Thank you, Boel. And thank you, Nat, for a wonderful talk. It's always a great opening session for the conference. And we'll touch on some of the themes that Nat raised as well with these two cases here. So as often happens with aortic insufficiency cases, the primary indication for surgery is not necessarily that related to the direct severity of the AI as is measured instantaneously, but to some of the related pathology or secondary morphologic changes that happen as a result, such as ventricular dilation or aortic aneurysms. And these two cases kind of further illustrate that as well. I have no competing interests with respect to this presentation. So our first case is a young patient with Marfan syndrome, chemopinetic differential diagnosis that Nat put up for aortic aneurysms. She was diagnosed as a young child after her mother passed away quite suddenly, unfortunately, in her 30s from aortic rupture. And she'd been followed since then. And she was known to have an aortic aneurysm that was followed with serial imaging. And about three years before coming to us, it had reached 46 millimeters. And she was taken to the OR for an attempted valve sparing repair. Unfortunately, this had to be abandoned because she had pretty severe Pectis and the exposure was very limited for the surgeons. So they basically closed everything up and consulted the surgeons here. The recommendation was to actually send her for a ravage procedure, which is a modified version of the NUS procedure, which you may be more familiar with. But the ravages, from what I understand, use more commonly in adult patients because for the NUS it works best when it's done on young patients who are not, whose bones aren't fully developed yet. So she had the ravage procedure done and had the bars in for a few months before coming to us. And the bars had just been removed a few weeks prior to her OR. Otherwise, her prostate was significant for some of the common comorbidities of Marfan syndrome, including mild asthma. So her pre-op evaluation included some CT, ECHO, and angiogram. She was asymptomatic from a cardiac functional perspective. And her aortic root now was at 55 millimeters. And looking at the trend of her size measurements over time. So starting from when she went for the first OR three years ago to when she came to us, to the OR here, you can see why 50 millimeters is often the criteria that threshold for operating on these patients. Because you can see how the growth of the aneurysm goes from a fairly linear trend to suddenly becoming looking much more exponential after that. So not all patients obviously follow this exact trend, but she was a good illustration of why that number is there. The other finding we had in her pre-op imaging, which I'll some of which I'll review, is that she had annual dilation and prolapse of the mitral valve with only mild MR. So the question was whether we should fix this or leave it. She's a young patient. You don't want to replace the valve, but it may be repairable. And obviously the reentry arrest for a restronomy in this patient will be very high if we leave it. And she has to come back to the OR a few years and a few years time. Her LB function was preserved and there was no CAD on the angiogram. We had some of her external transoracic images on our system, so I'm just going to go through some of those. She has some atrial enlargement related to the possible for the elevated pressures of the AI because she didn't have a lot of MR. Her ventricle was definitely dilated. Here the diastolic diameter is measured at 5.4 in the peristernal long axis view. Looking at her function in the OR, she had a fairly typical sort of bulb or globular LV. Now our image is a bit foreshortened as well. And as I pointed out in her talk, you kind of get a fourth chamber where the fourth chamber is the aortic root. And you kind of see that here as well on the left. And her RV function was reasonably normal. And her LV function was probably well preserved, but you can definitely see that thinning and dilation of the ventricle in this transgastric short axis view. And note that we're imaging at a depth of 10 centimeters. So that sort of clues you in that if it takes that much space to fit the ventricle in. Looking at the aortic valve, this is a aortic valve short axis view in the middle itself, I guess. Notice the leaflets are fairly normal. You have a nice clover leaf shape. You do see a bit of a co-optation defect in the center. And if you look at the edge of the right coronary cusp, you may sort of see a double line in a few frames. So there may be some prolapse there. That double line is a pretty sort of telltale sign. This is actually the best long axis view we had was from her thoracic thoracic, which shows a little bit of prolapse on what is the left or the non on the right hand side. To this image, these leaflets would be reversed from what you're used to from the trans salvageal echo, because the right cusp is at the top here. And we're seeing possibly a little bit of prolapse as well as I think that line you're seeing. Let me see if I can get a laser pointer here. This abnormality here is probably just the edge of the cusp that we're catching. That's the line there. Putting on some color in the short axis. We see that this is both a central jet and what looks like a commercial jet as well between the right and the left cusps. And it's good to always look at your blood pressure when looking at these color droplets. And I'll show a few examples where we're comparing the pre-op trans thoracic to the interop. A trans salvageal echo and what difference the blood pressure can make. So we can go into the summit for deep trans gastric. Again, we see a fairly central jet. Obviously, the goal here would be to ideally repair this valve. And so far, there was a little bit of a concern about the leaflet prolapse, but the valve was fairly normal. And having a central AI jet is sort of a reassuring factor. But you notice that this jet is not entirely is not entirely a central jet. So you have a central component, that's the predominant component, but there does seem to be one area that's going towards the septum here. And that raises some concerns that there might be leaflet, more leaflet damage than we've seen. Looking at measurements of the route on top, we have the trans thoracic measurements from pre-op and the interop measurements from echo from TE at the bottom. And you can see they're generally in fairly good agreement. So for the sentence of El Salvador measurement, we're about three millimeters within three millimeters. And in the trans ophogil, we also were able to measure the diameter, all three diameters. And you can see the significant eccentricity. So they go up the range from as low as 4.4 to over five centimeters. The biggest difference you actually got was in the measurement of the annulus, which was about four millimeters different 2.9 on the trans ophogil. And that's significant because it looked like there was no real annular dilation previously, but the annulus is slightly dilated. Let me look on the TE. Looking at the vena contracta, and again, in this patient, the key decisions did not rely on severity of the AI. But I will go through the evaluation of the severity to illustrate the case of the comparison between the trans thoracic and trans ophogil. I have some good points. So on the trans thoracic, with the blood pressure of 162, she had a vena contracta of six millimeters, which sort of threshold for severe. And if she was coming, if her social indication was the severity of the AI, this would sort of qualify her for surgery. Whereas on the trans ophogil, with the disloct pressure now of 40 instead of 60, we're measuring about three millimeters, so half as much. Obviously, the orifice itself is not entirely circular, and these views are not directly comparable. So some of the difference has to do just with geometry. But it's very likely that this jet, especially if you compare it to the alveoterea, is smaller now under anesthetic conditions. Looking at the pressure half times, again, you see that these are sort of in a moderate range on the trans thoracic, just around 500, but in more or less the normal range on trans ophogil against comparable pressure difference. So again, it's important to, if you can, document the blood pressure at which you're taking these measurements for future interpretation, especially because in the OR, as you can see, the blood pressure can be quite labile. So if you're getting unexpected numbers, it's always good to repeat the numbers under different hemodynamic circumstances. And looking at her descending aorta, we have the pulse wave Doppler in a descending aorta long axis view, and we have some early reversal that's pretty clear, and it looks like there is some late diastolic reversal as well. A lot of times, in a lot of sort of borderline cases, you get this fuzzy signal under the line, and it's not totally clear whether that's noise or how much of it is real, but certainly it's not the very classic severe pattern, which is often fairly unmistakable, but to keep in mind that here the blood pressure was fairly low now, 80 to 90 over 35, and again that can influence the severity of the reversal that you see. So in this case, we have a bit of angular dilation in terms of mechanism, so the cause in her case, to clarify that point, would be her Marfan's syndrome and the connective tissue disorder that that includes, but the mechanism is dilation of the annulus and the aortic root. Her ascending aorta is generally intact. There was some dilation at the STJ and the proximal ascending, but their men are fiora was normal in investigation, so she fits in a sort of between the B and the C category or B and a half. So the decision was to take it to the OR for valve sparing root repair with a 28 millimeter graft and also