Welcome you all back to Human-Human Architecture, the show that looks into humility and humanity in the built environment. And this show here, I'm referring to another genre of the arts, which is music. And if you watch Axis TV, that movie show on TV, I'm thinking of sort of a journalist approach, sort of an angle to things. And I'm thinking of Dan Rather and his shows, The Big Interview. There's actually two other shows that are referred to more because that's like Brian Johnson's, so the ex or still ACDC frontman, his show is called A Life on the Road, or Paul Schaefer, who is the music opening act of Letterman's night shows and his show is called Plus One. And staying in that realm, I actually have the privilege to have a Plus Two show. If we can go to the first slide here, I also want to share some background, how I could sort of position myself to the subject matter. This is a project we've been doing some years ago about bringing back sort of nurturing and daily food supply to a neighborhood that has grown old and so have its inhabitants, as you can see on the top left. You can also see a musician there. So this relates to one of our guests today, Richard Lowe, is a gifted musician. The project is out of a prefab concrete, which reminds me of our fellow guest, Bunnit Kanisterkon. One thing at the bottom right that I wasn't able to accomplish, and I'm sad about it, that we're unable to keep the original building, the original structure. And so this ended up being a new construction, and so our two gentlemen are able to shoot for that and able to tackle that issue. And so let's go to the next slide. Here we are. We already know them from previous shows. To the left here is Bunnit and Janice, they're experts in urban infill, in prefab concrete, in ecology. And on the right we have Sir Richard Lowe, who's an expert in music, as we already said, in master's planning. And the two of them come up with fascinating polemic propositions, as in the bottom right, where they were suggesting for Waikiki, in fact, a very light rail, and so light that it can float. So again, they've been in the Molowili neighborhood, where the lofts are. They've been in Kakaakau, rich a while ago, and they went to Waikiki. So you guys, welcome back to the show. And thank you. Thank you, Martin. And I wouldn't bring up one slide that you just sent to me, and you wouldn't have known, you wouldn't think I would bring it up, but I like to do so. So Rich, this subject matter is very close to you. And please tell us why and what does it have to do with this image here? I'd have to put on my glasses to see it. That's OK. This is to give you a hint. This is to end the hospital where you wrote me a note. Oh, yes, yes. Oh, yeah. Thanking you, I guess, for the opportunity to appear on your show, and that I'd like to do it again. Yeah, it was more actually than thanking me. I think it was promising us to be back on the show recovering from the little work you had to be done. And now you're up and running again, and you guys were actually running together. And again, as you've been in Molo-Ili before in Waikiki and in Kakaakau, where did you guys walk and run now? And let's bring up your first slide here and tell us about that. Well, this is sort of a double district. Makiki, this is above the freeway, Malka of the freeway in both Munoa and Makiki, but not all the way back into the valleys or into the mountains behind. So we selected that area because it interested us. Yeah. We live close to that area as well, and during his time after hospitalization, he liked to walk around, and that's the area that we venture out into to keep his heart rate going. Well, and in fact, if you go to the next slide here, you tell us about the history of the place. That's of course important. I'll just do a quick key on that. You can see that the method of transportation for people in the very old days was to get up to many of the people, old families in the city, obtain properties up in Tantalus, which is exactly behind this picture. And they would go up on horse and carriages. And I used to work with a person who was within a family that did that. And let's go to the next slide and see obviously how the place, well, where the place is, where it's located here on this map. Obviously, we're on the island of Oahu, and it's in this very sort of central part at the bottom on the south shore. But let's go to the sort of early of Oahu and tell us more how it's sided in its context between the Maoka and the Makai, meaning the mountains and the ocean. You can see the hills and their valleys and so forth on the upper right side of the picture. And then you can look down and find it kind of in the middle, off the middle, the Honlu Airport. And then to the right of that, between the tidal airport and Makiki and lower Manoa, you can see Sand Island and then below the word Makiki, you can see Alamoana and Waikiki. Yeah. And let's go to the next slide. Again, this shows it sort of it vastness as you had explained, and it's sort of covering two discrets. It's touching our workplace hood Manoa as well. And go to the next slide here. You started, this is where it gets really interesting because you started to basically sort of start to map sort of the diagram and look at certain aspects of the community. And again, we should reiterate and say recap. When you were out of the hospital, you weren't quite mobile as you used to be, and you needed to work on that, and you discovered that actually certain things you weren't able to do because there was a lack of certain things that, and that very personal experience got you very sort of sensitive and sensitized about what you guys were starting to discover. And so let's go through the different sort of aspects of elements in the community. And this very first one, which is very sort of fundamental for what you're proposing. Right. These are, you know, the dots. The pink one are the one that we went to visit. And then the purple one is the other churches are temples that we haven't gone to visit. So this, just to show you how many churches that we have, you know, in that, in our neighborhood. So, Richard can talk a little bit more about it, about, you know, what is so important, you know, in our neighborhood. Well, the pink dots sort of to the left of the center of the photo you see right here are, we picked them because they were significant architecturally. And they had long history in the positions that they're shown there. And there are a few new ones. And then we thought it would be very interesting to explore into what the churches might do that would make them a little more functional as parts of the neighborhood and vice versa. What could the neighborhood do to make the churches more functional? And while you were walking them, you talked to the people running them, operating them, and you discovered some challenges they have these days, right? Right. Yeah. That's right. So yeah, a lot of it, you know, they're not doing so well. Because of the decline of the attendance of people who like to come to church in the decline. And a lot of people, you know, going to church now, we always make fun of each other that we going to church of Alamona shopping mall. So this is something that, you know, we found out that a lot of people spend their time at the shopping mall, that's their church, that's where they go buy stuff. We worship our God capitalism, Ryan. Let's go to the next slide here. And talk a little bit about the sort of the sectional quality of placing, you know. Well, the highest points that are in green, those are round top and tanneless areas which we, you saw when you saw that carriage in the woods kind of thing. And then it slopes down to toward the flatlands of both Makiki and Manoa, and that's that low, slung area. Right. Is that comfortable that we see right there? No, this is the Manoa elevation. The reason why we choose these two neighborhoods is because we feel very urbanized because when you are in Manoa or in Makiki, where a majority of people live, you don't see the ocean. You feel very like a part of their city. And we want to reemphasize that, you know, as the way that we can really make it more fun and memorable and, you know, meaningful for the people that live in this neighborhood. So that's why Richard and I start walking everywhere and start to look at it, you know, not only in the urban planning side, but sectional side as well, that we look at it closely. And that's like the total contrast or opposition to how our island is portrayed in the revamping of a Wi-Fi or a Magnum PI, where it's basically all around these little blue guys there, which is oceanfront, high-rise property, all hermetic, all invasive, could be anywhere in the world. That's where they're shooting the scenes, and that's what they're portraying is what the island is about. But we're questioning, is that actually real life, right, or is real life more where you're talking about? Let's get the other nice section up here to illustrate that more. I hear you see it even more, right? That's down there where we think, I mean, again, portrayed by the media where life is, but you're actually seeing, and to be further discovered, in the next sort of diagrams, you figured out real life might be actually up the hill more. So let's go to the next slide.  