Okay, hey friends, you're watching behind the scenes divine intimacy radio first. I got to just tell you EW 10 rocks They do I I don't know lately. I've been thinking about what watching the Synod on Synodality and I I'm I am shocked That a German Bishop actually said Yesterday that we need to set aside apostolic tradition And I'm just gonna say it that he's not deposed right this second is a scandal to the church Now why is the church in the United States and my wife's afraid she's like Well, no, no, no, I'm just trying. I'm waiting for the connection to EWT So now yeah, here's the EWTN connection. Why is that not the case in the United States? Because of mother Angelica EWTN Bishop Fulton sheen.  I don't know the Senate on synodality Yeah, and she's a she was a woman of fire. I'm praying and sacrificing every day. I can tell you that it's really quite striking so hopefully Anyway, I just I didn't want to focus on the negative. I just want to say thanks to EWTN for Allowing us to do this show and folks you got to support them If you're looking for good Catholic books always go to EWTN's religious catalog So before we jump into the show, I always say I'm excited about shows Because I am I'm telling the truth But this one, you know It's a higher level really because I just think what we're gonna talk to you about is so cool And I want every grandma grandpa mom dad That's got young people in their lives every priest every priest. You got to hear what we're gonna talk about Cation director every youth director. I'm telling you the solution The this young man we're gonna talk to today is contributing huge is Atomic bomb in the devils You know, don't say any My wife is really oh my she's my she is my she's my prudence meter Andrew, so I she just has to look at me like don't say She she uh that that's really the look and she's only given it to me about a million times Are we ready get started yes, I will one second still the pregame I know I know I so just gosh I just want everybody to know about what this guy is doing Before we do our Community apostolate VA and the Avala Foundation, of course also needs your support We have formed over 500 men and preparing them for seminary in the United States Teaching them prayer Catholic anthropology How to pray the literature the art of the solution part of the solution ding ding ding We have an auction going on spiritualdirection.com forward slash events if you want to help us out Auctioning off an altar that I've used in my in my Here at the retreat center. That's really beautiful as my favorite icon of the Pato Krontor an amazing items We've had so many beautiful things donated for this auction. Yeah, so very cool spiritualdirection.com forward slash events, okay? That's good enough We we do have intro to introduction to spiritual theology course coming up here November 27 Mondays 8 3 8 30 p.m. Eastern Avala-institute.org Dr. Mary and Sigmund is just an incredible woman and You'll want if you want to dive into graduate level studies and spiritual theology check that out So we're gonna start the show on your mark get set go This is Dan and Stephanie Burke. Welcome to divine intimacy radio your radio haven of rest your hermitage of the Heart your monastery of the mind where we lift our hearts and minds to heaven to draw upon the wisdom of the saints to help us navigate this crazy insane wacky life Yeah, yeah, she's valley of tears this valley of tears We're in by the way We can be joyful right and we can be warriors for Jesus and we can make a difference and the dude that's coming on the show today Is a warrior for Jesus and he's making a difference. I think in a way That is so unique and so powerful As we said before the show every priest every grandparent every parent every vocation everyone who touch every vocation director Everyone touches a young man or a young woman every Catholic school principal. Yeah, I'm telling you so who is this guy? What's his name again? We have a new friend. We're so happy to welcome a new friend Andrew lawback lawbacker And he Andrew I'm just gonna go right into his bio Andrew is the executive director for human humanality Humanality Andrew has been traveling the country and world Leading worship and speaking the last 15 years sharing the gospel and is now helping people heal and detox Did you hear that helping people heal and detox from phone and tech? Addiction phone and tech addiction. I the most dehumanizing Mind-scrambling forces in our time and this guy's got the got the antidote. He's got them. He's got some help M16 he's got them the tank weapon.  Well, we're really happy you're here with us Andrew I'm happy to be here. That was an incredible intro I'm so excited now I'm always passionate to talk about These topics, but you guys got me even like more excited. So I'm ready. I'm ready to get into it How old are you Andrew? I am the year. Uh, I'm as old as Jesus was I'm 33. Oh, great year. Just love it This is gonna be the year for you. Just you know You you know, I we're fighting for the church and fighting for you know healing and all that And I'm always you know, it's always is so much more exciting to me When young people like you Are out on the front lines and figuring out new ways jordan you and jordan need to hang out our producer He has an amazing, um Instagram page called do the harder thing. I really think you too should do an interview As well to get to his audience because his audience is dead center um to the folks you're serving so but You know, I so what I'm struggling with is how to talk about this because I want to I want to say I want to get to what it is but Uh, just humanality is what tell tell our listeners what what what the project is about Yeah, so humanality is a 501c3 nonprofit That is helping people discover freedom through an intentional relationship with technology So it actually started at franciscan university last year by hope and justin schnear um and this unplugged scholarship some people might have heard about but Started with 30 kids, uh who joined this scholarship where we paid them scholarship money To give up their smartphone and take on a dumb phone To really start to engage reality again and detox from phone and tech addiction. So that same year Over 50 kids just willingly gave up their smartphones to be part of the movement And now we're expanding to universities across the whole country And we really believe that this is a movement that's gonna really transform the way that we interact with each other And we really want to lead with the good of technology like you and me are communicating right now on technology It's a good thing But at this point the data is very clear that there is negative mental health outcomes I'd say physiological spiritual Uh, you know negative outcomes that come with direct, uh exposure To these devices and social media platforms. So that's a little bit about how we started Let's get right to what a dumb phone is. Yeah, I want to know what that is Yeah, so we're partnering with light phone Light lightphone.com and uh, this phone literally is just calling Texting uh, it has an alarm clock calculator A hotspot in some directions. So it's the phone I use And it's literally just it fits in the you know palm of your hand And it's just the basics, uh without the addictive aspects. Let's pause for a second. Um, He's his audio faded back A little bit ago I noted that too It's it's coming through good on you. Okay. All right. We won't worry about it So I'm what I want to do is uh So we'll just come right back in and after that last sentence. Okay. Look, do you have it near you? Yeah, I can give you more volume too. You're good. No, that's fine. Is that better? We want it? Yeah, we want to see it. Can you hold up the? Oh the light phone. Oh, we have it in your pocket. Yeah, and let me let me just direct how we come back in really quick Okay Got it. Okay. I want to come back in just like we were on that Hold on on that same sentence. Hold on to the phone. Yeah, hold it. Put it down the table Just okay, so I'm gonna I'm gonna just say I'm gonna say the sentence over again and I want you to show it We'll describe it more on your market set go. Do you have the phone with you right now? Yes, this is the light phone. Okay, so if you can see that it's simply, uh, the basics it has Yep, there's the phone alarm clock calculator directions hotspot and it's just the basics, you know It looks like the size of a credit card. Is it bigger than the credit card? Yeah, it's very small. I mean it Yeah, it's in the palm of your hand, right? Yeah, and when we so just to describe so that's for the live streamers can see that Yes, and you can see our live stream show by the way out on spiritualdirection.com. We post them all out there, but The you showed it to us. We were at where we met andrew was at a wedding of a mutual friend And he showed it to us now the difference visually than a smartphone is How a smartphone is designed and I want you to comment on this It's it's designed to make you addicted to Looking at it all the time dings colors sounds vibrations vibrations emojis all these things that add That give you, uh, what is that? Stimulus? Stimulus dopamine hit. Yeah, the dopamine hit that caused us to be addicted, right? Yeah, yes So the science on this is actually like really interesting and this is what many phds and mds are talking about But these devices are directly correlating to this dopaminergic pathway in the brain Which you know makes us feel good when we eat and when we sleep if you have sex. I mean, it says the good feeling You know chemical in the brain and there's multiple ways that these devices are essentially hijacking that neural pathway to keep you as addicted and and the word that they're actually using in Uh in the tech world is engaged So they want to keep you engaged in their products So there's two really main ways and this is out of uh cal newport's book digital minimalism But the