do a mitral annulplasty and left atrial appendage ligation. Because of the very high risk of reentry, so she had a previous sternotomy for the attempted repair, then she had previous surgery on the sternum for the ravage to repair her pectus, so the risk of reentry was quite high, so they accounted her by the femoral artery in vein and went on bypass before opening the chest and replacing the cannulus to central cannulation for the surgery. Coming off, we have the same imaging issues that I mentioned, so you have the graft material in there and the valve has been resuspended. The leaflets on surgical inspection were found to be fairly normal with just a little bit of thickening at the tip of the red coronary cusp. And here we're seeing essentially no residual AI in this image, and we looked at other views as well, and it was comparable. You see the thickening in the space between the aortic root and the left atrium, that's the graft coming in. And we can see the leaflets fairly clearly. And it's important again, initially coming off pump, the surgeons are often obviously keen to know whether there is any significant AI, because they want to know if they need to go back on pump or not. But at that time, the blood pressure, especially labile, and it's important to repeat these measurements once the blood pressure normalizes as well, because this is reassuring now at this pressure, but we need to look at it again once the diastolic pressure is up in the 60s, 70s, 80s, as well. Looking at the morphology, here it looks fairly good. We zoom in. And this is sort of three good prognostic factors for the durability of this repair. So the first is the co-optation height, which is the actual length of the two leaflets are contacting each other. And there's a good evidence that if this is above four millimeters, the risk of residual worsening of the AI is fairly low, even if there is a trace AI immediately. The other good prognostic indicator is the fact that the co-optation point, the point where the leaflets first come together, is above the annular plane. That makes it a much more mechanically advantageous place to be, because it's not experiencing downward forces. If the leaflets are meeting down here, there would be a constant force trying to push them further down, and that would stress the attachments of the leaflets to the aortic root, and cause a stretching over time and further prolapse. So this is very positive. And the last thing is the size of the annulus itself, which was in this case about 22 millimeters, and an annulus under 25 is also a good prognostic factor. A more dilated annulus, again, typically entails more stress on the leaflet suspension, and more risk of stretching and deformation of the root over time. The mitral annuloplasty was also pretty successful. We've seen no turbulence on the inflow here in the four-chamber view. You see the fairly thickened leaflets there. We don't see any SAM or any LVOT, ex-flow acceleration. And looking at the gradients of both valves, the aortic is amena 4, peak of 10, and the mean gradient for the mitral valve is 2. And the ventricular function was well preserved here. And you can see the ventricular actually looks much smaller now, and it would be sort of convenient to think of this as the remodeling resulting from the repair, but obviously this is just due to the fluid fluctuations prioroperatively, and it would take some time for this ventricle to start returning to kind of a more normal shape. Unfortunately, we also discovered this, which we hadn't seen before, because now that the left side of pressures are slightly lower with reduced AI, this PFO, which we had missed previously, the side of the show itself. So it's always a good idea in patients where you're suspecting elevated left pressures to do a bubble study or a valsova maneuver to check for a PFO.  It's not a very large one, but it would have been nice to fix it while they were in there. So we had tribute residual AI, a good prognostic indicators for durability of the repair, and a good mean gradient of four, and a successful multiranguloplasty. But unfortunately, we missed the PFO. So I'll talk a little bit about pressure half times. You saw the use of pressure half time in the case there. And basically, we spend a lot of time in peroperative echo worrying about the sizes of holes. And we have different tools for measuring holes. And some of them are morphologic measurements like vene contact and plenometry. But a lot of what we rely on, both for historical and technical reasons, has to do with inferences from flow velocity. And that's because historically, we were able to get good Doppler signals long before we were able to get good brightness mode images. And even now, our brightness mode images, depending on the angle and where the structure of interest is, are not high resolution enough for us to get reliable plenometry data. But as the imaging is improving, plenometry is definitely becoming more and more a part of our toolkit. So pressure half time and deceleration time, which are very closely related, are based on the same idea. So if you have two chambers, one with a higher pressure, one with a lower pressure that are connected by some orifice, you're going to get a passive flow from the higher pressure chamber to the lower pressure chamber until the chamber pressure is equalized. And the larger the hole is, the faster that takes place. And the smaller the hole is, the slower that takes place. And again, the model assumes fairly passive chambers. So you're not nobody's actively squeezing one chamber or actively applying suction to the other chamber. And the compliance of the chambers is relatively constant. So as you have volume flowing from the higher pressure chamber to lower pressure chamber, the lower pressure chamber fills up and stretches, and the higher pressure chamber gets smaller. So pressure half time is one way of quantifying this phenomena. Pressure half time and deceleration time are basically two ways of quantifying this. And pressure half time refers to the time it takes for the pressure gradient to go from its initial value to half that value. So for a given size, holy, that's your pressure half time. Then if it's smaller, you're going to have a slower equalization of the pressures. And your pressure half time is going to be longer. So the pressure half time is inversely related to the size of the orifice. But of course, we can measure pressure gradients directly with echo, we measure velocities. And it turns out that in cases where the flow is fairly passive, and the compliance of the chambers in question isn't varying significantly, you can often get a fairly linear profile on the velocity trace. And because we know that pressure and velocity are related by the Bernoulli equation of pressure gradient is 4v squared, having the pressure works out to going from the initial velocity to 70% of the initial velocity. So 30% reduction. We don't have to worry about that this all takes place within the machine. And here's an example that we just saw from AI. And we have pretty nice clean traces. What's important to note that you again, the blood pressure does make a notable difference. So it's not a load independent measure. And you do want to try to make this measurement intraoperatively with blood pressures that are as close to patients resting blood pressures as possible. There's a difference between the trans thoracic and spontaneous ventilated measure of 500 and two measurements, 726 and 627 at the intraop T. And you can see even just on the same trace, it's very easy to get a significant variation just by where you make your click. The other big application of pressure halftime is in mitral stenosis, estimating the area of the mitral valve. And one of the key things with mitral stenosis is that often in the trace, as you get an initial diastolic, this is the mitral trans mitral continuous wave Doppler profile.  And as you get the early active relaxation of the LV, you can get this period of very brief drop, very rapid flow and very brief drop in pressure followed by secondary slope. And it's important to actually use that secondary slope for measuring for estimating the mitral valve area. And so the classical rule of thumb, this is an empirically derived equation. So it's important to remember the units, the pressure halftime is in milliseconds, the mitral valve area is in centimeters squared. And deceleration time is just another way of quantifying the same slope. And deceleration time is always, sorry, pressure halftime is always about 29% of deceleration time just by geometric definition of them. So the MVA formula is 750 over deceleration time or 220 over pressure halftime. But aside from the size, so ideally we want to find measures that vary only with the size of the hole we're trying to measure and are independent of all the other biasing factors. But nothing is perfect and pressure halftime is no exception. And pressure halftime can be affected by really anything that affects the pressure volume relationship of the receiving chamber and less so the source chamber. So that can include any kind of filling impairment such as diastolic dysfunction or enterothoracic or pericardial pressure, for example, from pericardial effusion, high ventilatory pressures, or even just positive pressure ventilation. Anything that enhances the filling, so we saw at the beginning of the from mitral valve stenosis, whether from the high gradient in the original chambers on the left atrium for mitral stenosis, or the active diastolic suction, you can get an initial higher gradients, dilation of the downstream chamber will increase the compliance of the downstream chamber, so that'll give you a longer halftime. So it's important to kind of think about each of these and think about the direction in which they would affect their pressure halftime. So filling impairment generally would lead to faster equalization. If you have a more rigid receiving chamber, the pressure in it is going to equalize much faster, so you get a shorter pressure halftime.  