffuroxium formulation available and even if you do compounded suffuroxium there's a risk of TASS or toxic anterior segment syndrome. In Europe and perhaps in the countries that you're in there might be an intracameral suffuroxium formulation called aprochem but I believe that is very expensive. The reason I don't use vancomycin is that there is a rare but devastating risk of something called hemorrhagic occlusive retinal vasculitis, HORV, H-O-R-V. And anytime you have the word retina with occlusion or vasculitis that's a bad thing, right? We don't want to go there. As cataract surgeons we want a normal retina that's not bothered. Moxifloxacin which we get straight from the Vigamox bottle and you can divide it into probably 15 injections from a 3cc bottle of Vigamox is a little bit more expensive but doesn't have any of those other potential side effects or complications. For patients who have surgical complications where there's vitreous loss in addition to doing intracameral antibiotics I will give them oral moxifloxacin 400 milligrams a day for one week, maybe 10 days, as well as considering doing subconjunctival antibiotics including vancomycin and septazidine into the subconjunctival space not into the eye. If a patient gets end opthaminus after surgery this is something you have to jump on. If you have a cataract post op who's calling you at 2 in the morning with severe pain don't wait till the following morning. Go in and see that patient at 2 in the morning because every hour that the patient is not treated you can lose retinal cells. If the patient's vision is hand motion or better usually intracameral antibiotics are sufficient again vancomycin or septazidine. If the patient's vision is light perception or worse then they need a vitrectomy. That person doing the vitrectomy should be a retina surgeon somebody who's skilled at doing a parisplina vitrectomy and taking care of the retina. Together with the vitrectomy doing intracameral antibiotics is a good idea. Post-operatively I would give oral moxifloxacin for probably two weeks. Make sure whether you do the intracameral injection or vitrectomy surgery that you get a vitreous culture. You want to send that to the lab for microbiologic evaluation because you might have a fungal infection. You might have a rare bacterial infection and either of those situations you might need different drugs than what I've just discussed with you. Thank you very much. Again my name is Bala Ambadi and it's been my privilege to share some time with you discussing end ophthalmitis. Thank you.


Hey guys welcome to Snowbreak Containment and I am officially back from vacation which is a long long time I know but we have some goodies for you for Snowbreak it's gonna be three days before we can't officially launch so we have to know these things before we go to the launch date which is going to be on July 20 so we're gonna be starting with the newest announcement that they made so you can already do a pre download okay of Snowbreak Containment starting tomorrow July 18 UTC 8 at 3 p.m. so these pre downloads take note are available for Apple Google and Windows platforms this will start again in July 18 tomorrow at 3 p.m. so please make sure that you do a pre download because after you do download the software you'll be downloading additional resources for the game so that during launch you'll be able to play right away so no interruptions during launch once the servers are up you're gonna be playing your hearts out until you're gonna be you know it's going to be a very addictive game I've been playing this during my vacation for the CBT up until it ended so I did a lot a lot of playtesting with some of the characters not all unfortunately the official launch by the way is going to happen on July 20 UTC 8 10 a.m. so that is a reminder because I actually just saw the time I know the date the time I am happy that these days they they they stipulated it here but again take note pre download the game make sure that you download additional resources and more or less you can automatically or can down you can play the servers as soon as they are up okay but before we are going to finish with this we're going to be reviewing some of the things that you must know probably some details that you didn't know pre download then we have pre-registration pre-registration guys is actually ongoing still we already achieved pre-registration you have apple cool play and windows pre-registration is important because might I suggest that you pre-register through your email I know you could pre-register through iOS and through iOS and through Android but if you pre-register for using your email through the website you can actually join the draw the draw is going to be happening I don't know the complete details of the draw you can actually access the website all of the details that I'll be discussing their pre-registration link the website it's going to be all in the description so you know you could actually feel free to go through the link go through all of the details including the raffle so that you could be informed as well if you plan to join the raffle so again these are your prizes here in terms of okay this is the prize draw the gifts for the pre-registration like to go back to that so the pre-registration gifts are going to be these so we have silver buck digikash digikash this is important the operative recruitment shit we'll discuss more on that the skin for your main character then the exclusive weapon which is actually purple rarity but it's actually good go going back to the prize again please make sure that you pre-register using your email so that you could participate in the raffle we'll be going to a summary in terms of all the benefits that we would be getting when the launch starts then up until probably the launch events happens up until the last event okay so official launch benefits overview so claim up to 60 plus echoes including weapon permits and operative recruitment shits redeemed for the from digikash so echoes is I think the term in terms of summons so this means is 60 echoes 60 total summons including digikash digikash is converted to summoning you know tickets but this is actually 60 plus a mix of operative recruitment and weapon permits so seven day missions you have seven 14 day login rewards you also have here operative recruitment