Thanks everyone for joining us today for our knee and hip arthritis webinar with Dr. Suman Nandi from University of Maryland Orthopedics. Dr. Nandi is the Chief of Adult Reconstruction for University of Maryland Orthopedics and he's also an associate professor of orthopedics at the University of Maryland School of Medicine. Dr. Nandi will go through his presentation about the symptoms diagnosis and treatments for hip and knee arthritis. We invite you to leave your questions for Dr. Nandi in the chat or questions box and we will get to the Q&A at the end of the presentation. We hope you enjoy. Dr. Nandi, take it away. Thank you very much. So thank you everyone. It's wonderful to have the opportunity to speak to all of you this afternoon. Just to tell you a little bit about myself, I am one of the total joint replacement surgeons at the University of Maryland. I'm originally from the area I was born in Baltimore and grew up in Howard County, went to school at NYU for medical school, did my training in orthopedic surgery at the Cleveland Clinic, and then did my specialty training in hip and knee in Boston where I was faculty before having the opportunity to return to Maryland. So today's talk is going to be very informal. I would love to hear questions from all of you, from each and every one of you, please do write your questions in. And at the conclusion of my talk today, I'd love to answer any questions on your mind. So again, today I'd like to speak to you about the symptoms diagnosis and treatment of hip and knee arthritis. So first things first, what is arthritis? Well, arthritis is a process. It's not a thing. It's a process by which the cushion in your joint wears away and then your bones grind against one another and that causes pain. So if I could just draw your attention to the left hand side of this slide, the panel on the left, that's a cartoon of the knee. So you see at the top, there's the thigh bone or femur. At the bottom, there's the shin bone or tibia. And the ends of these bones are coated by a smooth glistening surface called cartilage and it's depicted in this picture in pink. Well, if you take a camera and put it into a nice normal knee, what you see is the picture in the middle of the slide. And you can see those surfaces are nice and smooth.  It'd be pain-free and that patient is pain-free, all right, because that's a normal knee. Now again, what happens in arthritis? The process by which the cushion in your joint wears away and then your bones grind against one another and that causes pain. Well, what happens is what you see in the panel on the right. So if you took a camera and put it into an arthritic knee, that's what you'd see.  You can see how instead of the smooth glistening surfaces that you see in the middle slide, you have these beat-up surfaces like crab meat that are floating in the knee and you can see towards the right-hand side of the picture on the right-hand side of the slide that there's exposed bone. So there's literally bone rubbing against bone and that hurts. And that's what happens in arthritis. Well, there are different types of arthritis. So let's go over a few of these types. I'm sure many of you have heard of rheumatoid arthritis. What's rheumatoid arthritis? Well, it's an autoimmune process. It's a process by which the body attacks its own joints. One of the hallmarks of rheumatoid arthritis that differentiates it from other types of arthritis is that it's bilateral. And what does that mean? That it affects both hands, both knees, both hips at the same time. And it can be so significant that it can cause deformity as you see on the left-hand side of this slide here. If you take a look at that gentleman's hands, you can see that his fingers are no longer straight. And his x-ray of his hands is shown on the right-hand side of the slide. And as you can see, those bones are no longer straight. And that's what's happened as a result of the rheumatoid arthritis. The arthritic process is so deforming that it's caused his fingers to be no longer straight, to be bent. So this is rheumatoid arthritis. Well, there are other types of arthritis as well. One group of arthritic conditions is called crystalline arthropathy. And it's a family of conditions. And one member of this family is called gout. And I'm sure many of you have heard of gout. Well, what happens in gout? Well, the fluid within the joint fills up with crystals. And as a result, you can get joints that look like the image that you see on the left. Where there are large collections or deposits that form right above the joints. And those large collections are called TOFI. And if you took a look inside those large collections, it would be filled with this cottage cheese material. And if you then put that underneath a slide, you would see what you see on the right-hand side of this slide under a microscope. All right, you would see these millions and millions of needle-shaped crystals underneath the microscope on the microscope slide. And as you can imagine, that would hurt. So these crystals all cause a lot of inflammation within the joint and pain. So what I've shown you here in this slide is gout, which is one member of a family of crystalline arthropathies or arthritis. Well, this is not the only type of arthritis. We've got more. So in this slide, what I'm showing you is osteoarthritis. This is the most common type of arthritis. And many of you in the audience may have osteoarthritis. It is, as I've said, the most common. It is unilateral. So remember when we talked about rheumatoid arthritis, I said it was bilateral. So it affects both knees, both hips, both hands. Well, typically osteoarthritis is unilateral. It affects one side of the body at a time. That's not to say that it can't affect both, but it typically affects one side at a time, or at least one side is worse than the other. And what happens in osteoarthritis? Well, it's just like a wear and tear phenomenon. It's just like treading your tires, right?  