And this is what this map about, right? It's, yeah, originally, when I first started walking following one particular break, I was looking for a place to stop and call a friend and let's say, let's have a beer or a coffee or something. And there are very few opportunities at all, Malca of the Freeway, which is the thicker line going from the upper left corner to the lower right corner, except near the university, there are a number of such things. Not in Makiki. There's one old one that's very cherished by those of us who've been there. We see some sparse dots. Let's see what else you were digging out and what there is actually. Next slide. Bike routes, right? And I feel very close to that because I'm a suicidal bicyclist on a daily basis. So I know how hard it is that University Avenue or main route up to school doesn't even have a bike lane, but you also saw some positive signs and there are diagrams at the very upper right. Talk about these. Yeah. The upper right, you start to see some bike lane going through the university. In addition to that, you start to see these darker blue dots that represent the Bikki station. So those are the good seeds that the city planned and we love those. We wish that we have more of those and all those green paths connected to all the Bikki station. So this way the city is more walkable. And speaking of which, absolutely, let's go to the next slide because there's another mode of transportation that you were analyzing here. The bus system, which was sort of invented by Mayor Fawzi as the bus is considered one of the best bus systems in the country. And the most of the red lines you see here are for are the pathways of the city buses and they're very, they're reasonably thickly placed in the areas we're talking about. So for example, you can get from the university over to Punchball and other places very quickly. Yeah. And while it's typologically, I guess, progressive, but architecturally speaking, what could we maybe improve and also referring to history of that mode? Any thoughts on that? Yeah. You know, I kind of like to see it more like what Richard was showing, the old history of Makiki. I can start to see more like an easy breezy tram that can go up the hill in the old days up in Manoa that a lot of old houses are. So it would match in well with their context without having to get on the air con and catch the corona disease at the point. There you go. Very timely thing for reminding us. All right, let's go to the next slide. You were already in the sea level rise again is what's your your you're lucky, right? As far as that usually that's a problematic thing, but your might benefit from that even to what degree? Well, from a real estate point of view, I think you mentioned recently that people, the sea level rise of let's say I've heard that three and a half feet is in the near future. And that would inundate many of the blocks that are, you know, just not the side of the beach. And so, but the elevation of most of Makiki, even the flat areas is probably at least 50 feet, more or less, and higher, of course. So, yeah. So basically, we're going to be safe from the inundation and the water rises. Yeah, and it would give us a flow of increase of population, because they're going to be these immigrants, migrating up the hill and further populating the area you're talking about. And next slide is you already talked about the color green and green spaces. And this is really eye opening. Talk about that diagram. OK, so the next slide is the green space. You know, those are the diagram that I think it's very important to have, because when you study, start to think about the bus route and the by group and everything, and these are the places that you can really accommodate. All those activities that connect to each other, not only recreational, but also in the commercial side as well, that we can start to have more retail coffee shops and things that can connect to all this green space. And some belong to the schools and our university. So and it really makes it so obvious how sort of nature depreviation syndrome we are sort of Makai, meaning down from the big diagonal line is the our main interstate H1. And down there, we're really deprived of what we consider to be paradises green and lush, right? But it's all gray as you perfectly diagrammed. And up there is actually might be more paradissel than down there. So that's a potential as you. Exactly. And like within five minutes, you can go hiking. Yeah, absolutely. From your Makiki and Manoa. So next one. And this is again, where where you collapse all the layers. And this is how we, you know, before you start to dissect that and look at each individual one, it looks like that. And obviously, when put all the layers together and that's how you have to look at it after all that all these things, you know, have to work together and be synced and finding a synergy between them, which, but you kind of go back to the to the initial that you put the two things, the two first things together where you said there is sort of the churches have a problem and and and the people in the communities have a problem finding, you know, their daily nutrients, both as social interaction around, you know, food. And you are the our food Buddha. And because you've done so many, you know, projects with and around food. I mean, food is the thing to get together, right? And to come together around food. So let's go to the next slides here where you actually walk us through a couple of potential, you know, projects that that could could be discovered further along the lines you're suggesting, right? Well, this little church is a it's not so little, actually, but it's old. And it was just been repainted and re-roofed and things like that. So it's a prosperous enough to do those kinds of things. It ended pipe organ in it. So we have a music program that's that's I happen to sing with is part of the choir and there are a lot of activities like that that happen in this church and and and others as well. Yeah, and they also have like a farmers market every Thursday where we do our grocery shopping there as well. So there's a multi layer of usage in this church. So within the sort of seven minutes left, let's sort of quickly walk through these and maybe you, you know, briefly describe. And again, they're they're suggestive. Next slide, maybe already. So these are suggestive ones. And I I referred to previous shows. We've done the utmost scholar on hardwood, who is the architect of that one is obviously our friend Don Hibbert up there. So you can watch his show.  So they're jewels as you bonded. And I found out the hard way in our critical practices. It's hard to do that these days, right? You buy it. Yeah, exactly. And your tongue when you try to do that church. Yeah. It's a beautiful, beautiful church with a lot of grounds around it and so forth. And it's also a very stable church with the headquarters, which, of course, is in Boston. Yeah. And yeah. So it's that's a very interesting building. I've been all through it with the. Yeah. And we're not want to hide that there is a conflict of interest. We all are Doko Momo board members. So for the mission of Doko Momo, we want to keep things the way they are, not just as their substance, but also as their use. But if that is sometimes not possible, what do you do? And that's where we have to step aside. Sorry, fellow board members and come in as the practicators to educate the young generation coming from practice and saying, maybe you have to do adaptive reuse. And that's what you guys are talking about to actually save the projects. Right? Yeah, it could be. Yeah. And let's move to the next case study here that you're pointing out. Oh, this this church, this is quite new, actually, or fairly new. It's been there for maybe 10 years, perhaps. It was designed by Spencer Lineweber, a former late Spencer Lineweber, former professor of architecture at UH. And it's a it's a large and well-equipped church and church plant, and they have. Terrific attendance. So they're there every every morning at five a.m. There's a service except on Sunday and there about four or five services on Sunday. So it's really thriving. Yeah, yeah. But I mean, we're the younger crowd who let go. Yeah. Yeah, but as you point out, and we got to walk through more quickly. But next slide here again, you pointed out that by nature, a church is sort of a very, I mean, it's a monofunctional use, but it's also sort of not very efficient and effective as as as it's sort of timeshare. I mean, there's no timeshare. So timeshare is I mean, this comes from another realm from the resort right in the hotel area. But don't we why don't we apply that to these typologies and say we timeshare so we still keep the services. But for the many hours they're empty, we we put it we add another use, right? Yeah, but this church in particular, Martin, I'm just going to make it brief. They have a lot of good music programs that we attend and we found very educational for us and very impressive how they organize their music program. A lot of good concerts have been performed there and we love it. Yeah, good. And let's go to the next project here. And tell us what struck you on that one. This this is a church designed by Vladimir Asipov and it's the chapel within the Punahou school. So it's very much integrated with the school, although they do have public events and so forth. And it's a very beautiful site right in the pond. Yeah, and it's very poetic. Yeah, very poetic. Yeah, yeah. And move to the next one, the Sacred Heart Church. This is very interesting. Sacred Hearts Church is connected to the Mary Knoll schools and they have schools from the very youngest to the graduating high school seniors and to the right of that tower. There's a there's a beautiful square. Talk about urban design with a very nice fountain in it. It's hard to see from this point of view, but that that reinforces the concept of really trying to create beautiful spaces. Yeah, yeah. Partly outdoor. OK, we are moving on to the next. Yeah, I'll move to the next one. OK, only two minutes left. So I think we unfortunately have to skip over these again. These are just appetizers, food for thought, so to speak, within your realm bounded. But when we go to the next one, this one, yeah, move on to the next one. I'm sorry, we have to do this. But one more one more. Yeah, it's not only talk about. Yeah, exactly. And so there are like some of my go back to the previous one. And so this one here is by by Alfred Price that Don Hibbert and and Jack Gilmer and Laura McGuire are prime scholars in. So, you know, there is some potential synergy in the research. And why don't we go to the very end already? Because that's the one you actually choose amongst the many ones to actually tackle and address in your current studio and talk about that for the last half minute here, please, guys. OK, when the extreme last is right. It's our Redeemer, another Lutheran church on University Avenue right across the street from the Department of Music of the University of Hawaii. And in itself, it has very, very good musicians and they are on the verge of exploring. Alternative things to do with it, including improving what the best that they have, but but adding some other features that could be of interest to the university, to the neighborhood and so forth. Yeah. And as the quotes show, you know, there are previous investigations by John Williams by Graham Hart, by Brandon. This is an Edwin Bauer building. And as you guys taught me, it's one of the first and early Edwin Bauer project. So we're unfortunately out of time. And but I obviously we have to bring you back to to to continue where we have to stop now because you are working on this twice a week with the emerging generation. And we're looking forward to do a show about the outcomes of that. So thanks for having been on this show, doing the appetizer for that. And then the main course comes next time. Right. So thank you all for having watched and thank you guys. So I'll see you next week for another episode of Humane Architecture, back with the solo brown and Ronald Lindgren about Harvard Square Volume Three. And until then, please stay as essentially exotic, as exotically essential as these two gentlemen, rich and bonded. Thank you very much again.