Filling enhancement will potentially shorten the early pressure halftime, which is why it's important to mitral stenosis to measure the secondary slope. And dilation of the downstream chamber, such as you will see potentially in chronic AI with LV dilation, will actually lengthen your pressure halftime and lead you to potentially underestimate the severity of the air deconsoficiency. And of course, any other source of flow into the chamber will affect this relationship. So if you're measuring the mitral valve area and you have air deconsoficiency, then you're going to get a shorter pressure halftime. Now one question is, why can we only use this for AI, MS, and less commonly for PIN, tricuspid stenosis? Why not for the other legions? Why is it, why can't we only use this to measure some or versus and not others? And that has to do with the profiles of the flow. So you notice that any situations where we're using these are where we're measuring dystallic flows, but systolic flows have systolic pressure gradients that are often parabolic. So this is the pressure gradient that drives aortic stenosis. So on top you have the ventricular pressure tracing. On the bottom you have the aortic pressure tracing. So you can see how it's the parabolic driving pressures, similar to from mitral stenosis, from mitral regurgitation, sorry, between the ventricular pressure and the atrial pressure. But for AI and MS, they have these fairly trapezoidal pressure gradients between the left atrium and the left ventricle and dystalli and the aorta and the left ventricle. So the first question is, how does significant aortic insufficiency influence assessment of mitral stenosis severity with pressure halftime? Does it lead you to overestimate it, underestimate it, or does it not make a difference because it's fairly low-independent? And again, we'll cover these with an explanation at the end. And for the second question, the evaluation of AI, is the increased enterothoracic pressure from positive pressure ventilation likely to increase pressure halftime and deceleration time, decrease them, increase PhD but decrease DT, or decrease PhD and increase DT. So moving on to the second case, again, another case where the patient presented with AI but the primary indication for surgery was not necessarily the severity of the legion itself. This patient was 65 years old and asymptomatic but hasn't been followed by a cardiologist because of the murmur and had been referred to the surgeon because he was found to have a moderate reduction in his LV function and the cardiologist was getting concerned about the dilation of the LV. His past history was otherwise significant for hypertension and a remote bout of infection undercarditis. And he really did not like the idea of having a prosthetic valve at all and being on blood thinners. So he had an angiogram that just showed moderate circumflex disease and then he had a pre-op transtheracic. And you notice that we had to depth of the image has to be 19 centimeters. And again, you see the fairly classic or globular rounded ventricle. So the apex is not pointed there, which definitely suggests ventricular dilation. And looking at measurements, we see that the internal diameter in Dastille is 5.9 and the Dastille is 4.9 with a pretty very large end diastolic volume of 283. And we'll look at the normal ranges for these in a moment. But a fairly preserved ejection fraction, although this number is so large that it raises some doubt about its accuracy. And if this number, if the EDV is overestimated and the ESV is measured fairly accurately, we might have an overestimate of the ejection fraction. So it's always very helpful with, if you have access to pre-op echoes to actually look at the images themselves and not just the reports. So comparing this, the guidelines from the chamber quantification by Zogby, the internal diameter in Dastille is 5.9. So that's just the upper limit of normal. But you can see that end diastolic volume is twice the upper limit of normal. And this is the end diastolic volume estimated just from the 2D diameter. And you can see the huge difference between that and this biplane measurement, which is why measuring three-dimensional things with a one-dimensional measurement is not great. Obviously, historically, this is all we had technology-wise, so it was quite useful. But really, we should not be relying on one-dimensional measurements as much as possible. And you can see the AI jet there hitting the anterior mitral valve leaflets, an eccentric jet, suggesting that the chances of repair may not be very high. A pressure halftime in the moderate range, 363 milliseconds. And this is some full reversal in the ascending aorta. And you can see there's definitely some early high reversal and then hold diastolic pattern. So we're probably most likely in the moderate AI range. There's no significant stenosis of the valve. And this is the aortic valve VTI ratio. So the ratio of the VTI from the aortic valve, 27.3 to the one taken from LVOT, which is the average of these about 25. So remember, in severe aortic stenosis, that ratio is about 25%. So it's a 4 to 1 ratio. Here, the ratio is 80%. And you can see the VTIs are quite close. And this is the range for pressure halftime. So 2 to 500 is medium. Less than 200 is considered severe. And under 500 is either normal or mild. So the patient is asymptomatic. He doesn't want a prosthetic valve. So what is the indication for surgery? What's the natural history of this if we leave it? And the best that we have is this one by Benota's side of the guidelines as well. And this is sort of a curve showing the percentage of patients asymptomatic with normal LV function. So this is not survival. These are patients that drop off in the asymptomatic patients. There's a couple of sudden deaths. They followed 104 patients here for 11 years.  While this is not great, it's not catastrophic. If this is a survival curve, obviously, we'll be much more concerning. But the patient's LV is quite dilated. He is already having mild systolic functional impairment. And the AI is at least moderate. So after extensive discussion with a surgeon, they decided to obviously proceed to operation. Otherwise, we wouldn't have the case. Looking at the ACC guidelines on management of VHD and the criteria, this version kind of falls into three possible categories because his EF is around 50%. And by dimensions, we could sort of currently monitor this patient or we could perform an AVR. So it doesn't really help us get a strong answer. So this is in what's to proceed with surgery, with a valve sparing repair, if possible, with a bioproposthetic valve as a backup. There's some initial images. So the function is well preserved. And in fact, it looks a little bit better than the transtheraistic. So I'm going to set up a long axis view on our short axis view. Now looking at the valve itself, there are a couple of immediate concerning signs. So we have a zoom of a parasympathetic long axis view with an x plane through it. And we have this unexpected anomaly here of the non-coronary cusp until we remember that because we're actually x-planing from 120, this view is reversed. So the non-coronary cusp is actually this one. And this is just our left coronary cusp and the left main coronary artery. On most machines, you have the option of reversing this. But always whenever you're looking at x-plane images, they're quite useful. It's very useful to actually scan through and know where your short axis image is coming from in the long axis view. But just keep in mind that the image is flipped. So we see the kind of double line here on the right coronary cusp. And you can definitely see there's a prolapsing segment through the valve, which doesn't increase, looks bad for our chances of repairing this successfully. And zooming in again, you see the same thing. And obviously in the patient with a history of endocarditis, this is likely to be related. The AI jet harbor is largely central. So that's reassuring. And the other leaflets look fairly intact. So there is some hope. But in this view, we have to say that even though the jet source is central, it's fairly eccentric and it's hitting the anterior mitral valve leaflet. Looking at the dimensions, the error group dimensions are fairly normal. There's a mild dilation of the ascending aorta and pretty good agreement between the transsterotic and transophageal views. But then there's this. So this is why you should always be careful about your LVOT diameters. So on transsterotic, we had a measurement of 2.6 centimeters, which yielded an LVOT area of 5.3 square centimeters. But in transsterophageal, and both these measurements look pretty reasonable, we got an LVOT area of 2.86. So almost half. And of course by continuity equation, which one of these would yield a higher aortic valve area? Because one of the concerns with these valves that you have to assess as well as whether they're stenotic. And obviously with one of these measurements, we're much more likely to find the valve stenotic than the other. And the lower your LVOT area is the lower your AVA is going to be for the same VTI. So we're much more likely to find aortic stenosis with this LVOT area than with this one. Looking at the pressure halftimes comparing the transsterastic and transophageal, again, we see a notable difference with the moderate range on the transsterastic and kind of the normal or mild range on the transphageal. Again, both with good traces. I didn't have the blood pressures for these, unfortunately. And the floraversal that we commented on previously, but in the OR we're actually not