two main ways that they're keeping us addicted to these platforms is through intermittent positive reinforcement So the idea that when you're scrolling And you have no idea what's going to come next That is preparing the brain for that pathway for dopamine to be released to make you want to Keep scrolling so you're seeing the next thing and the next thing and the next thing and you don't know and that unknown Keeps you scrolling and another way they're doing it is keeping us You know addicted is through this idea of social approval, which is so Deep in our anthropology and our desire to belong and our desire to be accepted And when we're on these platforms, they're literally playing on on multiple Psychological realities that are keeping us as engaged as possible. So they're not really interested In our well-being they're interested these companies are interested in us being engaged in their products, right? And that's how they make money. It's your attention That's actually being bought you you think it's a free platform But they're really using your time to be able to uh, you know get to their to their ends their means Which is again engagement the other thing about it the other the other thing about it that's nefarious at a Profound level is people who are trained with phd's in psychology are on these software development teams. Correct They're violating the Hippocratic oath To they are they are harming people To make money. Yeah, and they're using psychological sciences And software and they test the software and they can use kind of I read an article about it imagery of the brain and neural and watching activity in the brain And it's literally it's like brainwashing. Yeah, they do everything to tune the device color Yeah speed length of presentation haptics, which is like the physicality of it To watch where the maximum fire of neurons go Correct. It is it is it is deep. Yeah, it's demonic Trillions of dollars being paid into These platforms to keep you as engaged as possible. So most people don't want to be a slave, right? Most people want to be free and we and we obviously let especially my generation loves this idea of Of freedom and not, you know, having any rules or regulations and we don't realize that these devices I mean haven't slaved us. It's about 10 years, you know, since they've been out and it's funny There's an interview with steve jobs. I think in 2010 when the ipad initially came out And you know, the journalist was asking, you know, steve, how do you how are your kids enjoying the ipad and he's And he said quote, we don't give it to them Right, right, you know, like there's people doesn't give his didn't give his own kids these the stuff Right. Yeah one. I had there was a horrifying moment in our own family one time Where I just my eyes just about popped out of my head. Stephanie and I went to visit A good some good friends of ours Who have kids our age good? They're all good people are devout catholics, you know and So we're all we're in the kitchen or something meeting with our friends And I walk into the living room and every stinking kid Is on their own device In a room not interacting Yeah staring at a screen the different screens and doing whatever And I'm just like this what what what are the long-term ramifications? But I want to turn one more corner on this. Okay, and that is what elan musk has put a nuclear bomb to God be praised for that guy. I I'd love to see him become a man of faith All the lies and manipulation that that that's become a channel for political power to manipulate people Toward belief systems that are destructive socialism right communism, you know, all of the sort of The the the fake awake, you know, I don't want to use the words to get get, you know Tripped the youtube stuff, but the fake awake folks At just being fed this junk through these channels that they're addicted to I mean you can you can look at so many so many of the social ills right now Yeah, and and I'll just name a few of them One of them is this idea that that that we should not be having children anymore That there are too many children out there that need to be adopted. You shouldn't have children You shouldn't be open to life You need to give I mean the moral ills that are going on and if you think about all of the Temptations to adultery to to any kind of and that's going to be Harmful to you. I I now give you an example. I had a and I'll do it this real quick, but I had a student years ago started cutting You know an eighth grade student that started cutting and I and I met with her because it started to spread through my eighth grade class And I said, okay, I need to talk to you Tell me this idea didn't just come out of the air You didn't just reach up and grab it and started I said when's the first time you saw it Well, I don't know. I know I said when is the wind go back and think about this when is the very first time you saw it And she took a minute and she thought about it and she said I saw it on my snapchat Yeah, and it was just a picture with a a kid cutting It was just an arm with a cut slice in the wrist And then she kept seeing it over and over and over and over again and all of a sudden that idea and the demonic attached to that Absolutely, and then it passed through our eighth grade class and they all had to get counseling We had the priests come in and pray, but we're we're coming up on a break But technology is a problem and I love this solution. I love this solution So we'll be right back with andrew lawbalker on your markets, uh The auction go check it out help us avala foundation Up a Stoli be a community if you love the fact that we have prepared 500 men for the priesthood that we're training Priests who are already ordained to be spiritual directors for seminaries that we're serving 85 dioceses in the formation of with orthodox deeply spiritual all the richness of the church and we need your help to do that and we we don't ask for money much But we we could really use your help spiritual direction dot com forward slash events There's an auction there with amazing cool stuff including a couple of beachfront Properties for a week and you know really neat stuff that people have donated There's one other thing that's coming up. That's really really really important. Oh, yeah for married couples out there Or engaged couples. It's this it's divine intimacy and marriage retreat And it's coming up at the shrine of blessed sacrament in handsville alabama. Listen This is an amazing retreat. It is transformative to your marriage We have met with so many couples after the fact when they have gone through this Not because of us but because of a work of the holy spirit Of what is happening in their marriages and how it's changing their marriage for the better And so please please please please check it out. We have one coming up in the next few weeks In november and then we have another one in february. They will fill But we will get you in if you contact us. I will get you in personally Um, I will make sure you're there because it's it's a huge huge And it's it's for pre-marriage pre-married marriages in trouble marriage is doing well We have testimonies all across the spectrum and and anywhere from, you know, that you know the 20 year olds to the We've had couples in their 80s that are coming to an age and it's so beautiful So don't miss it spiritual direction dot com forward slash events for the auction and for the marriage retreat Yep, we're jump your i'm going to dumb my phone nicky palomino Yay Go out to humanality the dot com or dot org. I'm sorry humanality dot org All right, let's jump back into the show in your market set go This is danis ebony burk. Welcome back to divine intimacy radio. We're here with I don't know I'm saying top 10 important guests of this year.  I'm dead serious share this Show all over wherever you can send it in an email to your family share it on your social media Give it to your priest and tell them about humanality Now I want to go back to the design of the phone because for the radio, you know, people can't see So you talk the phone has no visual appeal So it doesn't have like you can text but it doesn't have those, you know, cute little bubbles and you can't do You know all the things you can do so it doesn't have the visual stimulus. It's just gray font This is dull gray font. The phone does not look cool at all.  Yeah how the phone is Counteracts all the evil junk that people are trying to do to our to us. Yeah, maybe just i'll articulate too quickly just again Some of the data of the problem and then we can kind of get to how humanality is sharing solutions And like you said at the beginning, I don't think there's anyone I've talked to yet once that's like Oh, there's not a problem like with our phones or like every single person is like, oh my gosh I need this. Oh my gosh. I need. Oh my gosh my kizzies. Oh my gosh my husband You know the wives look to the husbands and call them out and everyone we're all addicted to these devices And here's what I want to lead with is with mercy Because like we talked about earlier, they are very powerful Uh, you know companies that are literally trying to get you as addictive as possible And the thing is we're not strong enough. So we're we're actually being Um, you know used by our attention spans for means that I would say You know are not good, but here's some of the quick data points I'm just going to go through them briefly, but the average american is looking at their phones 87 times a day If you're 18 years and older the average time spent on entertainment based screen content is 12 hours This was in 2020 data Elementary age children now are using their phones or technology 7.5 hours a day A survey from common sense media reports that three out of four children view porn prior to 13 years of age 52 percent of those children viewed violent porn We are now 11 years 2 percent Viewed violent porn at what age? This