Similarly, in osteoarthritis, the cushion in your joint just wears away over time. You have enough birthdays and this happens, happens to everybody. So let's take a look at the picture on the left-hand side of the slide. All right. So this gentleman has one arthritic knee and one normal knee, and you can probably already tell me which one is which. So the knee, the left knee for this patient, which is actually on our right-hand side because it's the patient facing us, the patient's facing us. The knee on the left-hand side, okay, or the patient's left knee on the, again, on the right-hand side of the slide is the normal knee. You can see how that leg is straight, right? It's straight. It's not particularly swollen. But if you take a look at the patient's right knee, which is actually on the left-hand side of the picture on the left, the patient's right knee is swollen. His knee is bowed. He's become bow-legged over time. And that's as a result of the osteoarthritic process. Now, let me show you this gentleman's x-rays, which are on the right-hand side of the slide, and all of you are going to be experts at reading x-rays by the end of this talk, okay? I promise you. All right, I'll show you this one, and I'll show you a bunch, and by the end of the talk, you guys will just think it's as easy as pie to tell what's going on on x-rays, all right? So let's go ahead and get started. So on the right-hand side of the slide is the x-ray of this gentleman's knees, and on the right-hand side of the x-ray is the patient's left knee, the good knee, all right? So what you see on that side is the thigh bone on the top, the shin bone on the bottom, and in between, you have a space. And when you have a space between the bones, that means on an x-ray, you've got plenty of cushion left. Well, compare that to the gentleman's right knee, which is on the left-hand side of the x-ray, okay? And you can see that there's a part of his knee that has absolutely not one bit of space in that knee, and that's because of osteoarthritis, all right? The wear and tear phenomenon where all the cushion is worn away. Now there's no space between the bones. The bones are grinding against one another. And again, that causes pain, like we talked about in one of the previous slides. So this is osteoarthritis. Well, what are the symptoms? Well, like we just talked about with regard to the x-ray, right? With regard to the x-ray, the bones are grinding against one another.  So what do you feel with arthritis? Well, you feel pain. So for folks who have hip arthritis, you feel pain in the hip, meaning the side of the hip, the groin. You can actually feel it in your rear as well. Well, what happens when you have knee arthritis? Well, you feel pain in your knee, all right? Well, here's what's really interesting. When you have hip arthritis, you can also feel it in your knee. And that's why when patients come to see me in the office, I examine both the hip and the knee for every patient. And I also get x-rays of the hip, even if patients are just having knee pain because knee pain can come from the hip. And that has to do with how our nerves are wired. Very interesting, isn't it? So if you got hip arthritis, you can feel it in the hip, meaning in the side of the hip, the groin and the rear end. But you can also feel it in your knee. If you got knee arthritis, you just feel it in the knee, all right? Well, as you can imagine, if you've got a really arthritic joint and your bones are grinding against one another, your knee or your hip can feel real stiff. Your knee or hip can swell up. And you can feel grinding within your joint, as you'd expect, right? Because that's exactly what's going on. Your bones are grinding against one another. Well, how do you diagnose arthritis? Well, when patients come into my office, I speak to them and I enjoy speaking to them. And it can actually give me a lot of information. I ask folks, where does it hurt? When did it start? How bad is it? What makes it better? What makes it worse? What have you tried for the pain? I also ask folks, and this is very telling, what are the things that you like to do that you can't do because of the arthritis? That tells me how bad things are. And it also tells me the kinds of things that patients want to get back to doing, all right? So that's a very important part of our patient interaction. Well, next, I examine patients. First, I look. I look at the knee, look at the hip because it can tell me just by looking at a patient, whether there's any evidence of infection, whether there's redness. I can, by seeing a patient walk, I can tell from the limb, if there is one, what's going on, all right? So just by looking, I'm able to glean a great deal of information. And then I move the knee, push on the knee, just like it's shown on the pictures on the right-hand side of the slide. I move the hip, push