Hi guys, I am joined by one of my most favorite people in the whole world today, our David Cohn, probably one of your favorites too. David, great to see you and before we jump into the whole world of safer metrics, please give us a family update. How's everybody? Well, Nancy, thank you. It's good to be with you too. Everybody's doing okay, you know, we're getting along like everybody else, just dealing with the new world that we live in trying to homeschool an eight-year-old boy who's a handful and I'm sure a lot of parents out there can relate to trying to adjust to kids being at home and trying to get them on a distance learning program. And I have to add, he's beyond adorable little Sammy. Well, thank you. Yeah, he's been great so far. I mean, kids are very resilient. So I, you know, I think the, as each day goes by, they kind of understand what's going on and it's a tremendous learning experience for young children about how the world is so interconnected and we're all in this together and I think he understands that now probably as well as anybody. Well said, David. As always, that's what you do. Okay, let's get to work. We're going to talk safer metrics today. First question, when did you even get into it and when did you realize it was going to be important? You know, Nancy, I got into it through my agent back in the early 90s and these were the early, early days of saber metrics, probably even pre-saber metrics, but we use them for arbitration cases when I played for the Mets and went to arbitration against them, the front office of the Mets and I really became kind of schooled on the issues, especially with regards to pitchers and how one loss records with pitchers can be very deceiving. There's so many things that go into a pitchers performance that go way beyond his one loss record and, you know, his defensive support, his offensive support, what day he pitches on, how many runs they score. There's so many other, so many other things that come into play with regards to pitchers and, you know, I think that kind of opened my eyes a lot to the business side of baseball and how you can give credit where credit is due, Nancy. That's really what it's about for me. It's about finding out who really deserves the credit on who won this game or who contributed the most to winning any kind of game on any given day. That's so important, David, and that strikes a chord on the discussion of balance and the dominance of the sabermetric world. Is it out of balance? You know, I think you come full circle with it, Nancy. I think it's a good point that you bring up is that, you know, is there still a feel in the game? Is there still a place for a gut feeling throughout the course of a game? And I think when you're in the middle of a game, then absolutely. Pitchers and hitters still react by gut feeling. Numbers can't really come into play when the game is going on. During the middle of a game, pitchers still have to rely on what they feel, what their best pitch is, how they're feeling, how their arm feels, how the baseball feels in their hand. Same for a hitter, a hitter in the batter's box. And I know I've talked to Paul O'Neill about this a lot. Sometimes they just pick up something intuitively that's their gut feeling about what pitch is coming next or what they should do or how they react. So I really believe that during the course of a game, the gut feeling and the feel of the game is still a very, very big part of it, a very important part of the game. Yeah, I was gonna bring up Paul O'Neill as well, because he's always said he's a guy that did not want all that information. He did not want to know what was coming. He just wanted to get up there, see the ball, hit the ball. Yeah, there are a lot of players like that, Nancy, that don't really don't want to get jammed up mentally with all the information that's out there. They're coaches for that. There's certainly certain players that can thrive with more information. And I think as a coach, that's probably the most important thing that you need to learn about your players is who can handle information and who can't. And the ones who can't, certainly you're going to do more harm than good by trying to help them if you inundate them with too much information at once. So certainly there's a balance there and you need to respect that balance if you're a coach nowadays. David, back when all this was starting, did you ever think it would get to the point where it is today? No, I don't think anybody really saw this type of information that we get today. I mean, to me it's not just about Saber metrics anymore. The whole term analytics has taken a whole new meaning because every movement is tracked on the field. It's not just about mathematical equations anymore. It's about movement on the field, about Doppler radar being able to track every player and every movement that they make in terms of efficiency, how fast they are, how fast they throw the baseball, the efficiency of the spin, whether it's off the batted ball or if it's a thrown pitch, what type of spin efficiency is there nowadays? I think we've gone way beyond in terms of analytics what we ever thought we were going to see on a baseball field. And I wanted to ask you as a follow-up, do you think this focus, this kind of focus and spotlight on analytics and Saber metrics has changed the way guys play the game? I do. I think with each passing year the older players start to get more receptive to some of this new information and the younger generation that's just coming up is so easily adaptable to this type of information because that's kind of the way they've already grown up with computers, with social media, with that type of data information that they've been exposed to at a young age, they're ready to go with these type of information. They learn this way and I know even some of the young prospects in the minor leagues are already way ahead of the game in terms of the new analytics and how to read this information coming at them, how to interpret it, that they're much more advanced than some of the older players and I think the older players are catching up right and left. Guys like Zach Britton have talked about how you know what? From year to year this is starting to make sense to me. I'm starting to figure out how to utilize some of this information and how to incorporate it to help help me become a better pitcher or help me improve the design of my pitches, the movement and the grip that I'm using to get the type of movement that I want on my pitches. Let's practically apply some of this stuff. This is so fascinating. A guy like Garrett Cole, take a look at him. Are certain analytical numbers, certain sabre metrics more applicable and more informative with regard to which pitcher you're looking at? Yeah, I think there is. You know, Garrett Cole talks about now we have a baseline for comparison throughout the league so we know what an average spin rate on a foreseam basketball is. So you can compare to all the other pitchers across the board and as long as you have that baseline for comparison then you have credibility. So then you can look at that baseline for comparison and see where you rate and then see if you can improve it or see if say throughout the course of a season maybe you've dropped off a little bit and if you're in a slump then you can go to that baseline for comparison and compare notes and see oh where was I in in July? Where am I in August? Where am I in September? Am I getting a little bit fatigued? Does that show up in my spin rate? How do I compare to the rest of the league? I think that's the key and that's what Garrett Cole talked about most most importantly is you know we now have a complete database for a comparative nature in terms of a baseline for comparison across the league on everybody that comes through the big leagues and even in the minor leagues now they have this equipment in the minor leagues that everybody now is rated so to speak and we know exactly what the average is on every pitch that's thrown or every batted ball for that matter as well. Taking a look at all the safer metrics are there certain measures that you feel are the most valuable? You know I think it varies from from individual to individual. There are certainly things that are valuable for scouts and if you're out scouting nowadays instead of just using the eye test which I think is still very important but you also now have some numbers to back it up so when you're doing evaluation of talent coming up you now have some punch behind your evaluation you can you can back it up with the numbers you know whether that's exit velocity or spin rate for a pitcher and certainly if I'm pitching in the big leagues nowadays I certainly want to know my numbers you know and Nancy I think it goes back to the golf industry the golf industry the you know PGA were the first ones to come out with these launch monitors and all of these professional golfers use this information and this technology to get much better Tiger Woods is one of the premier golfers in the world over his career and he really benefited from this technology in terms of getting his golf clubs fitted getting the launch angle just right being able to hit the golf ball you know much farther being able to to get his spin rate just right now we're using that technology into baseball and you can design pitches that way or hitters can certainly evaluate their launch angle or exactly what they're doing in terms of trying to improve and to get the results that they're looking for. David if you had access to all of this information do you think it would have changed how you approach your game? Yeah I would have loved it Nancy you know I was enamored with putting spin on a baseball with the type of spin to make the baseball move to make a curve how to throw a curve ball how to throw a slider a slurv everything in between you know that was my sweet spot I was I was obsessed with how to spin a baseball and I never had a way to measure it I never had a you know a tool to use to design pitches and that's something I would have loved to been able to do to have that information that technology to be able to try to design new types of curve balls new types of sliders find out the type of movement on on splitters or fastballs it would have been right in my wheelhouse I would have loved to have had it I'm actually a little jealous of these guys nowadays that they have these advantages. And just one final question do you feel just like perhaps focus on wins and losses and ERA might have been out of balance back in your day is there too much emphasis on a couple of safer metrics analytics that might be out of balance? You know I still believe that there is a balance there between old and new school so to speak but I also know that whatever we use to evaluate pitchers and hitters whether that was just batting average for batters back 50 20 30 40 years ago or for pitchers just ERA and one loss record I think that was woefully inadequate to tell us that the full scale of who did what who deserve credit who was the best pitcher who was the best hitter I think we have much more numbers nowadays much more data to kind of give us more information and who won the game who helped you win that game you know who did the most you know when probability added who added the most value to winning the game winning the world series championship game to game pennant races I think the numbers we have now give us a much clearer picture a much more complete picture of who's who's doing what and who deserves credit I gotta say there is nothing better than baseball clinic with david cone you're the best thank you nancy always great to talk to you too I very much feel the same always thanks david until next time enjoy florida and the family take care thank you nancy