is prior to the age of 13 God Yep So we are now 11 years into the largest epidemic of teen mental health on record Self-harm amongst 10 to 14 year old girls has quadrupled since 2010 That's gene m 20 her book iGen The number of college students who have seriously considered suicide jumped 60 percent six 2011 And 2016 and more than four to five adults in the united states Say they check their emails messages and social media accounts frequently or continuously So the problem is is real and I think first just being aware right of the problem is necessary and actually in the dsm now Which you know helps diagnose You know mental disorders. There's legit behavioral Addictions which involve gaming technology or phones. So when I say that we're all addicted I'm not using that word. You know flippantly. This is actual Legit clinical data that's pointing to an addiction from our devices So, you know, some of the things we're doing if you want to get into that dan just with our clubs at university Yeah, please please. So the idea is with these clubs You join you get a free light phone or you can join with another dumb phone So there's you know other companies like pinwheel and the wise phone and there's other options But the light phone We're partnering with so the first 30 students that join our club at a university will get a free light phone And if you want to join with your smartphone, here's the parameters. You have to go grayscale So again to your point about the psychology behind the the colors and the flashing and the you know Paptonian experiment we're in of these dings and pings Uh, you go grayscale you take off the internet off of your device and all social media So you can join the club with your smartphone But those are kind of the parameters you have to do And then along with that each month, we're going to have monthly meetings where the students meet together And we actually start to dive into some of this data. There's incredible books out there sharing about what this technology is doing to us And what we can do Uh to counteract it. So the students will kind of have time of Accountability and as they're detoxing like literally withdrawing From snapchat and social media and instagram and tiktok. They're going to have community right because that's crucial So they're going to be diving into the data having that accountability and community We're going to bring in one of our speakers from our team. Maybe myself or another Speaker to actually come and give a presentation to the school on the science on the data And then along with that, you know, they get humanality hats shirts all the swag And then we're doing this really cool thing. Uh, we're really excited about it's a humanality concert on campus The idea is the students put on a concert whether a local band or cover band and the cost of admission to the concert is your phone So you have to go experience music without a screen and just be present to the moment, you know And so right now the stories that are coming out from students on campus are absolutely Mind-blowing one of them just to highlight. I really loved I was just visiting one of our campuses And one of the students said and I've never thought of this before but he's like I get to have first impressions with people You know, because now everyone goes and looks at your story. They look at your whole Last time many years and they see everywhere you traveled all your friends all your family There's no such thing as first impressions anymore.  I was traveling around the world leading worship like doing good Work for ministry, but at the same time I was addicted to all the platforms myself Okay, so I got to ask you a really tough question go for you can dodge if you want um If a parent gives a kind of food to their child That has just a tiny bit of arsenic in it like just the tiniest bit And uh And it eventually kills them You know, that's the grave evil Why is it different than this?   I really do. I just think it is so inevitably destructive We need to knock it off.  Yeah, it's not the kids. Oh, yeah, and that was that's always been one of my conversations when people tell me Well, I'm distressed because my kid's doing xyz And they're living under their household. They're providing them a room to sleep in food Giving them insurance paying for everything paying for the car paying paying for the smart paying for the computers And yeah, oh, but they're not acting right They're dishonoring me. They're destroying their lives. They're suicidal. They're addicted to pornography xyz and it's like you're funding it Funding it. Yeah, and here's one point to do to parents that are hearing this that are also Maybe feeling that conviction and also maybe feeling shame. I've noticed anytime I bring this up You know, especially traveling like people initially feel shame because they know we're all addicted And I really want to you know, lead with mercy in so far is that we did not know that this was going to happen to us Right, right like we were given these devices without without knowing. I mean for me Yeah, my friends showed me porn in high school and I left the faith in high school and I was Atheist I didn't believe in God my my conversion was after high school And you know, I was kind of being told that I need to show You know, what I'm doing for the gospel on media and it just started to become really odd For me to think about the saints like would Padre Pio have An instagram where he's showing like himself like hashtag just spent 14 hours in the confessional You know, like I I started feel the narcissism myself And my own life and it was leading instagram was leading me to lust It was leading me to so many other things and again, even thinking of uh, you know, blaze pascal this I love his quote, you know that all of humanity's problems stem from the fact that man cannot sit alone with himself for just one hour In silence in silence, you know, I think for me The more that I noticed this addiction in myself the more I was like, whoa, I need to do something I went back to flip phones I went back to these other options and I knew early on that this was a problem And then God has obviously now brought me into this work But now yeah with the data that we know that's out, which you know, you can go to humanality.org We're gonna have a lot more info in the next two weeks about the data about the stories And and I do believe Dan at this point. Uh, I think you're right I think there's no good reason To give a child a smartphone honestly before the age of 18 and for me, I'm like maybe 30 would be good You know, because there's so many negative outcomes that we're seeing with the devices That it's hard to use it as a tool, which is it's intended for without getting these addictive aspects Yeah, absolutely. Yeah, I can't wait to get that website all updated with all this So that people can go and and make their case and and make their case and look at the reality of it And individuals can see it and their eyes can be open because it is staggering The yeah, we're looking and we're looking to get into the home humanality home in the workplace We're actually talking with a couple of seminaries right now Uh, we're actually partnering with hallow to create on their app Which you can access an app from a desktop a 30 day digital detox with humanality Well, we're really gonna walk you through like some of our simple challenges Keep the phone out of the bedroom. Keep the phone out of the bathroom You know sometimes dad just disappears, you know for 40 minutes on the bathroom and it's like dad You're not going to the bathroom for 40 minutes, you know Or uh, you know your meals Whatever it is it and then it is kind of funny like we have to start to see Some of the comedy in some of this because it is kind of so dark But what we're what we're doing with these phones. It's hilarious. I mean, they are always Attachers people are running into signs looking down. I mean people.  Yeah, and just some of the simple things like keep it out of your bedroom Like I would wake up scrolling. I'll go to sleep scrolling Just keep it out of the bedroom and and I know you need an alarm clock Go buy a digital alarm clock and have that, you know, wake you up in the morning And I guarantee your life will start to feel exponentially better Just with that one little tool St. Thomas Aquinas taught that entertainment causes spiritual dissipation Facts your prayer life and it It deteriorates your interior life and that's when there was no such thing as a smartphone, right? So it's Andrew. It's been great being with you.  This is a bomb in the devil's lap Blow them up everywhere and anywhere you can Support them support this project I just there's not much out there. I believe in more than this in terms of like Direct assault against the enemy's work in the church in the world Humanality is the organization H-u-m-a-n-i-l-i-t-y dot o-r-g Humanity dot org Andrew, we're so grateful for the good work you're doing. There's anything we can do to support you You just you just give us a call And with that Okay, until next time may the god of peace make you perfect in holiness May he preserve you whole and entire spirit soul and body irreproachable at the coming of our lord Jesus christ amen. Amen