on the hip. And again, the exam tells me a great deal. And for patients who come to my office, I examine both the hip and the knee because, like we talked about in the last slide, hip problems can cause knee pain. So for patients who come to my office with knee problems, I always examine the hip and take X-rays of the hip as well. And that leads us to this slide right here. I promised you that all of you would be experts and I'm going to make good on that promise, okay? So we went over some knee X-rays. Let's go over some hip X-rays. So in the X-ray on the left, that is a normal hip. So here what you see is the ball and socket joint of the hip. The hip is a ball and socket joint. Here is the ball. Here is the socket, all right? And you see that there's an empty space here between the bones. And just like within the knee, when there's an empty space between the bones, that means there's cartilage left. That means there's cushion left. That's a good thing. It's good to be able to walk on cushion. That means that that patient is going to be pain free. But look what happens when you get arthritis and you have an X-ray that's shown on the right-hand side of the slide. Here you have the ball of the ball and socket joint. Here you have the socket. But now look, there's not one bit of space between the bones. The bones are grinding against one another. You can't tell where one bone ends and the other begins because there's not one bit of space. And again, because the bones are grinding against one another, you can imagine that this patient hurts because of the changes that have resulted from the arthritic process. I bet everyone in the audience can tell me what's going on here, all right? I'm sure you're already pros. But here I show you an X-ray of a knee, a normal knee on the left. Here's the thigh bone. Here's the shin bone. And look, you got plenty of space. So this is the normal knee. But look here, not one bit of space here in the knee. This is an arthritic knee and this patient hurts. So as you can tell, X-rays are very helpful in the diagnosis. You actually don't need any fancy imaging like MRIs or CTs. You can tell what's going on based on the X-rays. And in fact, X-rays are even more helpful in many regards because when I get X-rays, I have my patients standing when they get the X-rays. So I see what they're going through when they're walking. MRIs and CTs are done with the patient laying flat. So you don't see what patients' joints are doing when they're standing upright. So again, in a lot of ways, X-rays are actually more informative. Well, fine. So we know that we have arthritis on our hands. What do we do about it? Well, first, we always start with the simple stuff. Always start simple first. We always start with nonoperative treatments. And one of the things that we can try are oral anti-inflammatory medications. First of all, folks, if you have arthritis, don't go out and start popping pills that you get at the drugstore after this talk. Check with your primary care doctor before you start to take anti-inflammatory medications, which include Advil, Aleve, Motrin, Ibuprofen. Tylenol is actually not an anti-inflammatory. That helps take away fever and pain, but it's not an anti-inflammatory. Advil, Aleve, Motrin, Ibuprofen, Moxican, Di-Clophanac, these are all anti-inflammatory medications. And check with your primary care doctor before taking them. Anything that can help can also do harm. Certainly do not take anti-inflammatory medications if you got heart problems, kidney problems, ulcers, or if you're on blood thinners. Because anti-inflammatories can cause bleeding. If your primary care doc tells you it's okay for you to take them, then you can take them. The way to take them is every day for at least two weeks straight because it takes two weeks to build up in your system and really give you the relief that you need. And certainly stop if your stomach hurts. You should always take it with food, but stop if your stomach hurts. Right? And again, check with your primary care doctor before you start taking these medications. All right? Good. But anti-inflammatory is an important first step. What else can we try? Well, we can try physical therapy and you may say, Doc, I can barely walk from here to the room next door and you want me to do therapy? Well, here's what the goal of therapy is. The goal of therapy is just strengthen the muscles around your joints so that those muscles can function like a shock absorber when your natural shock absorber ain't working so well. All right? So if you go to physical therapy, as it's shown in these images, they can work with you to strengthen those muscles to help those muscles function like a shock absorber. It may not work, but we always try everything short of surgery. Something else we can try is steroid injections. What do I mean by steroid injections? Well, steroid injections are really powerful anti-inflammatories and these steroids are legal. These are not what the baseball players are taking. All right? These are legal. And what you can do is you can inject these very powerful anti-inflammatory medications directly into the joint and they decrease the inflammation within the joint. And it can provide some temporary relief. Relief that lasts varying periods of time, but sometimes it can provide relief for a good long while. Okay? Good. So now, suppose you've tried all these things. You've tried the physical therapy, the anti-inflammatory medications, steroid injections. Suppose you've tried an ebra.  