I want to conclude topical questions, and we turn now to a statement by Shona Robison on NHS Tayside. The cabinet secretary will of course take questions after our statement, so I would encourage all members who wish to ask a question to press their request to sweet buttons now. I would like to update the chamber on developments in NHS Tayside over the Easter recess. On Friday 6 April, I exercised powers under the National Health Service Scotland Act 1978 and instructed that Paul Gray, as chief executive of NHS Scotland, take immediate action to strengthen the leadership of NHS Tayside. The decision to exercise these powers was not one I took lightly and was the result of a series of issues that have come to light in relation to the management of NHS Tayside over recent months. As Parliament will be aware, since 2012-13, NHS Tayside has required brokerage funding from the Scottish Government to balance its annual financial position. The level of brokerage awarded each year has risen and the amount of brokerage outstanding now totals £45.3 million, excluding the repayment of endowment funds that will be added this year. In recognition of the need for action to tackle the rising deficit, NHS Tayside developed a five-year transformation programme, launched in 2015-16, with the twin aim of improving patient experience alongside achieving financial sustainability. To support this programme in May 2016, we have put in place arrangements to provide tailored support to NHS Tayside. By its very nature, the scale of change envisaged was not a quick fix. However, by the end of 2016-17, it was clear that the year-one milestones in their plan were not going to be delivered, and the board required a further £13.2 million of brokerage. In response in March 2017, we appointed Professor Sir Louis Ritchie to chair an assurance and advisory group, the AAG, to review the deliverability of the board's plans and the associated financial projections. On 27 June 2017, the AAG published its staging report confirming the financial picture being forecast by the board was unrealistic. It also highlighted issues in relation to the board's vision for the future, its service and workforce planning, its prescribing activities, as well as its leadership and governance processes. Upon receipt of the findings, we established a transformation support team, led by Caroline Lamb, chief executive of NHS Education for Scotland, to provide support and constructive challenge to the senior management of NHS Tayside. The transformation support team provided intensive input into the executive team from July to December 2017. The AAG's second progress report was submitted earlier this year and was sent to Parliament on 23 February. In the latest report, the expert team recognised that, while progress had been made, it was largely transactional, as opposed to transformational. Five days after the publication of that second progress report, an issue was uncovered by the Scottish Government officials and brought to my attention on how e-health funding had been recorded in the NHS Tayside accounts. We commissioned an independent investigation from Grant Thornton UK into the issue that has been shared with Parliament. The central problem that was highlighted was that the level of the board's deficit had been understated over a period of years. NHS Tayside's director of finance subsequently took the decision to retire and immediate steps were taken to strengthen the financial controls of all the organisations involved. That includes the withdrawal from e-health leads of the ability to make financial decisions and the review of internal controls in NHS national services Scotland. On 3 April, the then NHS Tayside chair highlighted claims to me that, on 24 January 2014, a decision was taken by the board of trustees responsible for endowment funds, which had resulted in a number of projects being retrospectively approved for charitable funding when they had already been approved for funding through core NHS resources. I immediately took action to have the accuracy of those claims independently verified. Following on from their work on e-health funding, Grant Thornton was commissioned to undertake a review of NHS Tayside's financial governance. That work has now been extended to cover the use of endowment funds. Given the significance of those issues, the review will now report to the Scottish Government. NHS Scotland chief executive Paul Gray wrote to all NHS board chairs on 5 April to seek their explicit assurance by the end of this month that all charitable funds have been used appropriately. The office of the Scottish Charities Regulator has recently opened a formal inquiry into the allegations of possible misconduct in the operation of Tayside's endowment fund. Once I have received assurances from all other health boards, I will share those assurances with Oscar, who have agreed to review them. Should they determine that spending of endowment funds by any board was inappropriate, then I expect it to be paid back swiftly and in full. In responding to such events, the maintenance of public confidence in the health service in Scotland is of paramount importance. The credibility of the board's updated reform plans, as well as public confidence in the board's leadership and in donating funds for the benefit of the health service, were significantly undermined by those events. The NHS Tayside chief executive's attendance at the endowment fund meetings in 2014, particularly in the January, when decisions were made on the use of charitable funds for retrospective expenditure raised serious concerns. Although the chair was not in post at that time of those decisions, the culmination of financial control issues, along with the limited progress that was highlighted by the AAG, led me to the conclusion that real change was going to require a new leadership team with a robust set of skills to restore public confidence in NHS Tayside. That is why I exercise my ministerial powers of intervention and ask Paul Gray, as chief executive of NHS Scotland, to strengthen management at NHS Tayside with immediate effect. The chair, Professor John Connell, tendered his resignation on 6 April, and I thank him for his service to the board over the past two and a half years. Leslie McLey is currently on sick leave and the role of accountable officer has been transferred to the new chief executive Malcolm Wright. It is not possible to comment further on Ms McLey's employment position at this time. It is crucially important that the new leadership team at NHS Tayside is strong and experienced, which is why I have appointed John Brown CBE as the new chair. Mr Brown already chairs a large health board and is a chartered management accountant with significant experience in leading change. I have also approved the appointment of Malcolm Wright OBE as chief executive. Mr Wright is a very experienced NHS chief executive and has already been involved in a number of successful board transformations. They have both started, as they mean to go on, with productive meetings already held with the rest of the board and with the chief executives of all three local authorities to underscore the importance of collaborative working in designing and delivering health and care services for the people of Tayside. Another priority has been to ensure that all staff in Tayside are cited on developments, with an all staff briefing issued immediately on the new leadership team taking up posts. In relation to the issue of endowment funds, an emergency board meeting held last week agreed to a proposal presented by Mr Brown and Mr Wright to repay in full the endowment money that had been retrospectively applied to programmes of work in 2014. Understandably stabilising the board will take some time, and I am committed to ensuring that the Scottish Government continues to support NHS Tayside with financial brokerage, with repayment currently suspended for a three-year period to provide breathing space for the board, to focus on achieving stability and to plan properly for change. I have also agreed that the brokerage will be increased to cover the repayment of endowment funds that have been inappropriately used. It is crucially important that the quality of patient services is protected and maintained throughout this challenging time. The staff of NHS Tayside have much to be proud of—a reputation for good, safe, person-centred and effective care, with many examples of innovation and good practice recognised across the country. I met the board alongside its new leadership on 9 April, and it is clear that there remains a real appetite within the board to drive forward positively, underpinned by clinically driven change initiatives. I have been clear with the