Good morning everyone. I'm presenting a paper on soft tissue tumors. Soft tissue pathologies encompass a wide spectrum of entities. Patients often present with non-specific clinical findings such as ill-defined soft tissue swelling or discrete palpable mass with or without accompanying tenderness of pain. With equivocal clinical findings, imaging can confirm the presence soft tissue lesion. The objectives of imaging evaluation are detecting the suspected lesion establishing a diagnosis or formulating a differential diagnosis and radiological staging if the lesion is no-plastic. The WHO classification of soft tissue tumors, the soft tissue tumors are divided according to from where they originate and which soft tissue they originate from. They could be adipocytic, fibroblastic or myofibroblastic, so-called fibrohistocytic, intermediate type from the smooth muscles. They could originate from the skeletal muscle. They could have vascular origin, chondroocious or they could be of uncertain differentiation. The most common examples of adipocytic tumors are lipoma, lipomatosis, lipomatosulophonauts, malignant variety being liposarcoma, benign fibroblastic tumors being nodular fasciitis, myositis, osophagants, and the malignant being edal fibrosarcoma or mixofibrosarcoma, so-called fibrohistocytic benign tumors like GCT of the tendon sheath and malignant like pleomorphic fibrosychistocytoma. Arising from the smooth muscle, benign tumors are like angioliumioma, malignant like gliomyosarcoma, skeletal muscles, benign being rhabdomyoma and malignant being rhabdomyosarcoma, vascular of vascular origin benign tumors being like hemangioma and malignant being epitheloid hemangioendotheliomas, chondroocious soft tissue chondromas, and of uncertain differentiation benign tumors like intramuscular mitzomas, thymomas, or malignant like synovial sarcoma, epitheloid sarcoma, pleosal sarcoma of the soft tissue. The aim and objective of this paper is to describe the MRI findings of various soft tissue sarcomas. The material and methods, it is a retrospective cross-sectional evaluation of MRI features in patients with various soft tissue sarcomas who came to the department of radio diagnosis in Krishna Institute of Medical Science, from October 2021 to April 2022. MRI was done for these patients on semen 1.5 tesla MRI with contrast sequences and other specific sequences as and when seemed appropriate. Coming to the first soft tissue sarcoma that we'll be discussing, that is in hemangioma, they are characterized under benign vascular lesions, the other entity being vascular malformations. They are common tumors in infancy and childhood that can occur in any age group. Clinically, hemangiomas can manifest with bluish skin dispellation and a history of size fluctuation. Occasionally, pain may occur following exercise going to the shunting of blood flow away from the surrounding tissue into the hemangioma. The imaging features on plain radiograph, the hemangioma usually shows multiple flabollets on USG, complex mass with inadequate channels, with flabollets and acoustic shadowing, CT, poorly defined region with attenuation similar to muscle and significant post-contrast enhancement and flabollets are noted. On MRI, the lesion is T1 iso to hyper intense to muscle. On T2, it's hyper intense in area with vascular components and post-contrast, which shows prominent post-contrast enhancement. We'll be discussing a case of a 21-year-old man who came with complaints of swelling over his left foot. There are coronal P1 and post-contrast images and axial T1, GRE and post-contrast images provided. Or well, we can see a well-defined altered signal intensity-logulated area in the inter-muscular plane of plantar aspect of the left foot. At the region of the first metatarsal pharyngeal joint extending anteriorly surrounding the interpharyngeal joint. The lesion is hyper intense on T1, hyper intense on T2 and PDFS, showing fluid fluid level in T2. There's no evidence of diffusion restriction. Patchy heterogeneous post-contrast enhancement was noted and few flow voids were noted in the lesion. Pressure erosion, cortices of the first metatarsal and the still end of the first proximal phalanx is noted with altered signal marrow intensity in the form of PDFS hyper intense signal. Later on, this case was biopsic ruling to be a soft-diffusion hemangiomy. Peripheral nerve sheet tumors classified separately as mingogenic tumors by WHO. Benign peripheral nerve sheet tumors include schwannomas and neurofibromas. Benign peripheral nerve sheet tumors are typically iso intense to muscle on T1 and slightly hyper intense to fat on T2 but are non-specific in terms of their signal intensity. Schwannomas and neurofibromas can be difficult to distinguish from each other at imaging. Either tumor can appear as a very defined smooth border fusiform mass that is aligned along the nerve. Occasionally on MR images, a schwannoma can be distinguished from a neurofibroma by its location related to the nerve. The nerve is eccentric to the mass, although within the capsule is a schwannoma and rather than being central or obliterated by a mass, which is seen in neurofibromas. Discussing a case of a 43-year-old male who complains of pain and swelling over the right elbow, the images provided are actually PDFS, dilated, GRD images, and diffusion restriction images, and society post contrast and angio images. In the case of a 43-year-old male, we can see a well-defined, well-encapsulated solid lesion in proximal forearm at the molar aspect just below the elbow in relation with the medial nerve located eccentricly. A thin drum of T1 hyper intensity was noted at the proximal and distal points of the lesion, representing a layer of fat, the split fat side. The lesion appears iso-to-hypo intense on T1, heterogeneously hyper intense on T2 and PDFS, with central hyper intensity on T2 rated images. Post contrast shows heterogeneous enhancement, and the lesion shows no diffusion restriction or blooming on medic sequences. Coming to the third soft tissue tumor, synovium sarcoma, the effective extremities, particularly around the and the majority of the cases. Despite of the name of the lesion, it does not arise from the synovium. It is extra-articular in a location near the knee joint. Adolescents and young adults, around 15 to 40 years of age, are most often affected, does not arise from the synovium, and is seen arising most commonly surrounded in the knee. It features, which shows an refined mass with calcification and marriage within the lesion. However findings are not specific. MRI is the modality of choice. However, immediately findings are not specific. T1 will usually see an iso-to-hypo intense mass to the muscles. T2, mostly hyper intense, and post contrast, we see enhancement, usually prominent, can be diffuse, heterogeneous, or peripheral. Imaging findings that may be useful in diagnosis or synovium sarcoma include seen in T2 rated images of calcification, hemorrhage, and flow flow levels. Triple-signal areas of high, low, and iso-intensity compared to fat on T2 rated images are seen, which could indicate the cystic, hemorrhage, fibroids, and calcification within the lesion. Bone erosion or invasion may be noted. Discussing a case of a 38-year-old man that complains of swelling and pain over the knee, we can see a well-defined, low-gulated, mixed-solid cystic mass lesion in the intra-muscular pain along the medial aspect of right leg extending into the thigh and crossing the knee jump. Signal characteristic view T1 rated heterogeneous is slightly hyper intense, with few bright hyper intense areas within, largely the proteinaceous content due to oil hemorrhage. On PDFS, on PD, and medics sequences, it is heterogeneously hyper intense, with multiple cystic areas showing fluid blood levels within. Looming in dependent portion of cysts on medics sequences is noted. Periligional edema noted in the form of PDFS hyper intensity. On diffusion rated images, the solid component shows areas of diffusion restriction, and on post-contrast, there is heterogeneous enhancement, with few non-enhancing areas within. Diabdomyosarcoma is a malignant tumor with stelaquine muscle cell morphology, is one of the tumors of muscular origin. In general, they are found in young patients yesterday, 45 years of age, with 65% diagnosed under the age of 10 years. Minutes are more effective than feelings. On ultrasound, the lesion is heterogeneous, well-defined adegylamas of low to medium ecogenicity. Synthetic, it shows soft tissue density, some enhancement with contrast, and adjacent bone destruction is seen in 20% of the cases. MRI signal characteristics include the T1 low to intermediate intensity, ISO intents to FJC muscle, T2 hyper intents, promen, flow, or it may be seen particularly in extremity lesions. On post-contrast images, it shows considerable enhancement. Embryology, embryonal diabdomyosarcoma, tend to be malignant, whereas angiolar and pleomorphic types frequently have more areas of necrosis. The latter is associated with haemorrhagic enhancement. Discussing a case, in a biopsy-proven case of ribromyosarcoma, of a 40-year-old male who came with the history of fall, pain, and swelling over the left knee, we can see abnormal marrow infiltrator lesion in the lower end of the femur, in the metaphyseal diaphyseal location, with permeated type of bone destruction, and periostein reaction, and large extra oscule for tissue quality. This results in displaced horizontal fracture of the distilled shaft of femur at the epipyces with displacement of the distilled fracture fragment posteriorly and linearly, which signifies a pathological fracture. It exhibits intermediate signal in P1, weighted and heterogeneously hyper-intensive in PDFS and T2-HB sequences. PDFS hyper-intensity noted in bisectomorous, vastis latralis and medialis, which are suggestive of muscle hematomas, subcutaneous and intermuscular edema was seen around the knee joint, modded to severe joint effusion extending to the supra-patenomous arms, also noted. Ten cases were examined, out of which three were of soft tissue hemangiomas, three of peripheral nerve-shaped tumors, two of synovial sarcomas, and two of rhabdomyosarcomas, of which one of each has been discussed in this paper. In conclusion, ten cases were segregated, some of which different imaging features based on various sequences of P1, P2-FLAG, Bersin and gradient sequences like HEMO phase SWR were taken into consideration, and their imaging characteristics were mentioned in the paper. These are the reference papers from which these points have been taken. Thank you.