Suppose you've tried and gotten to the point where you're even using a cane. Well, how do you know when you need surgery? Well, I don't tell my patients when to have surgery. I listen to my patients. When my patients tell me, I've tried everything short of surgery. It's not working and I can't live like this anymore. Then we start thinking about surgery. And when I say surgery, what do I mean? I mean total joint replacement surgery. Total joint replacement surgery is really the most reliable and effective surgical treatment for arthritis. In fact, if you take a look at the Medicare data, the most effective surgical treatments that a doctor can provide a patient are as follows. Number one is cataract surgery. But number two and three are hip and knee replacements, which is why I love what I do. It is really possible to change someone's life for the better with total joint replacement surgery, which I'd like to talk to you about in the next few slides. And I look forward to hearing your questions too. So I'm going to show you a little video on total hip replacements. And first I'm going to talk you through the video and then I'll show you the video. That way you know what you're going to be seeing. So what we do in a hip replacement is we remove the arthritic ball of the ball and socket joint, all right? Resurface the socket with a metal socket and a plastic liner, put a stem down the thigh bone and a ball on top. And that gives you nice smooth surfaces that glide against one another, as opposed to your bones grinding against one another. And that takes away your pain. It's as easy as that. So what we do is we first enter the hip, we remove the arthritic ball, resurface the socket with a metal socket and a plastic liner, put a stem down the thigh bone, put a ball on top. And that gives you nice smooth surfaces that glide against one another, as opposed to your bones grinding against one another. And that takes away your pain. It's as easy as that. So this is a before and after picture, all right? So again, all of you are pros now. So you know that that x-ray on the left hand side of the slide shows really bad hip arthritis, right? Here's the ball, here's the socket. There's not one bit of space there. That patient is hurting. And after they have a hip replacement, they have an x-ray that looks like this. Here's a metal socket, plastic liner, stem down the thigh bone and a ball on top. They've got nice smooth surfaces gliding against one another as opposed to their bones grinding against one another. And this patient is now pain-free. Now I'd like to show you a video on total knee replacements. Again, let me talk you through it first and that way you'll know what to look for when you actually look at the video. So what do we do in a knee replacement? We enter the knee. We resurface the end of the thigh bone and shin bone, cap the end of the thigh bone with metal, cap the end of the shin bone with metal, put a piece of plastic in between. And again, that gives you nice smooth surfaces that glide against one another as opposed to your bones grinding against one another. And that takes away your pain. So let's take a look here. We enter the knee. We resurface the ends of the thigh bone and the shin bone, cap the end of the thigh bone with metal, cap the end of the shin bone with metal, put a piece of plastic in between. That gives you nice smooth surfaces that glide against one another as opposed to the bones grinding against one another. And that takes away your pain. So now let's do another before and after. Again, I don't need to tell you what's going on here. This patient is hurting because they've got really bad arthritis. Their bones don't have any cushion left. The bones are grinding against one another. And here is the patient after a knee replacement. You've got metal capping the end of thigh bone, metal capping the end of the shin bone and a piece of plastic in between that you can't see because on an X-ray, you can just see very dense materials like metal, can't see plastic. The X-ray beams just go straight through it. And this patient is pain free. Well, what can you expect after surgery? Well, we have all our patients walk the same day of surgery. Why is that? Well, all the data shows that when you get patients up and walk in right after a hip or knee replacement surgery, it improves the speed and quality of your recovery. And that again, that's based on the data. So all the advice I give my patients is based on the studies and the data. That's what I use to guide my practice. Okay, because when it comes to something as important as your joints, your surgery, your quality of life, really, we need to have the data guide our practices and the decision making. So you'll hear me talk about the data over and over again as I go through the remainder of this talk and I answer your questions. For patients who are interested and are medically suitable, those patients go home later the same day. So the studies show that there are no increased risks with sending patients home the same day. Before the COVID era. This was very appealing to patients. They're able to recover in the comfort of their own home. They're able to have their own family members take care of them who takes better care of you than family nobody. All right. And now in the COVID era, it's particularly