new leadership that their priorities must be to steady the ship, provide clarity on where the organisation is going and to take the public and the staff of NHS Tayside with them throughout that process. I have every confidence in John Brown and Malcolm Wright that they will deliver that. I look forward to seeing NHS Tayside reach its full potential and becoming the organisation that staff and people of Tayside deserve. Alongside the work on going in NHS Tayside will also see the completion of the Grant Thornton review of Tayside's existing financial controls, including the use of endowment funds. Oscar will complete its consideration of the behaviour of the Tayside Endowment Fund Board of Trustees in the early 2014, along with its oversight of activities elsewhere in NHS Scotland, with any funding considered to be inappropriate being immediately returned to the endowment funds. I will ensure that all reports are made available to Parliament once completed and that all recommendations from those reports are implemented. I am happy to take questions. The public in Tayside and across Scotland have been rightly shocked and angered at the use of charitable funds by NHS Tayside to help pay for NHS board projects. In her statement, the cabinet secretary references the independent review by Grant Thornton on e-health funding between e-health NHS national services Scotland and NHS Tayside between 2012 and 2018, which raised many serious issues. The cabinet secretary, for some reason, has not mentioned the repeated failures of oversight in her own department over this period, which were clearly identified in the review. How will the cabinet secretary ensure that lessons are learnt from this, so that the cabinet secretary and her officials will in future provide the proper level of scrutiny and supervision that must be provided in relation to the use of taxpayers' money? In light of the concerns that other NHS boards might have also been using charitable funds in a similar way, does the cabinet secretary not agree that an independent broader inquiry into the extent of this practice across Scotland is now needed, one that is able to make clear recommendations about how to prevent this happening again in the future? Does the cabinet secretary not agree that that would be the best way to restore public confidence, which is now absolutely vital? The cabinet secretary also says that it is time to steady the ship. We have been raising those concerns for some time in Parliament, and it is quite clear that, for too long, NHS Tayside's leadership has been sinking under the leadership of this Government. Is it not now time to act and for this whole Parliament to have a role in supervising the finances of our health boards? The Parliament, of course, has a role. That is why we have an audit committee, which is looking into those matters, and that is quite right and proper. I have also said at the end of my statement that I will make available all of those reports to Parliament so that we can be open and transparent about those matters. I went through in some detail in my statement all of the support that has been given to NHS Tayside. I do not think that it is fair to say that the Scottish Government has not tried in its endeavours to support NHS Tayside. Over the years, we have given extensive support to that board. I laid that out in some detail in my statement, but it reached a position after all of that, particularly in the light of the e-health and the endowment funds issues arising. The conclusion that we reached was that what was required was a new leadership team at the top of NHS Tayside to take the organisation forward. That is not something that I did lightly, as I said in my statement. Miles Briggs also talked about the need for independent oversight of the issue of endowment funds. Oscar is independent. That is why we have asked him to look at all of the returns that will come from boards. At the moment, there is nothing to suggest that other boards or the endowment funds of other boards have been used in a way that NHS Tayside uses. However, Oscar looks at all of that. It is independent. As the charity regulator, it is the organisation that is best placed to oversee that. I should point out that endowment funds are also separate from ministers. Ministers have no role over the issues of endowment funds, so it is important that Oscar looks and has oversight into those funds. Once all of that is completed, we will make sure, as Oscar will, that all of that information is put into the public domain. I thank the cabinet secretary for prior sight of the statement. I note that she said in her statement that NHS Tayside needs new leadership and that her priority must be to study the ship, provide clarity and take the public and NHS staff with them. The leadership of our NHS cabinet secretary is you. You have let down NHS staff. You have failed too many patients. You have breached the trust of the public, and this has happened on your watch in your local health board. This is your mismanagement and your failure. The sad reality is that the public has lost confidence in this public cabinet secretary, and this cabinet secretary has lost control of her brief. Therefore, will the cabinet secretary do the decent thing and, at the very least, would draw herself from this investigation, if not would draw herself from this portfolio altogether? Anasarwar failed to mention that he agreed with the decision to remove the leadership team of NHS Tayside and replace them with a new leadership team. I think that he did not mention that fact, which is important, and I am glad that he supported my decision. In all of that, there was a question about the investigation. I do not know if he listened to my statement or, indeed, the answer that I gave to Miles Briggs. I think that I was very clear that Oscar is leading this investigation. If Anasarwar is suggesting that Oscar is not independent and is not capable of leading the investigation, I think that that is very unfortunate. Indeed, Oscar, as a charity regulator, is the best people to look at whether those funds, those endowment funds, have been appropriately used or not. That is how that process will be taken forward. The external audit of boards will also have a look at endowment funds, and that will also be taken forward. By the end of this month, we will have the returns from boards. By the end of May, Oscar will give us an initial view on those returns, and he will take any appropriate action thereafter. By the end of June, the external audits will have taken place with a particular look at endowment funds. I would have thought that, in anybody's eyes, that is a robust process with the independence of Oscar at its heart. Graham Dey, to be followed by Liz Smith. Graham Dey, can I ask the cabinet secretary if she agrees with me that the change of senior management must also lead to a cultural change at the top of the organisation, not least ensuring that the financial challenges that have been highlighted do not adversely affect the provision of services for patients in rural settings, such as those that I, John Swinney and Mary Gougeon represent? Graham Dey, I have been absolutely clear that the financial challenges facing NHS Tayside must not affect the quality of services that have been provided to patients. I have said that in a statement, I have said that previously, including to those in rural settings. That is why I have made a commitment to continue to provide brokerage to NHS Tayside, and it is why the repayment of brokerage is currently suspended to enable the board to focus on getting back on track. I think that that is important. I think that the new leadership team has already signalled that the quality of care will remain a key priority for the board. In both their words and their actions have already underlined the importance of a culture of honesty and openness and engagement with staff at all levels. I think that they have signalled a new culture and a new approach, and they should be given the time to get on with the job. Liz Smith, to be followed by Jenny Marra. Thank you, Presiding Officer. Cabinet Secretary, in reply to a constituent of mine, Oscar has stated that it did not become aware of the alleged issues regarding the use of NHS Tayside's assets until the media reports appeared on 4 April. Can I ask the cabinet secretary if, whether during the period 2014 to 2018, the Scottish Government had any communications whatsoever with Oscar about the use of NHS Tayside funds, given that a key role for Oscar is to review the charity's accounts? Liz Smith raises an important issue, and Oscar will be looking into all of this because bearing in mind that they are doing a specific investigation into the endowment issue of NHS Tayside, and it is right and proper that they do that. I can tell Liz Smith that in the return from NHS Tayside on 17 June 2014, from the Audit and Risk Committee, there were no significant issues raised that they were given a clean audit opinion. That issue was not escalated to the Scottish Government as a matter of concern at the time by either internal or external auditors. I think that there are issues there in terms of the reviews that are under way. I think that will help us to determine what further controls are required in the light of all of that. Liz Smith can be assured that that will be taken forward. In addition, I can tell her that the guidance that Oscar helped us to develop around the use of endowment funds back in 2013, Oscar has signalled its intention that it wants to review that guidance because it is concerned about a potential conflict of interest between people sitting on the board and sitting on trustees of endowment funds. I can assure Liz Smith that that will be taken forward with Oscar. I am concerned about governance on the board at NHS Tayside. In 2014, board members agreed to suspend the constitution to transfer charitable funds to core expenditure, breaking the trust of local people who give so generously. I welcome the decision to pay back the money, but we now need a full review of every board member at NHS Tayside to ensure that they have the requisite skills to prevent a breach like this ever happening again. Will the cabinet secretary outline a full appraisal and skills review