shit the main story completion benefit you also have so there are a lot of summoning opportunities within the game so you just have to make sure that you know up to when you're gonna be receiving this and pre-registration milestone rewards of course will have digikash and operative recruitment shits one thing to note guys we have a is a selector ticket for a orange tier operative so we have five to choose from I'll be doing a separate video on this gonna break down each character so that you could have a better understanding on who you're gonna be selecting for that selector ticket take note that that selector ticket is going to be available and after the main story 5-12 so you have to complete you have to complete 5-12 for you to be able to use that selector ticket okay next up is going to be controller support so don't forget the game is actually friendly for controller support but I only read for a while that it was stipulated that you can really use Xbox and PlayStation controllers I think 4 and 5 will have to know as you play this if you could use the other controllers that for example Nintendo switch because I myself have a switch so I'll have to test it out and give you more information but if you guys know already that other controllers can be used please do comment in the comment section of this video so that we could share it with other players in the community and again it's gonna go back to it's gonna go back to the benefits please do check them out also these content the content are available in the official Facebook page but all of the links I will put in the description including Facebook website pre-registration just in case if you need to know all those details so that is it guys I'm actually happy to be back it has been you know it has been a while since I you know I will be you know I haven't been doing videos but I'm actually happy to be back and expect more from me in the coming days as we cover snow break containment zone so thank you very much guys for staying this far take care stay safe this is The Warden and I'm out of here


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Bismillah Khman Reem and As-Salaamu Alaykum Pakistan. Welcome back to the corporate governance module and we are going into the nitty gritties of corporate governance and the various stipulations of the Securities Exchange Commission of Pakistan Act and again we are seeing that how the directors and how financial reporting should be taking place. Today, ladies and gentlemen, we are going to talk about a very important topic and that topic is corporate and financial reporting framework and this is extremely important in the context of how the various financial and corporate reporting is basically done and what are the different stipulations. Now, the first thing is all of you do know is that the directors are responsible in listed companies and they are responsible that they have to include the statements prepared under section 236 of the company's ordinance. So, what do they have to oversee? Number one, the financial statements of the company. Number two, proper books of accounts and number three, appropriate accounting policies. So, these are the three main items or responsibilities of the directors in the context of the reporting framework. Now, when we look at these then another very important thing is that they also have to foresee and also ensure that the international accounting standards are met. The system of internal control is there and again that the listed company has the ability to implement these international accounting standards and the system of internal control. So, this ladies and gentlemen is extremely important and the directors have to ensure this because this is a very backbone of corporate governance and of listed companies own credibility and again all of this is being done in the context of good governance and corporate governance. Now, another thing which the directors report must disclose are the reasons that why they did not consider a company to be a going concern. Why did they not declare the dividends or bonus share for the previous year? So, these two are also mandatory in the directors report. Now, when we look at other contexts and other dimensions there are outstanding amounts in respect of taxes, duties, levies and charges along with its amount that has to be specified in the report. All material information relating to the business effect, the market price that also has to be a part of the report so that the stakeholders and the shareholders especially the smaller shareholders they have a appropriate and a completely contextualized understanding of the financial performance of the firm so that they can take the right directions and reach towards the best of results. So, that is again what we see again in this unordered statements should be published and distributed by the directors. Statutory audits should review half-ordered financial statements and the CEO and CEO have to have the annual accounts and quarterly accounts maintained in the best possible way. So, this is again what we see and have to be included in the directors report. Annual statements should be distributed no later than four months after closure of the financial statements and every information has to be registered and delivered to the Securities Exchange Commission of Pakistan. So, again what we see ladies and gentlemen is that in the reporting framework there is a lot of responsibility of the directors of a listed company and there are various stipulations which have to be met if they are not met then that can lead to many fines and penalties and also various closures which can take place. The statement has to be candid, has to be truthful, has to be basically encapsulating the most genuine statistics and performance results of the organization so that the smaller shareholders and the other stakeholders can take the right decisions in the future for that particular listed company. And most importantly again is the fact that every information has to be delivered to the Securities Exchange Commission of Pakistan for future reference and also to ensure that there is a continuity of financial policies which are there within that particular organization and so these are the reporting frameworks which have to be maintained by the directors of the board. Thank you so much.