seeing the floraversal. So we're just seeing some early floraversal and this is but no prolonged floraversal. So also important to note that this is in the ascending aorta and this one was in a descending aorta. So the further downstream you see floraversal, the more likely that is to represent severe disease. So in this patient we have some prolapse that we saw and an inspection of the valve there's actually also a perforation of the leaflet. So we have a combination of sort of 1D and type 2 here. And surgeon described the valve in the left the non-coronary cuts were fairly normal, which was the same as we saw, but the right cuts had a large perforation with loss of substance. A patch would be needed to reconstruct this valve and they deemed that a hangover valve would be more durable for this patient who was her early 60s. A delta-decoronary bypass graft to distal circumflex and ended up putting in a hand clock size 27 bioprosthetic, which is the one on the right there. And coming off we have a pretty good function of the valve. There's maybe a couple of pixels at 12 o'clock, but nothing significant. Let's proceed to look around and again looks probably good in the long axis view. A little bit of acceleration on the inflow, which is not unexpected, but we'll measure the gradient. The gradient's fairly reasonable. Now with gradients again oftentimes immediately coming off pump. Ionotropes have been given in the patient's hyperdynamic. So you may have gradients that are higher than they would be under normal conditions. So if you're getting very high gradients initially, but everything else looks normal with the valve, it's good to come back when the blood pressure is more normal and reassess that. But the patient was quite unstable and requires estimating doses of ionotropes. And they found on ECHO that this is actually without any pacing that there was some echinacea of the inferior wall and hypokinesis of the inferior wall. So they put in this device, which is an enteriotic balloon pump. And there was not any significant improvement immediately. So the patient, they dopper the graft. The graft was intact and the patient was taken to the intensive care unit. The enteriotic balloon pump was removed after two days and unfortunately there was no significant improvement in the LV function. So he had a trans-rassic echo at pulse update 5 and it was discharged at pulse update 10. The pulse update 5 echo showed a EF of 38% and pre-op we were up to 50%. Obviously the POD5 is still fairly early, but this is definitely concerning. And of course, first of all, he was really keen not to have a mechanical development beyond lifelong anticoagulation, but he ended up leaving the hospital with atrial fibrillation and warfarin. So in some cases, we clearly make people better. In other cases, the results are much more ambiguous and we have to wonder. But wonder is the thing put the images side-by-side of the trans-rassic echo pre-op and post-op. So the one that was reported as 51% ejection fraction and the one that was reported as 38%. I'm sorry, this loop is not working properly. But it turns out that they actually don't look that dramatically different. There is definitely some abnormality here in the inferior wall that wasn't there before. This is not both off inotropic support. So it may be that the ejection fraction initially was actually worse than we'd appreciated, although in the interop images, the function was quite reasonable. So some key points. Basically, measure and calculate with humility. Always remember that assessment of severity is quite limited in the operating room because of all the hemodynamic changes. But fortunately, in most cases, decisions we have to make in the OR are related to mechanism and much less so to severity. Try to document the blood pressure and measurements on your gradient measurements and any severity measurements when you can. And again, be mindful of how these change with all the hemodynamics, especially coming off pump at the end. Review the pre-op imaging if you have access to it. It's very educational and I definitely learned a lot by going through them in detail with this case. And the center operate on asymptomatic patients is often quite challenging, even if they're meeting all of your evidence-based guidelines. Thank you very much. That's a fantastic presentation and the standard is absolutely amazing today to start off this morning. I hope it stays that way. And does anyone have any questions? I'm just going to open up the Q&A. So Andre Dino, again, is asking, in situations when we observe discrepancy in AI between pre-op TTE and intra-op TEE, are there any rule for dynamic testing, i.e. increasing the blood pressure like we can do for MR? Derek, definitely, I wasn't able to actually find multiple images of the same measurement being taken at different blood pressures intraoperatively, but certainly being able to achieve at least blood pressures that are comparable to the awake state will give us a better indication. It's not perfect because there's are so other changes, such as changes in ventricular compliance related to positive pressure ventilation, for example, that we can't compensate for. But at least anecdotally, it does seem to be helpful to increase the blood pressures. There's a question from the House and not the Senate. I think, was there a conduction defect in this patient? A conduction defect in this operation? So in the second patient, the patient went on to develop azure fibrillation after two or three days in the ICU, although it was proxiesmal because on the day five post op echo, the patient was on sinus. There was an interventricular conduction defect. We have a number of ex fellows in with a few questions. So we've got Floren from Quebec saying, to be considered significant hollow diastolic floraversal, does it need to reach 20 centimeters per second at end diastole? Actually, I can't remember the answer to that. Yeah, I don't know either. My sense is there's a lot of variability in terms of the velocities that you measure in the descending order. And I wouldn't be surprised if you won't achieve 20 centimeters and still have significant AI. I'm not sure if it's more relevant to the proximal descending order with trans thoracic where you're probably going to be a little bit robust and get a 20 centimeter change. We've got a question from Yanis, who's our ex fellow who's in Kingston. Hello Azad, would you, how would you troubleshoot the LVOT measurements 3D MPR? So certainly, if you're able to do a 3D MPR, that would be the best option if you have good enough images and the time to actually do that, because then you can actually measure the LVOT cross sectional area directly by plenometry and account for the fact that it's not circular, instead of having to estimate the area just based on a diameter and the assumption that's often false, that it's a circular cross section. There is some interesting discussion about where to measure the LVOT diameter as well. And I didn't have time to dig into this in more detail. I've typically measured it at the narrowest part of the LVOT within a centimeter of the valve and tried to get it sort of to be as close to the point where I'm measuring my pulse wave Doppler on the argument that if that's where I'm measuring the pulse wave VTI, I want to be measuring the diameter at that point. But there seems to be better correlation with trans thoracic echoes under spontaneous ventilation, if you measure the LVOT diameter right at the level of the valve itself, which mechanistically doesn't make much sense to me, but in terms of the numbers correlating, that seems to correlate better. And now we've heard, we're hearing from the legend, really, Nair Yusuf over in Hamilton in here. So he's saying, hi Azad, thanks for a great presentation. What views do you use to measure for LV dotitation? So in the trans thoracic, they use the apical four chamber view and two chamber view and use the biplane. So the same views you would use to measure ejection fraction. You do anybody using biplane, you can measure the endostolic volume, if you're doing it with a Simpson's method. If you're measuring it just linearly, that classic as he's a parasternal short axis, and that on T, I would say the most reliable measurements would be from your four chamber view and two chamber view again, similar to where you would measure your EF. And obviously, if you can use X plane to make sure that your four chambers really going through the apex that would improve the accuracy of your image. Hopefully soon we'll have automated tracing of the cavity, so that a lot of these things will be much faster for us to do in both in biplane and in 3D. And Marcin Wasiewicz is asking, does velocity of AI need to reach four meters per second to apply the pressure halftime method? Not that I'm aware of. I will again call a friend on that one. Does anyone else aware of any low-rend limitation on that? Any of the panelists? Yeah, I think four meters is sort of the minimum requirement. It also speaks to alignment, because a lot of times with trans esophageal, it's very difficult to get good alignment and we take suboptimal tracings. So I think if you can get good alignment, you should be able to get a reasonable four meters per second. But the other thing to remember is there's so many factors you should correctly point out that will influence the pressure difference between the left ventricle and the order. So you may not be able to get four meters per second all the time, but I gather I think it's supposed to be where you're supposed to try to get it. And one point with the alignment is that you want to really align it with the jet itself. And if the jet is eccentric, ideally you want to get it aligned with the main body of the jet and not necessarily the long axis of the order itself for an eccentric jet.