of every board member at NHS Tayside? The first thing to say is, first of all, I welcome the fact that Jenny Marr welcomes the repayment of those funds. I think that that was an important early decision made by the new leadership team. It is also important to allow Oscar to do the proper investigation, and I reiterate that he is doing a full investigation into the endowment fund issue within NHS Tayside. He will look back to 2014 to the decisions that were made by the trustees and on what basis those decisions were made, so all of that will be looked at. On the wider issue of corporate governance and the skills of board members, that will be for the new chair and the chief executive to look at whether they have the right skillset across their board, and it is right and proper that they are given the support to do that. On a general point, there is work going on around a review of corporate governance that John Brown, the new chair of NHS Tayside, is leading. There is additional support being given nationally to non-executive members of boards, so that they are able to question, probe and ask the right questions in a way that they have confidence in doing. All of that will help us to strengthen corporate governance, but I have said in previous answers that, if there are any recommendations coming out of all the reviews that are currently on going that can further strengthen that governance, then Jenny Marra can be assured that that will be taken forward. Thank you. I completely agree with what the cabinet secretary said in her statement when she talked about the fact that the maintenance of public confidence in the health service and in the boards leadership is of paramount importance here. What assurance can the Scottish Government give that the appropriate measures have been taken to install a suitably high calibre of leadership to restore public confidence and trust in the board of NHS Tayside to manage the challenges that it faces going forward? I am confident that we have the people with the right skills that are needed by NHS Tayside at this moment in time. John Brown, as I said in my statement, is already chair of Scotland's largest health board and is also a qualified accountant. Anybody who knows him is also very good at leading change and he will do that within NHS Tayside. Malcolm Wright is an experienced chief executive who has already been involved in successful transformational change. He has been clear that quality of care is the priority for them, as well as getting back into financial balance. Restoring public confidence and trust is key, and although he has only been in place for a couple of weeks, it is fair to say that he has certainly hit the ground running and has been working closely with the staff side, as well as clinicians in order to begin to rebuild that confidence. I am also aware that they are offered to meet or, if not possible, to meet local members to give them a call. John Brown and Malcolm Wright were engaged in that over the past few days. It is right that we demand complete transparency regarding the financial decisions taken by the board as a situation like this cannot be allowed to happen again. It is right that a new leadership team takes over, but, as Audit Scotland pointed out last year, the majority of health boards had to use short-term measures to break even. I would like to understand how the cabinet secretary is going to address that at Root. Is she going to introduce longer-term planning for our IJBs? Is she going to tackle the significant use of agency staff that has been reported in NHS Tayside? Can I thank Alison Johnstone for her question? We are addressing the use of agency staff and a lot of work has been on-going to reduce agency staff spend. Fiona McQueen, as the chief nursing officer, has been leading that work. Alison Johnstone will be aware that additional funding for our front-line NHS boards will amount to £354 million, which is £208 million in real terms. NHS Tayside will see £13.7 million of increased investment and a share of the transformation monies. More money is going into the health service, but more demands are upon it. That is why reform also has to take place. Alison Johnstone makes a good point about integrated joint boards. We have been discussing with boards and councils about ways of being able to enter into longer financial planning beyond, obviously, the one-year that was required because of the budget processing that we have just gone through. There is also a financial framework that is being developed by the Scottish Government that will look over the five-year horizon, which will be able to not just plan the funding at a national level but also the shift in the balance of funding so that that can be visible over the next five years. That will be published in the next few weeks. Professor Connell was asked to resign in response to a scandal that had occurred before his tenure. What exactly is he expected to have achieved in the resolution of the situation to her satisfaction? What comfort can she extend to other board chairs concerned that they too may be used as scapegoats to protect this Government in the future? Will she rule out today any suggestion of abolishing and merging NHS Tayside with any other board, as proposed by senior back benches in her own party? Alex Cole-Hamilton said in my statement that I paid tribute to the work that John Connell had done for the past two and a half years. Of course, he recognised that he was not in post when the endowment issue arose in 2014. In fact, that period of times spanned previous health minister and my term of office as well, but no health ministers, I believe, could have picked up on something that internal and external auditors did not flag. That requires us to look at why those issues were not flagged by either internal or external auditors to the Scottish Government, because, obviously, we rely on those processes in order to be able to do something about it when they are. He asked specifically about the position of John Connell. It was an issue of a cumulative set of events. I laid out clearly in my statement all of the issues that led to the point of escalation to level 5, where ministerial intervention was taken, where we had reached the end of the road after huge amounts of effort and support being put into NHS Tayside. The only conclusion that we could reach was that new leadership was required in NHS Tayside and that required a new chair and a new chief executive to be able to take the organisation forward. In relation to the merging of boards, Alex Cole-Hamilton will be aware that we have been working to get more regional planning, that boards will work across boundaries but that form should follow function. The important thing here is realising the benefits of regional working and working across board boundaries rather than focusing on organisational change, which, frankly, would take up the efforts and the attention of senior leadership teams, whereas in Tayside, we need to be focused on getting the board back on track and restoring public confidence. There are still five more members who wish to get in. In fact, there are six now. My members wish to get in. Stuart Stevenson, please make your questions and answers quite short. Stuart Stevenson, to be followed by Bill Bowman. Does the cabinet secretary recall that intervening in Grampian NHS led to a very successful outcome on continuous improvement? Does she agree that the moving of the chief executive from NHS Grampian to Tayside should provide the reassurance that staff and patients need that this is a serious issue being taken seriously? I would. I met the board on 9 April, along with the new leadership team. Everything that I have seen and heard of the approach taken today gives me confidence that NHS Tayside will continue to make the provision of high-quality services for patients a priority, and that is very important that they do that. It is also important to say that work has been taken forward in Glasgow and Grampian to provide assurance that, because of John Brown and Malcolm Wright's focus on Tayside, there will be no impact on the work that is still on-going in Grampian and Glasgow in taking those boards forward. Bill Bowman, to be followed by Ash Denham. Regarding the on-going Grant Thornton review of NHS Tayside, will it or a further forensic investigation fully establish regarding the eHealth funds who approved the incorrect entries and, most importantly, who, both in NHS Tayside and in the cabinet secretary's own office, knew about the window dressing of the NHS Tayside financial statements for six years? As I said previously, all of the reviews, including the Grant Thornton review, will get to the bottom of all that and to make sure that there is full openness and transparency about the issue of eHealth moneys and the issue of endowment moneys, which is why we have brought that external process to bear, because we want to make sure that that is the case, and not least if there are areas that we need to change and tighten up on to avoid a situation like that happening again. Of course, that is the action that we will take. To ask the Scottish Government whether the independent investigation by Oscar will extend to other health boards. As I said earlier, the process by which the returns of boards will come to the Scottish Government and, indeed, Oscar, have written to the chairs of the endowment funds asking for those returns. Those will happen by 30 April. We hope that Oscar will be able to give an indication of any further issues that he wishes to look into in more detail by the end of May. In addition to that, the external audit will have a particular look at endowment funds. All that is taken in the round, particularly the role of Oscar, which is entirely independent of the Scottish Government, should give members assurance that those matters will be looked into fully. I apologise to the members who still wish to ask a question, but we have really run out of time and we have already taken substantial times out of the next debate, which we now move on to, which is a debate on motion 11643, in the name of Graeme Dey, on behalf of the Environment, Climate Change and Land Reform Committee. I will take a few moments for the ministers at least to change seats.