appealing to patients to minimize the time spent in the hospital. Now that being said, the University of Maryland has done a wonderful job performing elective surgery in the COVID era and doing it safely. So fortunately, I can say that I have not had a single patient develop COVID as a result of having elective surgery. Okay, so the University of Maryland has done a wonderful job. However, patients still have an added sense of comfort being able to leave the same day and minimize their time spent in the hospital. Now, our goal is not to make anyone feel like they're being pushed out the door. So for folks who have an added sense of comfort with spending the night in the hospital, we certainly allow that. And we make the experience as wonderful as possible. We've got a dedicated team of nurses for our joint replacement patients. We've got private rooms dedicated for our total joint replacement patients. So we really make it a wonderful experience. What we don't do is have patients stay longer than overnight. And the reason for that is, again, based on the evidence, based on the studies that show that if you spend longer than overnight in the hospital, there's an increased risk of developing a blood clot in the legs that can go to the lungs and cause problems. And we don't want that. We don't do anything that increases the risks after surgery. And speaking to our efforts to minimize risks, that's why we give everybody blood thinners to prevent blood clots after hip and knee replacement surgery. That's standard of care.  Thank you for the opportunity to speak to all of you today. I really enjoyed it, and I'm really looking forward to answering any and all of your questions.


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How old are you? My partner doesn't answer.  All right because it's been you and I'm getting bored of that Yeah, I will talk about something that I've been Encountering and realized that's actually kind of new and it's I'm a polyfilts which are not new But conditional loading of polyfilts in a world where we all use ES6 modules All right, because it's quite an important thing to do now because we're in a situation where You know some browsers have like web components some don't and you don't want to be loading all those polyfills for all It can be quite big But also you don't want to like go to the lowest common denominator all the time because that's not the great experience for you as a developer All right, come on show me what you got Right, it's not not polyfilts yet. But for example, let's say I want to use transform streams personally I've been loving transform streams. They are amazing. Yes Not only just to do streams, but I actually just use them as a as a fifo queue For example, if you want to if you have an event handler and you want to make sure your previous event is Completely processed before you process the next one. Just pipe into a transform stream Because the if you're returning a promise from your transform stream handler It's not going to give you the next one until all that's resolved and it buffers it up That's actually quite neat. Very clever. Right. Okay problem though. We have transform stream in chrome I think they're just about to land. It's a far Farry they're not in firefox. I should look this up. I don't know but there's Basically what I'm saying is the landscape is uneven in terms of support for transform stream Right. So what you want to do is load A polyfill. Yes. And so in in the olden days, you would just do this, right? You would just put a script tag ahead And you could be sure that that script tag would execute before the other one executes transform stream is fully polyfillable Exactly, it's completely it's technically completely user land But you don't want to load that code usually right so in this case the polyfill would Put their implantation on the global Maybe even only if it is not already there So you would use a native implantation because it might be faster and otherwise it just adds it and then transform stream exists And you can just use it great Right brilliant problem now, of course is it gets loaded every time Yes, and you might have a browser that doesn't need to load that it might be a lot of code Like chrome right now like and if you can avoid that Yeah, you would want to avoid that excellent. So now let's look into how you do conditional learning and that's Where we already start looking into Like importing stuff because in the olden days again You would probably create a script tag dynamically and wait for the on note event now. We have dynamic import And I think this is something I got wrong in a previous episode because you can use the dynamic import Even in a regular script. Yes, you can that's very good. It's very exciting You don't have to use a module script to use dynamic import only for static import So in this case i'm just taking dust transform stream exist on self. Yep, and if that is not the case Time to load the thing right so this is a module that's not Returning anything. No, that's it's a polyfill. It just attaches to the global right, okay, okay, that's exactly the point We are now Preferring in advocating people to don't in general polyfill shouldn't do that They shouldn't attach them to the globals because then you land in this place where you might be overriding in native implementation That might not be up to date or it's it can there are so many complications the whole uh smooch problem Exactly, we don't want to have a second smooch.  