datory inquiry in every case of industrial disease. He has also made points that are very supportive in terms of the reporting process. I think that it is important that we have some scrutiny of the individual decisions that are made by companies or organisations and respond to sheriff recommendations. I do not necessarily—my personal view is that it would not necessarily be appropriate for the Justice Committee to do so, but if the Justice Committee felt that it had a role, I would not prevent that. Post-legis of scrutiny is a very important function of the Parliament and perhaps something that we should do more of. The sheriff's role is finished after the determination, and that is on the basis that it would probably be time-consuming for the sheriff's to continue to oversee the process of recommendations coming back and perhaps be inappropriate for them to do so when they are having to take on other cases. However, as Hamish Goodall has said, if information is presented that suggests why an organisation has not been able to take forward a recommendation, then that is open to regulators and others, including those who are concerned about the practices in that organisation to flag that up. There is a reputational issue there, so I would hope that the process would be effective in driving change within those organisations to whom recommendations were made. It would not necessarily be appropriate for sheriffs to continue the role after that point, which is after all a judicial function rather than a monitoring and evaluation function in that respect. I understand that you might not have seen that response. Is it just come to us this morning, Minister? Is that correct? I haven't seen that myself, I could be sure. Sorry, I was just a bit distracted there to see whether responses had to be published, but they do under section 275A, which would be important now. Who have I got now? Jane, thank you. I'd like to ask a little bit about delays. Whether you think, Minister, that this concept of an early hearing, as proposed by Lord Cullen, would help to speed up proceedings, if you think that that would be a positive impact on the process? I certainly recognise the point that Jane Baxter is making about the need to avoid unnecessary delays. The whole bill is designed to make the process more efficient and effective in delivering an FEI and clearly anything that we can do to smooth the process and make sure that it happens as effective as possible is helpful. I wasn't present for the solicitor general's evidence. I've been made aware of the point that was made regarding a milestone charter. I think that that's a constructive suggestion, which, obviously, the solicitor general is going to come back to the committee with more detail and understand on that. That, in a sense, will help to ensure that, at a three-month interval, the solicitor general is referring to that there would be reviewed by the current office itself of where they are at with the inquiry, what needs to be done in terms of making sure that it happens and to ensure that there is a minimum delay in the process. I think that that's a very constructive suggestion. I would hope to largely deal with the intent behind Lord Cullen's recommendations in that respect. It's also worth stating just for the record that the Crown Office has made significant efforts in recent years to keep families themselves better informed about the progress of death investigations. We don't believe that there is a need to hold such hearings in every case, which is what Lord Cullen has suggested. The Lord President made a valid point, and he said that it is not like the court to put in a position of exercising some supervisory role over the Crown's decision-making process as that would give rise to a serious constitutional issue. I think that, if I stop the answer, we did hear the Crown this morning saying that they were bringing forward a charter to bring before the committee, before stage 2, which should be helpful. I believe that that will—I mean, it's a very positive move by the solicitor general, and I think that it will help to deal with the intent, I imagine, of committee members to make sure that families are well informed and that everything is done to bring forward the inquiry as quickly as it can be. The flexibility in the accommodation should also help in that respect, I believe. Just lastly, do you think that COPFS is adequately resourced to take on these not new roles but enhancements to the role? Do you think that that will become a resource implication as time goes on? Clearly, I would hope that any problems that are raised by the Crown Office in terms of resourcing of that would be raised at the justice board and would be dealt with at that level, and recommendations would come forward by any change that is necessary. However, I believe that it is an efficiency measure that it will help in terms of the proposal that the solicitor general has brought forward will help to ensure that there is good co-ordination of the commencement of an inquiry that minimises any risks of potentially unnecessary costs by delays or any problems in the initial process. That, in a sense, could be seen to be prevented of spending in some ways so that it will make sure that the inquiry happens more smoothly and the appropriate location and resource appropriately. I would hope that it would not be particularly onerous on the Crown Office, but clearly if there are issues as the legislation is applied, we would keep that under close watch and the help, if necessary, with the Crown Office. Just to raise the point that the Crown Office is obviously aware of the bill, it has looked at the financial memorandum and are comfortable with the figures in there. The committee has currently got in front of it a couple of active petitions relating to how the COPFS carries out death investigations. Have you given any consideration to whether there is scope for introducing a review process that families can use if they are unhappy about the way in which that death investigation has been carried out? I will certainly be happy to take on board any points that are made in specific concerns in that respect. We have obviously seen the Crown Office bring in family liaison positions. It is obviously a local sheriffdom to the extent to which they are deployed. It may vary from one ear to another, so we would like to see and ensure that there is consistency in that process. However, the judicial review is the due legal process available in those situations. We can certainly address that in due course, perhaps once we have a chance to reflect on the evidence that the committee has received. Will you perhaps, as part of that reflection, consider whether or not it would be appropriate for a sheriff to be invited to, I suppose, adjudicate on whether it was appropriate that the investigation had been closed? Greg, are you happy to address that point? If I may convener, he is earning his cross today, as you can see. We are missing you already, Mr Walker. I think that there are two points that use the word scope. This is a bill about inquiries, and it is not a bill about the investigation stage. Perhaps the charter that will be published can address those sorts of points, but I would suggest that it is not for this particular bill. On the point about a sheriff having a greater role, I think that that is squarely in the territory of the Lord President's concerns about constitutionality, the Scottish tradition in which we heard pre-date. The coroners are to have the discretion to investigate deaths, and to have a sheriff review that is something that the judges are not comfortable with. As the minister said, although I would not encourage that to happen routinely, crown decisions can be judicially reviewed under the ordinary grounds for judicial review. That is the final one. That is just about regard back to families. Minister, do not expect you to pull the rabbit out of the hatch just now. If you could provide the committee with the costs to the legal aid fund of supporting families at FAIs in the past three years, there are issues involved in, obviously, the FAIs and the public interest, but families obviously have a great interest themselves in what takes place and quite often require legal aid representation. It would be helpful to know that, or any other comment that you might wish to make about legal aid to families? I agree, convener, that that is an important issue, because while the inquiry is there to establish in the public interest what has happened to individual individuals and to find the cause of death and to learn lessons and to disseminate those lessons and recommendations, we recognise the important role that the inquiry is playing. It is not the statutory purpose, but it is there and it provides a very helpful service to families to help them to understand what happened to a loved one. In many cases, they may require to raise some questions themselves. The role of the legal aid board, which is making legal aid available, where a person entitled to be represented at an FAI can show that they have concerns about what a procurator of fiscal is not going to raise at the inquiry themselves, because, obviously, a procurator of fiscal has a specific role and is acting for the public interest at that point. Any application for legal aid will be subject