May 17 is observed as World Hypertension Day. The theme for this year is measure your blood pressure accurately, control it, live longer. Hypertension or high blood pressure is a serious condition. It increases the risk for heart disease and strokes. The World Health Organization, WHO estimates that 1.13 billion people have hypertension and only 1 in 5 people with hypertension have it under control. In St. Lucia, an estimated 27% of adults have high blood pressure and only 1 third of the people with high blood pressure who are registered within the primary healthcare system have their blood pressure under control. Given the serious implications of high blood pressure and the fact that it is the most common preventable cause of cardiovascular disease, St. Lucia, in collaboration with the Pan American Health Organization, PAHU, launched the HEARTS Initiative in the primary care clinics. HEARTS provides a comprehensive and strategic approach to improving awareness, accurate measurement, management, and control of high blood pressure. Over the past two years, despite the challenges faced by our population during the COVID-19 pandemic, health and non-health staff and patients have received training that has helped improve the overall management of high blood pressure and improve the number of individuals who are aware of their condition. The ministry appeals to all St. Lucia's to know their blood pressure status by checking regularly and documenting the results. Measurements must be done following the appropriate techniques and using a validated blood pressure monitor. Controlled hypertension results in significantly fewer deaths, disabilities, and events such as heart attacks and strokes. High blood pressure can be controlled by changes in lifestyle and the use of prescribed medicines called antihypertensives. Lifestyle changes include reducing mental stress, weight loss if overweight or obese, not smoking, reducing alcohol intake, increasing levels of physical activity, and eating a heart-healthy diet. High blood pressure is a chronic condition and persons may need help to manage their condition. The Ministry of Health has introduced the self-management program which empowers persons with hypertension and other chronic diseases. Registration for this program can be done at the nearest wellness center. The Government of St. Lucia has approved the implementation of a process which will lead to universal health coverage, UHC, and the management and treatment of hypertension will be an essential part of Phase 1 of the UHC. Additionally, the Commission for Noncommunicable Diseases has been reactivated by cabinet and activities of the Commission will help to create even greater awareness. St. Lucia's, remember that early death, disease, and disability from high blood pressure or hypertension can be avoided. Take charge of your health. Visit the nearest wellness center for blood pressure measurements, nutritional counseling, or medical visits. Visit your doctor. High blood pressure can kill. Take it seriously. Measure your blood pressure accurately. Control your blood pressure and live longer. I thank you.


How can I add teachers and learners to my courses? When a new account is created in Moodle, the account holder is called an authenticated user. They don't have a specific role on the site. It's the administrator's job to make them a student or a teacher in the courses where they will learn or teach. This video explains how you can add users to courses one by one and give them the roles they need for that course, such as teacher or student. As an admin, you can add several users in bulk with a text file made from a spreadsheet program. To see how to do this, watch our video How Can I Bulk Upload Users to my Moodle site. To add users to a course, access the course and from course navigation, click Participants and then Enroll Users. As an admin, you can choose to enrol them as teachers, students or other roles. When a regular course teacher clicks this button, they cannot enrol other teachers. If you need that, read the documentation, assign roles for information on how you can allow teachers to enrol other teachers. Clicking Show More offers the option to specify the start date and length of enrolment. When you save, the newly enrolled users will appear in the Participants list with their roles. You can make changes by clicking the Edit icon and remove them if needed by clicking the Unenroll icon. To summarise, admins can enrol teachers and learners in bulk into courses with a text file. Admins can enrol teachers and learners into individual courses from participants, enrol users. Course teachers can enrol learners, that is students, into their own courses from participants, enrol users.


Today was all about catching the best Black Friday deals, but tomorrow your favorite neighborhood stores take center stage for Small Business Saturday. Small Business Saturday is a retail holiday meant to highlight the local businesses that keep a community thriving. Shopping at small local businesses not only helps the local store owners, it also helps your local economy. According to Fawn Bureau financial services, when you spend $100 at a local community business, exactly $68 stays with the local economy. We feel that there is a ripple effect when you shop local, really preserving the local flavor of a community and supporting businesses that are invested in the community. A lot of businesses that are locally owned, we as a co-op are owned by our members and so people have a really big stake in the success of the business. Another benefit to shopping local is you get to learn exactly where your items come from. For example, at the Harmony Co-op, the employees can tell you exactly which local farmers provided the produce. It ripples out into businesses like ours purchase more goods and services from other local businesses and have a vested interest in the success of those around us. And then it's also shopping local is a really good way to just get to know your community, to know the products that other people are excited about. If you enjoyed this segment of Lakeland News, please consider making a tax-deductible contribution to Lakeland PBS.