Ladies and gentlemen, the President of the United States, Ronald Reagan. Thank you very much. Thank you. Your lunch is going to get cold. Well, thank you, Dave and Penny and Bill, and I know Ruthie's out there, too. Well, I'm glad to see so many good friends here, especially because I've got a 90-minute speech. But actually, I'm going to keep my remarks very short. I was told that that was a key selling point for this luncheon. Now, I realize that we're reversing custom here and they're not going to let you eat until I stop speaking. But you know, I'm reminded of a story. It's strange how that happens. I've told this story more than once, but at my age, people aren't surprised when you start repeating yourself. Of course, I've been repeating myself for so many years now that it'd be risky to stop. And then there's some people to be saying, I'm losing my memory. Well, this has to do with the story of ancient Rome. Down on the floor of the Coliseum huddled this little group of Christians waiting there for the lions, and then the gates were open and the twelve hungry lions came roaring in at them. And one man stepped out of the little group and said a few quiet words, and the lions laid down. Well, the crowd was furious. Their show that they were expecting had been done away with, and Caesar sent for the man and they brought him before him and he said, what did you say to them that made them act like that? He said, I just told him that after they ate, there'd be speeches. Well, this is not just an ordinary Washington luncheon. That's because a plain load of Dave's supporters flew in from Minnesota to be here today. So on behalf of Nancy and myself, I want to give all of you a very special welcome to your nation's capital. Now, maybe you can tell me where you all were in 1984. Yes, we're in 1984 when I needed you. But seriously, our friends from Minnesota know what all of us are here in Washington also know so well, and that is what an experienced and effective senator the people of Minnesota have in Dave Durenberger. Now, I have a lot of respect for Dave Durenberger, but I'll tell you right up in front, and if I didn't, Dave would, that we may not always see eye to eye on every issue. Dave's reputation for independence is something he got the old-fashioned way. He earned it. But I will also tell you that on every major issue, Dave Durenberger will be involved. He'll know the details.  I figure he must be part Irish. And Dave Durenberger is a staunch defender of the rights and interests of his constituents. He spent at least 100 days each year in the state listening to the people so that he can put their concerns first. And in Washington, he's recognized by his colleagues on both sides of the aisle for his dedication and expertise on issues ranging from health care to the environment from tax policy to arms control. On the Hill, he is known as senator health care because of his record of accomplishment in this area, including the major role he's played in the catastrophic health care legislation past this summer. And Dave's strong support for the INF Treaty helped us win ratification by a large margin for the first agreement in history that actually eliminated an entire class of U.S. and Soviet nuclear missiles. Now, next year, there are going to be some tough budget battles, and we're going to need Dave's help. No, I'm not going to be in the White House, I got a pretty good hunch, but my friend George Bush is. Dave knows that the cause of the federal budget deficit is not that America is undertaxed, but that the federal government overspends. And I think having someone in the Senate who understands that will be worth a whole lot more than the cost of this lunch. And he understands what the basis of America's prosperity is. It's not the government, it's the people of this nation, it's an assistant that leaves them free to work their magic. He supports the Graham-Rudman deficit reduction law. He supported our tax cuts and tax reform bills, and he favors an amendment to the Constitution to require that the federal government have a balanced budget.  Right after the Constitution was approved, he said it has one glaring omission. It does not have anything in it that keeps the federal government from borrowing. Well, tomorrow I'm leaving on my last campaign swing as President. Now, listening to the Liberal Democrats' campaigning this year, I'm reminded of what someone once said, that politics is the art of looking for trouble, finding it, whether it exists or not, diagnosing it incorrectly and applying the wrong remedy. To listen to the opposition, you'd think that America had fallen on hard times. The fact is that America is now, as Dave told you, in the longest peacetime expansion ever recorded. Quite some time I've been saying over 71 months, I keep overlooking the fact that a couple of more months have been added. Unemployment is near a 14-year low, and a greater proportion of Americans are at work today than ever before in our history. In this expansion, we've created over 18 million new jobs. That's more jobs than Western, Europe, and Japan combined. And these are good jobs, contrary to what you've heard in some campaign rhetoric. 90% of them are full-time, and 85% of those are the kind that pay $20,000 a year and up. Two-thirds of the jobs are high-paying technical, professional, and managerial jobs. And yes, you've heard of this decline, the so-called decline of the middle class. But what they forget to tell you is that it's not that more Americans are slipping behind, far from it. Yes, the middle class is shrunk because there are more Americans better off than ever before, too well off to be called middle class. Yes, they've moved up into another bracket. Before I go on, I just want to put something in here. When I spoke about the proportion of the people in this country that are at work, and you say, well, yes, but there's a 5.5% unemployment rate. Yeah, most of that are people between jobs by choice or newcomers coming into the market. I had to come here to learn that the statisticians consider the potential employment pool in America of everybody, male and female, from age 16 and up. That includes all of them still getting an education, includes all the retirees. Well, 62.7% of that potential pool have jobs in this country today. Well, now the tax cuts that Dave helped us win for America's working people and entrepreneurs were critical to what we've achieved. Now the liberals are saying that what we did was give tax breaks to the wealthy. Nope. When we came to office, the wealthy were paying less than a fifth of the federal individual income tax revenues. Now the latest data shows, with our reforms, that group, the very top, that small percentage, are now paying more than a fourth of the total, a lot more than they were before when the rates were higher. I got a degree in economics years ago and I've sometimes thought it was honorary. But I remember out of that teaching one thing that I've never forgotten. Back in the year 1200, there was a man in Egypt known as Ibn Khaldun and he cited something that we could all find, understand is true today. And that is, he said, in the beginning of the empire, the rates were low and the revenue was great. At the end of the empire, the rates were high and the revenue was low. Well, now that we're talking numbers, you may remember something called the Misery Index. That was an election year gimmick that candidates Carter and Mondale cooked up for the 1976 campaign. They added up the unemployment and the inflation rates and it came to 13.4% in 1976 and they declared that no one, meaning Jerry Ford, had a right to seek re-election with a Misery Index that high, 13.4%. Well, four years later, after they had been in office, in the 1980 campaign, they didn't mention the Misery Index. Perhaps because during their term in office it had soared to almost 21%. And this year, the liberals still aren't mentioning it. You see, it's dropped more than half. It's down to less than 10% today. And if you care about working Americans, I think that number is something to cheer about. Now, I thought our liberal opposition would thank us for fixing what they broke and they haven't. Instead, they've dreamed up the charge that real family income is no higher today than it was 20 years ago. Well, the fact is that it's 14% higher and one reason it's not even higher than that is because between 1977 and 1981, I don't know why I happened to pick those years. After inflation, income of the typical American family dropped by nearly 7%. And now, since 1981, I don't know why I picked that year either. It's risen by more than 10%. And America's new prosperity also includes a lot more affordable housing. Real estate economists report that back in 1980, with inflation, interest rates, and housing costs soaring, while real income plunged, the average family earned only three quarters of what it took to buy a home. It was so bad, the top housing official in that administration threw up his hands and disbared. If the liberals are good at anything, it's throwing up their hands and despair. And said, for many hard-working families, housing is growing beyond their reach. Well, that's changed. Today, the average American family makes nearly 110% of what it takes to buy a home. And for families who rent, there has also been strong improvement. When the other fellows left the White House, low and medium income families faced a low vacancy rate for apartments of just 5%. That made rentals scarcer and more expensive. Now vacancies are up around 8%, and the apartments are more available. And it's the landlords who are having to wait longer to find tenants. So there you have it. Inflation cut by two-thirds, interest rates cut in half, housing more affordable, rates and employment at an all-time high. This is record prosperity we've achieved. I want you to remember one thing. Our economic recovery would not have been possible if George Bush and I had not had the help of a Republican majority in one house, the Senate, for our first six years in office. That's why it's so important to elect as many Republicans this year as possible and regain control of the Senate and help America to sustain and expand on the prosperity that we have today. It is vitally important to return Dave Durenberger to the Senate, important for Minnesota to have his strong and independent voice, and also important for the man who I believe will be the next President of the United States, George Bush. Well, I just want to thank all of you because you're working to make this happen, and I'm confident that with your help Dave is going to win. Let me just add one thing in here, another set of figures. Counting this year is the 58th. For 58 years, the Democrats have controlled 54, for 54 years, the House of Representatives. And for 48 years, both Houses of the Congress. Those six years that we had the one House were very exceptional. A Republican President in these 58 years has only had a Republican Congress in both Houses for a two-year stretch, and that was Ike. He had them for two out of the eight years. The Democratic Presidents, except for these years here, where we had the six, they have only had two years that a Democratic President had a Republican Congress in both Houses, and that was back in two years of Truman's administration. So it's 48 with both Houses and 54 for that other House. And that means, as we know, that every 10 years, the reapportionment laying out the congressional and legislative districts takes place. They've been in charge for that reapportionment. We're sitting here with a gerrymandered America that, over a half a century, they have been laying out the districts to suit themselves. Well, they can't change the state lines, so we may have trouble still getting even in the House of Representatives, but not in the Senate. Go out there and do the right thing. Get Dave back there in the Senate. Thank you, and God bless you all. Thank you very much. On behalf of the President, thank you very much. The first time I had heard about his economics degree I referred to as honorary because I started admiring this man in 1961 or two when he came and gave his general electric speech at the St. Paul Chamber of Commerce, and I got to tell you in reflection now that's almost 30 years ago that your consistency is incredible. The very same things you talked about then are the values that have been our foundation in both the six years that we had the majority in the two years in which the Democrats had it, but we were able to dictate some of the good things that happened in this country. Now, each of you has at your place a little gift, a small gift from a couple of wonderful women in Hopkins, Minnesota, but this is a slightly larger one I'm going to present to President and Mrs. Reagan. Just thank you. Actually, it says thank you for eight great years, which is the way we, a lot of us, think about Nancy Reagan and Ronald Reagan, but for those of you, I just mentioned that I heard a little bit of the governor in here, and you really have to remember that this person has been in public life in a wide variety of ways a lot longer than the last eight years, and this just happens to be the most visible part of it, but for all of those many years, Mr. President, especially the last eight years from Penny and myself, this gift does our way of saying thank you for all those here. Thank you very much. And thank you all again, and now a little nine-year-old girl wrote me a letter the first week that I was in office here, and I've tried to follow her teachings. She outlined all the things that had to be done, and by golly, at that age, she had them correct, the taxes, everything else, and then wound up the letter saying thank you to get back to work.