to the usual three statutory— I know all that stuff. Sorry, minister. Time presses on, but Lord Cullin's recommendations were that you were not going ahead with legal aid from the cost grounds. If you wanted to spell that, we need to know what has been given in the last three years and why. I know the tests are about reasonableness, but those are very different circumstances being in a civil case. We will certainly look at the figures that you have asked for, convener, in terms of trying to provide them for the committee's benefit. The Scottish Human Rights Commission acknowledged in its own evidence before the committee that there was no ECHR issue with the current provision of legal aid for FAIs. We certainly have not seen any changes in circumstances that would cause the Scottish Government to visit its attitude to the provision of legal aid for FAIs. However, as you know, convener, we are doing work on legal aid at the moment anyway, so I will certainly take that into the remit of that work and look at it if there is any scope. That is the kind of sweeping up questions. One is, again, that the bill removes the sheriff's power to award expenses. Why, when there might be somebody abusing process and one would feel that expenses should be awarded against them for costing the court and everybody else's time and money? If I can ask Hamish to address that. Please. Expenses are awarded in civil litigation. A fatal accident inquiry is not civil litigation. We believe that if someone is behaving vexatiously at a fatal accident inquiry, we believe that the sheriff has sufficient case management powers to be able to deal with that without any award of expenses. Against him? Is that not the case just now? Can he not award if he has got vexatious? I believe that. There was one case recently. So you are changing the position. That is why I am saying why. Because we do not feel that it is appropriate, because, as I say, expenses are awarded in civil litigation, this is not civil litigation. Greg, do you want to? There is a wider picture in the background, which is a courts reform act, where the civil courts review was moving to all the civil courts with all their hats on much more actively managing cases. The power to make court rules has been expanded and the power here for FAI rules to be made by the Lord President is again expanded with the expectation that much more than has happened to date there will be active case management at all stages. So I suppose what we are saying is rather than letting parties get away with murder and then punish them later, the sheriff will, from that outset, be able to stop wastes of time, so there shouldn't be wasted cost expenses on anyone's part. Well, we'll hold you to that if it's not going to be in the bill. I thank you very much for your evidence and conscious of time. If there's anything else, once minister, you have the opportunity to look at the evidence that I've had that you want to comment on, that you've not had the opportunity, and we've not questioned you on from previous witnesses, this morning, please feel free to do so. Thank you very much. I'm moving on to the next item on the agenda. If you're a forgiving minister, I'll just press on. It's item 4, our annual report from 11 May 2014 to 10 May 2015. This is a factual account of the years of work that we've undertaken during that period. Here it is in all its glory. Are you content, John? I think that it's a very good report. I just took two very minor points of a May, and that's on the first paragraph of paragraph 24. I think that if we just refer to the second line, I think that we should insert many significant implications there. Yes, that's all right. Yes, the Febdy's agreed the significant implications that it opt out would have. On one other small point of a May 2, and that is paragraph 32, the final line to her says, they provided witnesses with an opportunity to engage with each other. I think that we should insert engage with the justice committee and each other. Yes, it's rather like we were sitting having cups of tea buns. We were just spectating. That's a sort of more grammatical question. It says the report covers right up the 10th of May 2015. I just thought, to the colleague this morning, we were dealing with six villages now. Is the apology bill where we're not starting to deal with it before? Which one? Yes, we can reflect the Apologies Bill call for evidence. You just want to get the right number on. Yes, so we put the Apologies Bill early stages call for evidence. Thank you. Right, we now move into private session, which is as we are now.


What's up? How are you guys today? I'm going to show you every single thing I've been eating for basically the past few years on my new diet now This is kind of like a grocery haul But not really because we have everything on Frankie syringe meat and Frankie syringe food So the only thing I had to get at the grocery store was these apples Breakfast lunch and dinner. This is what I've been eating to detox my liver Kind of recover from taking Accutane as well as the carnivore diet making things worse and After all my research after all my experimenting. This is what I've found to be delicious Sustainable and slowly feeling better. It does not include my supplement routine Which I might do in another video, but again guys, this is literally every single thing I've been putting in my body for the most part especially considering a left New York So we're not dealing with any sewer rat ladies We'll get into that another time So you guys have seen a lot of this in my day of eating We did the food pyramid video which you guys should definitely watch But this is like a more hands-on Literal me showing you guys. Okay. This is what you should actually be eating So if you combine my food pyramid video with this it'll basically give you an excellent idea of what you should be doing We also don't have the water kefir and water kefir grains here, which arguably Can be a supplement can be considered part of the diet, but We have a lot of videos on water kefir water kefir grains the importance of probiotics I don't know if you guys can see it in frame here I actually have my water kefir on the counter there and we also have some bread here, but we'll touch on that later So starting with breakfast I've had a few different Carbohydrates and breakfast probably has the most variety compared to the other meals for the protein source. It's been the same I have Ibarico pork Lately, it's been breakfast sausage. If I don't have an Ibarico pork breakfast sausage I'll have either like some tenderloin that I just sear off in the pan or I'll take some lean ground Ibarico pork tenderloin all exclusively available on Frankie syringe meat comm and I'll just sear that and maybe put a little maple syrup and honey on that But I don't really like having meats besides pork. They don't really mix well with breakfast for me So just get the highest quality pork you have access to we even have the corn and soy free Amish pork in the pork share, which is much more affordable than the Ibarico pork So that's our protein source, you know getting our B vitamins cholesterol saturated fat I don't usually have too much protein in the morning right when I wake up The most recent carbohydrate you guys have seen me eating is combining our organic birch benders pancake mix with organic quick oats in the pancake mix is just we flower sugar and then just a few Organic ingredients for the leavening so very simple not much in it I didn't show you guys we have the organic sugar in the cabinet and there's a little bit of vanilla powder That I do put in the pancake mix So some spices and seasonings might be omitted here if I'm not having those pancakes, which we did a recipe on the mix of Equal parts pancake mix and quick oats. I'll be having just quick oats So I'll take the oats maybe put some maple syrup and honey in there with some vanilla And I'll have that in the morning real quick and what's recent and I haven't showed you guys yet is Organic cream of wheat. I kind of like the flavor of this more than the oatmeal I prefer the pancakes to both of these but for me cream of wheat is very nostalgic So the Italians might know it as farina baby cereal We'll do we'll do a few videos on that but those are the the main carbohydrates that I've been having with my breakfast now the fiber content of The you know the pancake mix and cream of wheat. It's okay. It's not it's not crazy crazy high That's why I usually mix the oats in and but but the cream of wheat isn't that bad from a fiber perspective, however We're gonna be having more fiber later in the day and with every meal the organic honeycrisp apple is providing gut motility fiber Sugar because when you're having carbs and starches you want to actually utilize all your body's digestive capabilities That's why we have the lean protein. There's a little bit of fat in there sometimes I'll put a little bit of coconut oil here in the carbohydrate mix especially when I'm like cooking the pancakes basically frying them an oil in the pan So we have our protein. We have our fat and we have our carbohydrates we're utilizing all our bodies digestive capabilities the liver and the pancreas and also adding the sugars in the apple is also Utilizing more of that because if you just have a starch, you know your body can only