Good day everybody. This is Dr. Sanjay Sanyal, Professor of Department Chair. So this is going to be a demonstration of the Karate Triangle. This is Subangadabur. This is the right side. We have completely exposed the following structures. Antiaservical region, lateral cervical region, the root of the neck. We have removed the clavicle. We have removed the ramus of the mandible. And we are even showing the in front temporal force on the right side. So let's start from here. The Karate Triangle is mounted by the sternocleidomastoid which we have dissected out. Pustearly, superiorly it is bounded by the posterior belly of the digastric. In this particular cadaver, we cannot see the style of hyoid. And inferiorly it is bounded by the superior belly of the homohyoid. So therefore this is the Karate Triangle. It was roofed over by the Pritismal muscle which has been removed and the floor was composed of the muscular component of the predracheal fascia. Now let's take a look at the contents. The most important contents are this one here. This is the internal jugular vein. Normally we have seen that the large veins are medial to the artery but in this case the neck, the internal jugular vein is lateral to the artery. This is the common carotid artery which is bifurcated in the internal and external carotid arteries which I shall describe just now. And the posterior aspect is this nerve here. This is the vagus nerve. These three structures were completely enclosed by one tough sheath called the carotid sheath. This carotid sheath is derived from three layers of deep cervical fascia. The prevertible layer of deep cervical fascia, posteriorly from the prevertible layer of deep cervical fascia and medially from the predracheal layer of deep cervical fascia with components also from the ilar fascia. We have completely removed that also. So let's start with the internal jugular vein first. The internal jugular vein is this one here as I told you. It starts from the base of the skull. High up here, it emerges through the jugular foramen and there's a bulb which is called the superior bulb of the internal jugular vein. It's a continuation of the sigmoid sinus and just at the beginning when it is forming this superior bulb of the internal jugular vein and there's a valve also, it receives the atria-patriotus sinus. Then the internal jugular vein descends down. It receives tributaries in the neck corresponding to the branches of the carotid artery and it continues all the way down and here we can see it opens into the subclavian vein. The subclavian vein and the internal jugular vein they unite at this point which is at the level of the sternoclavical joint. We have removed the clavicle. This is called the pyrogeof angle or the venous angle and then it becomes continuous as the brachiocephalic vein. So this is the right side. So this is the full course. Just before it enters there can be another small dilatation which is called the inferior bulb of the internal jugular vein and that is also associated with the valve. The internal jugular vein is a very useful site for cardiac catheterization. The puncture is done medial to the sternoclear mastoid and the needle is directed downwards and we can enter into the right atrium of the heart for various procedures that is called cardiac catheterization. So this is a very useful route for cardiac catheterization. Now let's take a look at the next structure here. This is the common carotid artery. In this particular case because it's the right side the common carotid artery is arising from the brachiocephalic trunk. So this is the brachiocephalic trunk here and we can see the brachiocephalic trunk is dividing into the right subclavian and the common carotid, right common carotid. You can see there's a big opening here.  The common carotid artery runs on the middle side of the internal jugular vein and approximately at the level of the upper border of the thyroid cartilage, it divides into an external carotid and internal carotid. Internal carotid artery I should describe just now. First let me finish with the external carotid. It is called external carotid because it supplies all the structures outside the skull. Of course there are two exceptions that I shall mention briefly later. So this is the external carotid artery. The external carotid artery, it runs under the posterior belly of the digustric. You can see that here. And this external carotid artery typically gives six branches. We can see five of those branches. So let's take a look at the branches of the external carotid artery. We can see three branches here. One, two, three. This is the superior thyroid artery and you can see it is going down and entering into the upper pole of the thyroid gland. This superior thyroid artery is accompanied by this nerve here. This is the external laryngeal nerve. When we are doing surgery of the thyroid gland, this nerve is likely to be injured. The next branch that you can see here is the lingual artery. The lingual artery enters into the tongue deep to the hypoglossus muscle. And you can see it is accompanied by the hypoglossal nerve. And this inside the tongue, the lingual artery divides into three main branches. The dorsal lingual artery, the deep lingual artery and the sublingual artery. The next branch is this one here. This is the facial artery. The facial artery, it makes a loop under the mandible and then it gives branches to the pallet, ascending palletine into the console and then it comes back down here and we can see the remaining portion of the facial artery here. As it's coming down, it makes a deep groove on the posterior aspect of this, so the mandible or gland and we can see that also here. And then it runs in a very tortuous fashion on the side of the face and we can see that portion here. So this is the third branch, the facial artery.  These are three anterior branches. Now let's take a look at the medial branch. This is the medial branch. This is the ascending pharyngeal artery. The ascending pharyngeal artery runs up on the side of the pharynx and it gives basically two sets of branches. One set of branches are called the pharyngeal branches. The pharyngeal branches are the ones which supply all the pharyngeal constrictors, superior, middle and inferior pharyngeal constrictor. And the other branches are called the meningo vascular branches which supply the meninges of the posterior cranial fossa and also supplies the lower four cranial nerves. This ascending pharyngeal artery, though it's quite small, is an important artery. That's the fourth branch. Coming to the remaining two branches, we can see only part of it. So this is the continuation of the external carotid artery. As it passes under the stylohyide and the stylo-pustiability of the gastric, it enters into the parotid gland. We have removed the parotid gland here so therefore this was the course inside the parotid gland. And there it gives this branch here. So we can see, typically, it should give a branch below the pustiability of the gastric and a branch above the pustiability of the gastric. But here it is not doing so. Here it is giving only a common branch and that is further dividing into two. The one upper one is called the posterior auricular artery. The lower one which should run along the lower border of the pustiability of the gastric, that is the occipital artery. The occipital artery is the one which runs up to the scalp like this and it goes across the apex of the posterior lateral cervical region. That's why the lateral cervical region apex is called occipital triangle. So these are the final two branches, the six branches of the external carotid artery. And thereafter what does the external carotid artery do? Inside the parotid gland it divides into this branch here. This is the maxillary artery. And you can see it is entering into the infratemple fossa. This is the infratemple fossa. And inside the infratemple fossa it has got three parts which you have already described in another section and it gives a total of 15 branches. And the smaller terminal division is this one here. This is the superficial temporal artery which runs across the front of the tragus of the ear, across the zygomatic arch which we have cut where we can feel its pulsation and then it supplies the skin of the temporal scalp and we can see that running in the superficial temporal fascia here. So this is the complete course and the termination of the external carotid artery. As I said, external carotid artery supplies all structures outside but it has got two exceptions and one of that exception we can see here. The maxillary artery, it is giving this branch here. This is the middle meningeal artery. The middle meningeal artery enters into the cranial cavity, middle cranial fossa through the foramine spinosum and it supplies the meninges of the cranial cavity. So therefore that is an exception and there should be an accessory meningeal artery that enters through the foramine avail but we cannot see that here. So this is the full course of the external carotid artery. Now let's take a look at internal carotid artery, whatever we can see here. The internal carotid artery is called internal carotid because it supplies all the structures inside the cranial cavity. Again there is an exception. It is an anterior circulation of the circle of Willis. How do we recognize the internal carotid artery by this dilatation here? This is the carotid sinus. Inside it has got receptors, there is a paroreceptor. The internal carotid artery runs up. This portion is called the cervical part. And here in this particular cadaver we can see something very unique. We can see that the internal carotid artery is highly tortuous here. This is called dolicoectasia and we can see that tortuosity here very clearly. This is the tortuous part. And then it enters into the carotid canal in the Petrus temporal bone. That is called the Petrus part. And then it enters into the middle cranial fossa. That is the cavernous part. And then it becomes the intracerebral part. Which divides into anterior and middle cerebral arteries. So this is the internal carotid artery. Coming back to this carotid sinus. This carotid sinus and there is a small body here which is called the carotid body. They are respectively the paroreceptor and chemoreceptor, the peripheral chemoreceptor. They are supplied by branches of glossophageal nerve. And they immediate what is known as the carotid sinus reflex. So when we are palpating in the neck we should not palpate in the carotid triangle because we might produce carotid sinus syncope if a person is hypersensitive. That brings me to some clinical applications of the carotid artery as a whole. When we are seeing a person who is unconscious on the side of the road we have to determine whether the person is alive or the person is dead. We should palpate for the common carotid artery below the superior belly of the hormone, approximately at this level. We do not palpate in the carotid triangle proper. That is called central carotid pulsation. The carotid artery is a very common site of occlusion and we can feel in this particular cadabra also it has got some calcified material on the tunica media. Carotid angioplasty, carotid Doppler, carotid endartrectomy, all these are commonly performed procedures in the carotid artery. Common carotid and internal carotid artery. And this occlusion of the intercarotid artery produces stroke as we all know. So that is the next important content of the carotid sheath. And finally coming to the last part of the carotid sheath is this big nerve here. This is the nerve, this is the vagus nerve. Content, this runs on the posterior aspect of the sheath behind these two vessels. It comes out through the jugular ferrament and as it runs down it goes across and it crosses the subclavian artery. We can see that it's crossing the subclavian artery and then it will give branches called the recurrent laryngeal nerve which we shall show in another description. While it is running down we can see two important branches that it gives. We can see this branch here. This is the superior laryngeal nerve and the superior laryngeal nerve I've shown from this side also it divides into an internal laryngeal nerve which pierces the thyroid in my brain and the external laryngeal nerve which accompanies the superior thyroid artery which I had mentioned just a little while back. The vagus nerve has got many branches but we can see only these branches in this particular dissection. So these are the three important contents of the carotid sheath and the carotid triangle. That's all for now that I wanted to show you. Dr. Sanjeev is signing out. Mr. Solomon is the camera person. If you have any questions or comments, please put them in the comment section below. Have a nice day. Please like and subscribe.