So instead of a polyfill you would use a module Something that doesn't actually modify the global at all, but just returns Something to you that you can use. Okay. Okay. And so in this case We're just importing and don't use it. So in this case This will still be undefined. So this right doesn't work anymore Right because it's expecting like something around here to be returned and that would be your module Right, okay So now we have a module that exposes these things. Yes, but you can't Just attach them to the global because you have to load them ahead every time you have to at the start of your module You have now to check do does it exist? Does it not exist? If it doesn't exist Hold the entire module until I've loaded the polyfill Oh, I see and then I have to Load the module rip it out and attach it to the global Right because especially if it's like third party code you want all of that to wait somehow and it gets really weird Right. Okay. Yep. Yep. Yep. So now let's move on to proper modern world es6 modules. How could we solve this? The first Version bracing for modern javascript. Boom. Oh, look at that modern javascript We just turn it into a very very small two line module that loads the module attached to the global and you depend on this module In every other modulate user streams, right? And we've we've avoided the whole I mean this is still going to be asynchronous in terms of it's not going to block the main thread, but it's Synchronous in terms of that code that comes after it because and so this is completely valid completely Acceptable way to go about it, right? Right. So this works in the sense that you load the polyfill And it's just a global and all your code will now work for the polyfill if necessary But we lost the conditional loading Ah, yes, of course because conditional loading is not possible with static imports because they're static Yes, that is true That's kind of like it's it kind of hidden and once you think like wait, I cannot do you can't put an if statement around that The import has to be either you depend on this module or you don't Right the second you want to do conditional loading you have to go to ramic import And then you're back at the problem because now I have to hold my module until it actually Under the polyfill is loaded and that's really weird. Do you have a I hope this is going to end with a solution I have a solution I don't think it's perfect But I actually have been using and it's quite nice because the second problem with static import is it Delays the execution of the module even though you might only need the transform stream in some specific method Right, I see I see and that could be like a few interactions away Exactly. I might reload it at a deferred point or even on demand if it's some sort of background task So what I've been using is a different approach which feels a bit weird, but actually as a pattern works really well All right I'm creating a promise you are yes And so I'm creating a transform stream promise and that I can now Use an if statement and then check If transform stream exists, I'm just going to return the native transform stream I see And if not, I'm going to dynamically load the polyfill And return that one Yes So now we have a promise that will always resolve to a transform stream constructor And it might be the native one. It might be the polyfilled one But you don't have to worry about it anymore Right and that means your module can execute as fast as possible or as soon as possible And we'll load the code the second you need to And so this is this is going to be you've got the asynchronous problem back, right? Sure But that is usually this is kind of specific to the point of streams But most of the time streams are in a asynchronous context anyway So that's true either on the sending side You don't need to worry that it's a promise most of the time because it's already you can just Resolve it in line the function can return earlier and just Wait for this from to resolve and then send it because you don't need to worry about it On the receiving side It's asynchronous anyway because it's a stream So you most of them have an async that you can use a weight to await this thing Excellent. So I mean, so this is this is a pattern that works really well for for code that You're in control of right because you're now using transform stream promise instead of transform if it's for third party Code that is rely that is expecting transform to be on the global That's when you're going to have to delay the loading of that that being said if you have third party code It relies on transform streams something is a little bit Oh I'm I've got mixed feelings about that because I see what you're saying But then you could end up if each library is loading a polyfill for transform streams You've got that you could end up with problem where you're you're loading You know five libraries that are using transform stream each loading their own polyfill And unless they're using exactly the same version in that sense though That's where you would dynamically load the polyfill So then dynamically load the third part of scripts Yes, and just because I some people might be disgusted by this pattern at the bottom where you like await something and immediately call new You can also write in two lines, which might be nicer Of course Probably the