digest so much starch But if you have a smaller amount of starch with some sugar with some alcohol whatever You're kind of utilizing all different types of enzymes. So it's better to have a little bit of variety than to just overdo one thing But that's pretty much it for breakfast I'll touch on the seasonings briefly because they are included in every meal. So this salt filtered sea salt that we have on the meat website and the foods website that goes into almost everything I'm putting it in the starches when I make them Same with lunch same with dinner. That's the salt I'm using if I need to season the steaks That's the salt that's going on it and if I'm using a cooking fat the coconut oil Maybe I'll put a tablespoon in the oatmeal. I'll fry the pancakes in it I'll put a little bit of coconut oil in the farina when I have rice I'll put some coconut oil on the rice same with the udon noodles. We'll touch on that more when we get to those meals But I think that's everything for breakfast moving on to lunch Which has been Different recently. I've just been having rice with protein and beans. You guys have eaten this meal a few times either that or I'll have bread with protein and I'll dip the bread in the Wiping puree that I also have for dinner. So again, lunch is either Meat rice and beans very simple. We have just I've been doing the pork ham that we've had in the Porkshare lately. That's really really tasty nice smoked flavor or I used to have the roast beef a lot with lunch Those are the two proteins. I usually have sometimes I'll have a steak We have the jovial organic cannellini beans on the side. That's our soluble fiber very important to have with the meal And my starch has been organic white bismari rice So that's the main thing lately. We've been doing most of probably the past year I've been having bread you guys can actually see I think it's in frame I have some bread that I'm about to bake and eat and I'll dip that bread in the white bean puree We've done a few different variations on this recipe I'll explain it when we get to dinner because that's also what I put on the udon noodles So that meal I think you guys have seen it in a day of eating as well I'll literally just take pieces of the ham eat them dip the bread in the bean puree I like that a little more for me. It's more enjoyable and the reason I'm not just eating you know beans rice and meat with every meal is because each food has some type of downside whether it's a pollutant or Arsenic like in rice or maybe the way they grew it. There's always a downside to everything Maybe a specific anti-nutrient So when you have variety and you can use different sources of things It's usually better to switch things up most of the time and then the honey crisp apple with every meal most of the time and For dinner which has been consistent So, you know breakfast has had a few variations lunch has had, you know two variations Dinner has been the same basically for I don't know how long now ever since I found these udon noodles Which I really enjoy we have these again again guys every I feel like a broken record everything you see here can be purchased on The meat website and the foods website besides the apples for the most part. So, you know, what's the saying? Practice what you preach. It's kind of what I've done with all my businesses you know, I didn't just make up my businesses because I thought they were good business ideas because It's what I do for my own health and I wanted to provide you guys with everything to be healthy What's special about these udon noodles is it's made from refined hard red winter wheat Which is like the lowest anti-nutrient flour that exists So I'm able to safely eat these noodles every night where I was like durham wheat semolina is not that good It's high in what the hell I always forget what it's called Lutein I think and other carotenoids not that great for your liver, but this is the carbohydrate base the udon noodles our white bean puree is a blend of the organic artichoke spread we have on the foods website the organic Jovial cannellini beans and some of the collagen bone broth This is actually the beef stock concentrate. I'll either use that or the collagen bone broth I'll mix it in with the white beans and the artichoke spread just take an immersion blender and mix it all together It's basically like a white bean hummus, and I use that to dip my bread in for lunch and and the sauce on the On the noodles for dinner. It's adding flavor. It's adding starch Carbohydrate not starch. I'm sorry It's adding soluble fiber in the beans which is very important for liver detox and the beef stock concentrate I like adding it for more flavor some of me. No acids glycine help heal the gut lining And I'll usually put a little bit of coconut oil and salt on those noodles when I when I boil them in Mountain Valley water so whenever I'm cooking something whether it's the oats the pancakes the Cream of wheat rice bread noodles everything is being usually cooked in Mountain Valley mineral water, and then I usually drink the fiyuji mineral water Shouldn't really call it a mineral water. It's it's very low mineral water very good for moving calcium out of the body I find that if I don't have the fiyuji if I only have the Mountain Valley I get very constipated So this is important and sometimes I'll even just cook everything in the fiyuji water as well so we have those two bottles of water here as I usually buy those in bulk and I even make the water key for with that too Protein source for dinner mixed in with those udon noodles.  I'll sear that in the pan I'll slice it thin put it in the udon noodles and then I'll deglaze the Pan with a little bit of beef stock and then put that in the udon noodles as well with the bean puree just for some extra flavor I really really also like we have like Ibarricle pork loin and Ibarricle pork chops I like that a lot more in the udon noodles than the beef, but but both are absolutely delicious And if you guys have watched, you know all my day of eating for for some time And you'll see the different varieties and variations that I've done. I don't really know what the cost of This would be to eat per month. If I had to guess probably between $400 and $600 I think we did a budget video, which was like a $280 thing, which is basically what you can get on food stamps So to spend like a hundred or two hundred more a month to eat as good as possible Isn't crazy, especially when you're having Ibarricle pork and steak and the highest quality meats with every meal But every meal has the same consistent theme We have an adequate amount of animal protein Saturated fat cholesterol amino acids the bioavailable animal minerals all that good stuff to to give us healthy cells and restore our tissue There's a small amount of fat in the meat as well as the coconut oil that we use because our body needs some fat But we try to keep the fat amount low Just to not stress the liver too much because when you have a lot of fat The liver releases more bile the bile is storing the toxins that the liver is excreting So you want to you want the liver to excrete the toxins, but you don't want it to be a crazy amount every single meal So we just have a moderate amount of fat Even though this is refined coconut oil it is Still saturated, so it's solid at room temperature. That's the healthiest type for your cells I have the the liquid coconut oil sitting there on the counter that it's just a little easier to use But that that your body is going to kind of burn his energy and it's not going to be stored as fat as easily as something like this I Could be wrong on that triglyceride conversion, but This one is a little bit easier on the liver and digestion From like a chemical perspective, it's not as processed. Yeah, my vision is still pretty impaired So I can't tell how long this recording has been I don't want this video to be too long But I will briefly touch on some hypothetical negatives here So, you know, there's a lot of plastic packaging that's offset, you know, we do Take the beef glandular supplements like the male virulity and stuff and the beef testicles a few times a week just to keep the testosterone high to avoid a lot of the negative effects of the plastics Maybe there's a few concerns with chemicals and can lining as well and maybe some water used like in the beans Even maybe some who knows what if there's any pollution concerns with Mountain Mountain Valley, but overall You know compared to what the average person is eating that this is about as good as you can get and you and you're really minimizing any sort of Toxin or pollutant concerns and also removing the most inflammatory types of foods from your diet But I think that'll be it So if you guys want any of this stuff, I've mentioned it probably at least half a dozen times now We have it on Frankie strange meat comm and Frankie's for infuse calm Maybe I'll do a video in a few weeks for a month or so on updated supplement routine I said earlier the only thing that you guys don't really see here are those supplements as well as the water kefir and water kefir grains I'm like I'm like half on half off with that right now We do have all the flavors I think in stock on the foods website If you guys want to try the water kefir and the water kefir grains are very affordable only like $5 a jar But I'll do like two weeks on two weeks off probiotics on and off depending on how I feel Or whether I mess up my homemade recipe or not, but that's gonna be it. So Thank you guys for joining me My eyes are still recovering a little bit. They probably look better but probably still a little weird and I didn't say it in the beginning but You know, we were banned for about a week. So this is like I think my first full video back But I'll talk about that more in the next few videos. Maybe and in the vlog. I don't know urge. We'll just do some shorts on it But if you guys want to support me instead of these corporate chills, you know What to do, you know place a nice big order on any of the businesses available on frank dash to found calm and Please drop a like on the video leave a comment down below Make sure to subscribe and check that notification bell and I'll see you guys soon Oh