Live from Las Vegas, it's theCUBE. Covering VMworld 2017, brought to you by VMware and its ecosystem partners. Hi, I'm Stu Miniman here with Keith Townsend and you're watching theCUBE, SiliconANGLE Media's production of VMworld 2017 here in Las Vegas. For the last few years, hyper-converged infrastructure has been one of the hot topics and I'm happy to welcome back to the program Jesse St. Laurent, who is the chief technologist of hyper-converged software group, hyper-converged, sorry, software-defined, hyper-converged and cloud group at Hewlett Packard Enterprise. Slightly longer title than the last time I interviewed Jesse. Thanks so much for joining us. Yeah, thanks Stu, it's great to be here. All right, so hyper-converged has had a lot of hype. Hyper-converged has also had a lot of customers, a lot of dollars. First of all, I have to say, I think you're the first employee of SimpliVity that we've had on since the acquisition. We've had the pleasure of knowing, I've known you since before SimpliVity, but we've been watching SimpliVity since Stealth Mode, $650 million acquisition in CAS for HPE, so congratulations on that. And what have you been doing since the acquisition? I think one of the biggest changes really is going from being a product company where in reality startups, if you're going to be successful, you have to focus on one thing and you have to do it well. And for SimpliVity, well we spent a lot of time building technology that was much more broadly applicable from an industry perspective. Taking it to market, it had to be narrow, and that's why we focused specifically on hyper-convergence. But we always felt that, and you know, you and I have talked about this long ago, that some of the underpinnings of our technology really were about this concept of a data fabric. So fast forward to today, SimpliVity is no longer a single product company, we're part of a portfolio company that has technology that span the entire hybrid IT marketplace.  You've written this wave, I sometimes joke, I'm still yet to find a CIO that had a convergence problem. But you're solving real customer problems, obviously you've got a lot of customers. As you look back, what have you learned along the way? What are some of those key drivers that kind of got you to where you are? And what's changed in the conversations recently for your customers? I think it's always been about simplification. The strange thing is, SimpliVity always talked about simplifying IT. Whenever any of us talked about what the company did, the first slide was, our mission is to simplify IT. I didn't know it prior, but after the acquisition, HP's one of the core strategies of the company is to simplify hybrid IT, which aligns remarkably well. I think that's the common thread for SimpliVity is we've seen the product evolve and the use cases evolve early on, smaller customers, much larger enterprises over time, different use cases, ranging from data centers to extreme robo examples. I think that really the thread through that is hybrid IT's complicated. What I think is a common thread through all of, we see on the floor here for the most part, is IT is really hard. I always use the term the messy middle. In the end of the day, vendors like to make the world seem binary, right? It's either you either public cloud or your private cloud, or you're either X or Y, and the reality is no customer I've ever seen has come in in the morning and said, you know what, today we're going to flip this switch and everything is going to go from the mainframe to open systems, or open systems, bare metal to virtualization, or virtualization to containers. Customers live in a very messy world and that's where simplification is that scene. So Jesse, no matter the technology, technologists, we love to say scale, break stuff. SimpliVity is used to scale, but coming into HPE, much different size organization, organization that looks at the industry a little bit differently than SimpliVity does, how has things changed for your view now that you're inside of HPE? Yeah, I mean, one of the things that is a huge change is we're everywhere. But I mean, SimpliVity talked about being in, I don't know, tens of countries before, and we were excited about that. And for a startup, the number was huge. Right. It paled in comparison to the footprint of Hewlett-Packett Enterprise, right? I was in one of the first couple of weeks of the acquisition, I was presenting to some customers and Meg Whitman was part of the discussion as well, and I said, one of the biggest changes will be, we will be in 90% of the opportunities where somebody's talking about hyperconvergence. And Meg stopped me and said, no, no, no, we will be in 100% of the opportunities where someone's talking about hyperconvergence. And just to a scale perspective, that's a scale that no startup has ever experienced, right? You can't be everywhere and that's a huge transition just in terms of enabling a global sales force to be able to be everywhere. Jesse, I'd like to get your take. People talk about software is eating the world. We live in a software defined world right now. Cloud's a lot of software, but hardware still has an impact. I mean, we all know virtualization, boy, some of those underlying things, the devils and the details on networking and storage specifically. Hewlett-Packett Enterprise, obviously your solution is predominantly software, but now you have a lot more hardware that kind of goes with it. I know you've done a lot of the integration on that. What, has anything changed as to how you think of the software and hardware? And I'd love to hear a little insight as to kind of that integration work. Anything surprise you or excite you coming into the HPE family? Yeah, I think, let me talk about a little bit of sort of the SimpliVity hardware view and how that's evolved, because I think it's an interesting transition, which is we've always based our technology on one, our accelerator that just made everything faster and more predictable. It was a core part of our technology, but we've always talked about having a software optimized version of the stack as well. And doing that across a whole suite of hardware platforms was never a simple thing to do because there was one SimpliVity and there were a lot of hardware platforms out there. What we've seen now is we're going into an environment where there's one suite of hardware technology and it's a company that has a massive amount of expertise in Hewlett-Packett Enterprise, developing hardware technologies. So where SimpliVity had an accelerator, one of the things that I didn't think about in advance of the acquisition is a whole bunch of people coming to us saying, we've got some really interesting ideas on how to take what you've built around this accelerator and make it really fast. You know, you imagine when you own the chassis, when you own the motherboard, when you own everything about the platform, the idea of putting a card in, well, that's easy, but what else can you do? When you have an army of people that can build hardware, you can do all sorts of really cool stuff. So I think what you'll see is actually us doing two separate things in the market. You'll continue to see a hardware optimized version of everything SimpliVity's done for years now. Seems just a little strange to say years, but years now. That's not going to go away. In fact, it's going to get even better. But at the same time, their form factors and their places where you want to run in software, whether it's to be extra small, whether it's to bounce down the road in a Humvee, whether it's to be in an airplane. There's a whole bunch of reasons you want to do that. So you'll actually see us having a portfolio that embraces both sides of that. So one last question around that hardware and software abstraction. HPE, while a lot of expertise, you have to be a little bit overwhelmed. DL380, which you guys are supporting now. DL580, synergy. Where are we going to see SimpliVity next in HPE's massive hardware profile? Yeah, my hope is you see it everywhere, but it takes time to get there. I think one of the things that's most exciting about this transformation that SimpliVity will go through is really becoming a data fabric company. So hyperconvergence isn't going away. But in hyperconvergence, we'll come to other platforms. Whether it's a one-U platform or a four-U platform, more sockets, higher density, you'll see all those things over time. You'll also see what does it mean to be part of a software defined stack, living in a composable world. I think those things fit together really well, and you'll see a lot of cool stuff coming around that. We're seeing the biggest boost in terms of exposure in the market has caused huge SimpliVity product growth in the market. Now what we want to do is broaden that portfolio to be in a lot of other places in the market. All right, well, Jesse, really appreciate you catching the update. We're sure going to be watching as to how composable infrastructure and the portfolio of the HPE offerings fit in with SimpliVity. So thanks so much for joining us. For Keith Townsend, I'm Stu Miniman. We'll be back with lots more coverage here from VMworld 27 Las Vegas. You're watching theCUBE.