You're creating panic. You're telling everybody to freak out and now there's not enough for me Hey there friends. Thanks for checking in in December of 2023 everybody was caught by surprise a bit because the CEO of this two outdoors the world's largest ammunition manufacturer said that Price increases should be expected in 2024 they said one of the primary reasons was a lack of Gunpowder as well as other components that make ammunition you could expect to pay more for ammo Than you did in previous years now. We've been through several ammo shortages It's been horrible and we finally reached a point Where most types of ammo was available at our local gun store as well as online outlets And they weren't so much of a gouging price like we saw Couple years ago during the ammo shortage. There was major price increases and very slowly It dropped and now what do I see? I see ammo all over a place. I see gunpowder all over a place Why is that and is there going to be a major price shift for the worse in? ammunition Well, there are a couple reasons the first one I want to bring you back to September of 2019 when Walmart said we are going to be done selling Center fire handgun ammo as well as rifle ammo that is meant for 30 round magazines. Okay, the the modern sporting rifle ammo the 556 the 223 They said we're done with that. We're done with handgun ammo. Yes, they will sell 22 and rimfire and shotgun and hunting rounds, but everything else is done and initially you saw just boxes and boxes and cases of handguns set to fire ammo and 223 556 you name it 308 and People said what what are they talking about? It's all over the place. Well, the issue there was that They had contracts that needed to be fulfilled Therefore, they were still getting truckloads of ammo in but once they sold all that off They did they stopped selling set to fire handgun ammo and modern sporting rifle ammo. And so That is a bit of the example that I want to talk about now because when I go to my favorite online spots Or my local gun store, it seems that just about everything is available This is a point that we really wanted to see Back a couple years ago when you could hardly find Anything and I think that the contracts are still being fulfilled at the current prices that they were negotiated Months ago. And so we're not seeing an increase Will there be an increase? Well, I am always not increased at the rate of food or the products that you use 7 to 10 percent is well below what Inflation has been the past couple years and so I think we dodged a bullet if you will with with inflation and the cost of ammo also I Think that the season that we are now entering the warmer months in the US It's been a fact and all you have to do is go to any shooting range And you will see there are fewer people shooting when the weather is warm There's more to do and so people just they they they put their guns away for a little bit They do other things they don't purchase as much Ammo so as it sits now. I have not seen hoarders and resellers Buy up everything for the mere purpose of selling and making a profit I have not seen major shifts in ammo costs It is possible that we still could see that but I do believe that the contracts are still being fulfilled at the rate that was negotiated so yet couple that with the Change of season the warmer months fewer shooters out there that are practicing and training We have not seen a price shift in ammo that still could happen Anything could happen. I remember they were saying well It's gunpowder or it's primers or in at one point or another it was all of that now I'm seeing stock shelves everywhere. I go and that is certainly a good thing I want to take a minute and talk about hoarders people really beat up on the hoarders when They would buy up all this ammo and just save it away for a rainy day Shouldn't we all be doing that to a degree? Shouldn't we all have an adequate supply? You know, I like to keep my gas tank over half full and if my gas tank is over half full I know that if something happens, I will be able to get from point A to point B It's just a little prepper mindset that I have. You know, it's it's just a way that I live I like to keep the the food cupboards half full because when they're half empty and then something happens You could find yourself in trouble. I think we should treat ammo the exact same way But in terms of the price it will never be back where it once was 10 years ago when there was a box of $7 9 millimeter 50 round target loads full metal jacket or 16 17 bucks for a box of 50 45s or very very low expensive Rifle ammo the rifle ammo is still extremely costly The handgun ammo has dropped a bit But we have not seen that price increase that so many people were freaking out and so many YouTubers were blamed. I had a lot of people say you guys are the problem You're creating panic. You're telling everybody to freak out and now there's not enough for me. Well, I never did that I said this is not a panic situation I don't think it will be a crisis if it raises in cost a little bit then so it does it will Probably not reach the point where we were paying a dollar a round for handgun ammo and that was a disaster Yes, it's sporadic 22 Magnum was impossible to find some rifle rounds were impossible to find now. It seems available I think there are many factors that are playing into that But I don't think it's panic time actually I think it's time for you to stop watching this video and go out and buy yourself a case of ammo because right now It's available. Keep that gas tank half full and you will be in a better shooting situation and not caught Caught by surprise. If in fact we do have another ammo shortage If you like videos like this, please subscribe and share I always appreciate thumbs up button Thanks for watching and you guys be safe


In Edo state, the police command has paraded 46 suspended criminals for varying degrees of crimes in the state. Among those paraded is a 48-year-old man identified as Isaac Odom who confessed to he had arranged for some scavengers to mod a co-staff of a filling station company that he claimed failed to pay him a one-month salary or team. The incident, according to the suspect, happened on the 9th day of September 2023 when they held the victim hostage and stole over four million-dollar cash from the now-diseased worker where he used the proceeds to buy a car. A group has condemned the spate of insecurity in the federal capital territory and the role of Maitrema.


What's up everybody welcome back to the channel for another poster giveaway I want to start off by apologizing that this video is going out later than normal There was an office Christmas party last night So I'm a little rough this morning didn't get chance to upload it yesterday because I didn't get a chance to do it So we're giving away the Dean Kearney autographed poster card here. We're gonna set our randomizer to go Lifted racing games with a comment of I want that poster really babble Congratulations, you did get that poster and congratulations on winning one of the autograph postcards here on the random giveaway of my 25 days of Christmas I remember a comment on a prior winning video that says man.  Well Congratulations lifted racing you did win the Dean Kearney autographed poster So I will catch you guys later with the normal upload for another poster giveaway. So until then later I'm tiffy because I've been sipping on handy. I got the study of my vision and she


As Christmas fast approaches, many people look forward to getting a break from work and school. One thing that does not take a break for the holiday is the need for blood donations. The Red Cross recently issued an urgent call for blood donors as the holidays approach. Every year, a decline in blood donations occurs around the holidays from Thanksgiving to New Year's Day when donors get busy with family gatherings and traveling. To combat this, the Red Cross is giving away free t-shirts to all those who give blood until January 6th. It's an important time for blood donation right now. Again, we do see a seasonal decline, and that coupled with possible bad weather when blood drives need to be canceled, we really need to ensure that patients have the blood that they need. To see a list of upcoming Red Cross blood drives in the area, you can visit the story on our website at lptb.org slash news. If you enjoyed this segment of Lakeland News, please consider making a tax-deductible contribution to Lakeland PBS.