Greetings and welcome. My name is Annette Vegas. This session is on the bicuspid aortic valve, the role of TEE in surgical decision-making. I have no conflict of interest. During this talk, we will review the recent consensus classification for the congenital bicuspid aortic valve and its aortopathy. Explain the key anatomic features that determine success of bicuspid aortic valve repair. Review the echo assessment for bicuspid aortic valve repair and show some clinical examples. The number of cusps can vary for the aortic valve. Most cusps, most valves have three cusps, but two, one and even four cusps may be present. Each valve, with an abnormal number of cusps, has associated morbidity and specific echo findings. This talk will focus on the bicuspid aortic valve. Key numbers regarding the epidemiology of the bicuspid aortic valve include a prevalence of one to two percent in the general population, depending on whether autopsy, echo or clinical studies are cited. A three to one gender bias, being more common in males. Abnormal genetic findings occur as it is familial in nine percent of patients. It is recommended that first order relatives be screened. It is the most common congenital heart lesion worldwide, comprising 75% of all lesions and causes more morbidity and mortality than all other congenital lesions combined. Bicuspid aortic valve can be broadly categorized into three clinical prognostic subgroups, uncomplicated, typical, or complex. Uncomplicated is a retrospective diagnosis, as disease is silent and the patients are asymptomatic. So in typical, aortic valve function generally deteriorates over time, causing a valvelopathy, aortic stenosis, aortic regurgitation, mixed, or even endocrinitis. In addition, up to 30% of patients have an aortopathy, presenting with an aortic dilatation or more acutely with aortic dissection. Patients managed appropriately have a normal life expectancy in this group. In the minority of circumstances, patients may be complex with associated lesions that may be even more severe. The other congenital lesions associated with bicuspid aortic valve include syndromes such as Turner's and Williams. Coarctation is present in 7 to 10% of adults with bicuspid aortic valve, whereas bicuspid aortic valve is present in 50 to 60% of patients with coarctation. Other problems with aorta may include sinus aval salva aneurysm in 15 to 20% of patients and supervalvular aortic stenosis. PDA occurs in a known number of patients. Patients may have abnormal coronary anatomy, a non-dominant right, or coronaries adjacent to commissures. VSD and Shown Complex. The morphology of the bicuspid valve is the form and structure. The genetic material creates specific phenotypes or characteristics or traits. The morphology of the bicuspid valve varies resulting in different phenotypes that relate to, one, the orientation of the open casps, two, the position of the commissures, and three, the presence or absence of a rabbi. The caspenslinuses are often asymmetric in size. Though several classification systems describe the bicuspid valve, the most often used is a severs classification. This classification categorizes the bicuspid valve into three subtypes based on the number of rabbi present. Type 0, no rabbi, 6%. Type 1, 1 rabbi, 89%. And type 2, 2 rabbi, 5%. This is often considered the unicuspid valve. Type 1 is the commonest and is further subdivided by the spatial position of the casps into left-right coronary cusp fusion, 71%, right non-coronary cusp fusion, 15%, and non-left coronary cusp fusion, 3%. Shown here are the TEE, midisophageal aortic valve, short-axis views of different bicuspid valves based on the severs classification. Type 0, type 1, type 2. There is an associated systolic doming of the conjoined casps seen in the midisophageal aortic valve, long-axis view. Often, after making this diagnosis, this is where we stop and inform the surgeon. But what additional information will the surgeons require if they want to repair the defective valve? This brings us to the recent consensus classification published in 2021. This is an imaging-based, descriptive, comprehensive nomenclature and classification system that uses the English language and not numbers or letters. It is based on anatomical, clinical, surgical, and pathological scientific data. There are three types, fused, to sinus, and form frustrate. Within each type, there are further phenotypes, which we will explore in the next few slides. The commonest type is the fused bicuspid valve, occurring 90 to 90% of the time. The two cuffs are co-joined, like the severs type 1 classification, with phenotypes being right-left, 70 to 80%, right-non, 20 to 30%, and the least common, left-non, 3 to 6%. As shown here, the cuffs are of different sizes. There are three sinuses, and a raffae can be identified in the conjoined cuffs. As we will see, the commissural angle of the non-fused cusp is an important determinant of repairability. The two sinus bicuspid valve is uncommon, presenting in 5 to 7% of cases. The valve comprises two similar-sized cuffs with only two aortic sinuses. The commissures are positioned at 180 degrees. No raffae is present. In the lower TE example, what is the red arrow pointing to? This is a sinus of valve salve aneurysm of the non-cornery sinus. The other type is the form frustrate bicuspid valve. This valve has partial fusion of less than 50% of the cusp, creating a mini raffae. The valve appears to have re-symmetric cuffs, which create a triangular opening during systole. The commissural angles are at 120 degrees. While functionally normal, in appearance, the partial cusp fusion alters blood flow through the valve. Aortic dilatation may occur in 20 to 30% of patients with bicuspid aortic valve. Aortic expansion in bicuspid valves occurs at a rate of approximately 0.4 to 0.6 mm per year and is age-dependent. The consensus paper describes three aortic phenotypes, one ascending 70%, root 20% and three extended to involve the arch. The size of the aorta can be described as being mild, moderate or severe, depending on the measured size as indicated here. Patients with severe dilatation greater than 55 mm and those with more than 50 mm and risk factors should be considered for surgery. The different types of bicuspid valve aortopathy result in different aortic phenotypes. The commonest, the ascending aorta phenotype, involves dilatation beyond the STJ and occurs in older patients with aortic stenosis. Flow dynamics as shown here relate it most commonly with right non cusp fusion. The root phenotype, on the other hand, involves primarily dilatation of the sinuses, annulus and minimal dilatation of the ascending aorta. Presentation is often in the young male patient with aortic insufficiency. This type is more prone to aortic dissection. Flow hemodynamics relate those most closely with the right left cusp fusion. Here are TE examples of ascending aorta and aortic root dilatation. Accurate and more reliable measurements of aortic diameters at any level are best obtained with CT or MRI. As it is often hard to get truly perpendicular alignment with TE, so CT assessment is important. Aortic dissection is a known complication of bicuspid valve aortopathy occurring in 5% of patients over their lifetime. It is independent of aortic diameter. Regurgitant bicuspid valves are associated with a higher clinical risk for aortic dissection. The functioning cusps of most bicuspid valves exhibit asymmetric systolic excursion with marked bending strain insistently. This creates uneven systolic flow patterns and intrinsic morphological stenosis, such that bicuspid valves, even without calcification, may exhibit a small increase in trans aortic peak velocity. Bicuspid valve aortic stenosis from secondary calcification is the commonest pathology, presenting typically in older patients age 50 to 70 years old and is the indication for aortic valve replacement. Surgery is indicated for the usual indications. There is some debate as to whether tauve is an option. Newer technology and delivery systems may have made it increasingly an option after careful consideration in older patients. Bicuspid valve aortic insufficiency occurs less often in 30% of patients and is more frequent in men. The most important mechanisms of AI are cusp prolapse of the conjoined cusp or both cusps. Annular dilatation and root and STJ dilatation. The determination of AI severity and management follows current guidelines. The current guidelines recommend aortic valve intervention for symptomatic patients with left ventricular systolic dilatation and impaired function. The latter is a key determinant of survival and functional status after aortic valve replacement. In asymptomatic patients or those with moderate disease, the decision to intervene considers several factors, including aortic valve anatomy, aortic root size and shape, regurgitant severity, other comorbidities, and the patients' preferences and values. In asymptomatic patients, left ventricular end diastolic diameter is an important marker of clinical outcome. Intervening in bicuspid valve aortic top of the depends on size and the presence of these risk factors as listed here. Surgical options include traditional aortic valve replacement, replacing portions of the order combined with valve and aortic replacement, sparing the native valve, the ROS procedure, or isolated aortic valve repair. For optimal results, the latter three options should be performed at a center of surgical excellence. As we have seen, not all bicuspid valves are the same. Whether the surgeon can spare the bicuspid valve depends in large part on the cusp's aortic root geometry. The repair-orientated bicuspid valve classification is based on commissure orientation of the non-fuse cusp. The more symmetric type is easiest to repair. The asymmetric type, moderately difficult to repair, and the very asymmetric with commissural angles approximating the tricuspid valve, the most difficult. This animated video contains a commissure angle of 120 degrees. In a very asymmetric type 1 bicuspid aortic valve, the commissure angle is increased to 130 degrees while the fusion length increases and the commissural height decreases. The asymmetric bicuspid aortic valve has a commissure angle around 150 degrees and even more cusp fusion and lower commissure height. The symmetric bicuspid aortic valve has a commissure angle of 170 degrees, nearly fused cusps, and minimal commissure height. Finally, a completely symmetric sievers type 0 bicuspid aortic valve is displayed with a commissure angle of 180 degrees, complete cusp fusion, and only two commissures. Echocardiography plays a critical role in assessing feasibility of repair by identifying cusp phenotype, cusp condition, and measuring the commissural angle. This paper by Michelini is a worthy read on how to assess the bicuspid valve. The minisolphegeal aortic valve short axis view identifies the cusp phenotype as fused to sinus or form frustrate. The presence of three sinuses are confirmed. There may be asymmetry of the cusps and sinuses. A raffae is identified which may be calcified. Characteristics of a bicuspid valve amenable to repair include no or minimal valve calcification and good cusp mobility. An important determinant of the suitability of repair is the commissural angle of the non-fused cusp. This is measured in diastole to identify the non-fused commissures. Draw a line from the commissure to the center of the valve. Measure the angle where these lines intersect. The valve can thus be described by the commissural angle as being symmetric, asymmetric, or very asymmetric. The closer this angle is to 180 degrees, the better chance of successful repair. In addition, root measurements are important to correct the geometry of the valve. The annulus measured during systole should be less than 25 millimeters. The effective height measured in diastole from the annulus to the free margin should be at least 9 millimeters. The geometric height of the non-fused cusp traced in diastole from the cusp insertion point to the free margin in a bicuspid valve should be at least 20 millimeters. These measurements are detailed in these two papers and will be discussed further during the panel discussion. From a basic anesthesia perspective, the goal in bicuspid aortic valve repair is to correct the underlying cause of aortic insufficiency, be it cusp prolamps or abnormal aortic geometry. To optimize the commissure orientation to near 180 degrees. To improve cusp mobility by removing the raffa. To improve geometric and effective cusp height by placating prolapsing cusps and reducing redundant tissue to increase cusp coaptation. Cases with annular dilatation of greater than 27 millimeters require a correction by annular plasticity as this affects the geometric cusp height and length of cusp coaptation. The main aim is to make the commissure at 180 degrees and increase the geometric cusps lies to improve coaptation. Assessment post valve spearing shows a slightly thickened root. Assessment of cusp coaptation is critical. Ideally this cusp should co-op above the annulus without any portion of the cusp prolapsing below the annular plane. The highest point of co-optation is in the mid sinuses. Effective cusp height is the difference between the highest co-optation point and the annulus and should be at least nine millimeters. The co-optation length should be at least five millimeters. The valve is assessed for competency as well as global and regional function of the left ventricle. The presence of new regional wall motion abnormalities may reflect a problem with coronary blood flow. Now let's look at some cases. The first is a 33 year old female who is asymptomatic and presents with severe AI and a dilated left ventricle. The midisophageal aortic valve short axis view shows the presence of a fused bicuspid valve with fused right and left cusps creating asymmetric cusps, three sinuses and a raffae. The midisophageal aortic valve long axis view shows severe AI and the red arrow indicates prolapse of the fused cusp. So how repairable is this valve? There is fusion of right left cusps, asymmetric cusps, three sinuses, a long raffae and minimal calcium on the valve. The commissural angle is asymmetric at 155 degrees. There is prolapse of the fused cusp with eccentric AI. The annulus is measured at 38 millimeters insistently. The effective height is 7.5 millimeters. The commissural height is 5.5 millimeters. The geometric height of the non-fused cusp is 22.8 millimeters. The surgeon went ahead and spare the valve, which involved excising the raffae, implanting a 34 millimeter Dachron graph with subaortic annular plastic, orientating the commissures close to 180 degrees, flicating the fused cusp and reinforcing both cusp margin. The results show valve co-optation above the annulus, co-optation height of 9 millimeters, and a similar effective height. Trivial AI and a commissural angle close to 180 degrees. Case two is a 40 year old male who is asymptomatic with severe AI and a dilated left ventricle similar to the previous patient. The midisophageal aortic valve short axis view confirms the presence of a fuse bicuspid valve with fusion of the right and left cusps, creating asymmetric cusps, three sonuses, and no raffae. The midisophageal aortic valve long axis views show severe posteriorly directed AI, and the red arrow indicates prolapse of the fused cusp. So how repairable is this valve? There is fusion of the right, left cusps, asymmetric cusps, three sonuses, no raffae, and minimal calcium on the valve. The commissural angle is symmetric at 170 degrees. There is prolapse of the fuse cusp with eccentric AI. The annulus measures 27 millimeters insistently. The effective height of the non-fused cusp is 0.5 millimeters. The commissural height is 0, as there is no co-optation. The geometric height of the non-fused cusp is estimated to be only 14 millimeters. The surgeon went ahead and spare the valve, which involved implanting a 32 millimeter Dachron graph, placating the fuse cusp, and equalizing both cusp heights. The results show moderate eccentric and truly directed AI due to retraction of the fuse cusp. The surgeon went back on pump to revise the repair. The final echo shows co-optation above the annulus with a co-optation length of 7.3 millimeters and a similar effective height. The commissural angle is close to 180 degrees, and there is mild AI. The third and final case is a 68-year-old male who presents with a bicuspid aortic valve, ascending aorta dilatation of 55 millimeters, significant triple vessel coronary disease, and a left ventricular ejection fraction of 40 percent. The valve is sporadic with a mean gradient of 15 millimeters of mercury and mild AI. What operation should the patient have? These are the choices, ACB, ACB and hemiarch, ACB-bental and hemiarch, ACB-valves bearing, or just the hemiarch. Congratulations to those who chose number two. The patient underwent a successful operation, ACB and hemiarch. So in summary, the bicuspid aortic valve is a heterogeneous disease. Echocardiography is key to diagnosis and guide surgery. The new bicuspid valve classification facilitates assessment for repairability. Valve sparing procedures require surgical expertise. Thank you very much.