miniferous will go back and package it back up because of what minifers do nowadays And if you're confident in that the polyfill is is feature complete and the spec is settled then This is a point where you could assign it to the global if you are loading third party code But I feel like the promissified constructor pattern is a really nice way of loading polyfills on demands Ensuring for you to run as much code as possible with the request as possible at the start And you're loading this ahead of time as well, but asynchronously so And that's your choice now you can decide when the loading happens if you're like actually I don't need to load this Right at the start. I can actually load it In request. I will call back. You can do that as well The things work now Hulk is back Have you seen my bicep? This is like made of steel made of soy


Okay, welcome back. I think the internet is working okay now, so we are back on video. So we'll just continue from there. Did anyone have questions about the last one on the greater sin? Do you have online or in person? In the context of 1st John 517, all unrighteousness is sin and there is sin not leading to death. Okay, so that is a different context, right? Can you repeat the verse please? 1st John 517 Okay, so we'll have to read more in 1 John to look at what John is talking about. But in 1 John, John is talking a lot also about wrong teaching about Jesus, mostly that some questions about whether Jesus was God. And so when he's talking about sin, it's that rejection of Jesus as God that leads to death. In that kind of context is where he's talking about a difference in sin of whether you've done something that is wrong and whether it is also a one-time sin or a continuing in sin, a continuing rejection of God. A continuing rejection of God will lead to death. But if it is a sin that is one time and you're repenting of that sin, there is forgiveness for that sin. So yeah, that is also one of those difficult passages in scripture. Okay, we'll continue. So the next one is on page 40, forgiving people sins. John 2023 says, if you forgive the sins of any, they are forgiven them. If you retain the sins of any, they are retained. Okay, so what does that mean? Do we have the power to forgive people sins or to choose to withhold forgiveness? And based on our forgiveness is their judgment determined, their judgment by God. Or how do we understand this verse? Okay, so what are some rules about interpreting scripture that we've discussed in this class? When we are looking at a passage like this, how do we make sure we interpret it correctly? Because if we take it by itself, it looks like we can choose to, we can determine someone's eternity. We can either forgive them or choose not to forgive them and their final, that decision is placed with us. But what do we have to make sure we interpret this passage correctly? Sister, only God can forgive us and forgive sins. Okay, why do you say that, sister? That only God can forgive sins? Because Jesus said, I have the power to forgive sins. Okay, so you're looking at other parts of scripture where it says that only God can forgive sins, right? Yes, but I don't know the scriptures, sister. Okay, okay, yes. So one of the, now we want to also put into practice some of the things that we've discussed in interpreting scripture in this class. So one of the ways in which we make sure we can interpret this correctly is by looking at other passages of scripture talking about forgiveness, right? So who has the authority to forgive sins? So Jesus said that he has the authority to forgive sins or when he forgives sins and people questioned him, he shows that he has that authority to forgive sins. He has the power to forgive sins, right? And people were offended when Jesus forgives sins because they said only God can forgive sins. But Jesus goes ahead and still forgives sins to show that he had that power, which means that he is God. Okay, any other principles of interpretation that we need to apply here? What other ways can we make sure we don't wrongly interpret this verse? Okay, so apart from looking at the rest of scripture, we look at the immediate context. Okay, so let's turn to John 20. So the first thing to do is when we are looking at a passage is look at the immediate context. Why is the writer saying it? What was happening in that passage? And how does this verse relate to what he was saying before this? Okay, so if we read from verse 19 onwards of John 20, Jesus has appeared to his disciples after his resurrection. And he comes to them. He stands in their midst. He says, peace be with you. He shows them that he's truly resurrected. It's a bodily resurrection that he's not just a spirit. And then he says from verse 21 onwards, peace be with you as the Father has sent me. I am sending you. And with that he breathed on them and said, receive the Holy Spirit. If you forgive anyone's sins, their sins are forgiven. If you do not forgive them, they are not forgiven. Okay, so what is the context here in which Jesus is saying you can forgive or not forgive? What are those two verses 21 and 22 saying? Okay, so the Father had given Jesus authority and now Jesus is giving authority to his disciples. Okay, so what was Jesus sent for? The Father, why did the Father send Jesus? We know that Jesus was sent to die for our sins, right? But what was the purpose of that? To reveal the Father. Okay, to make way for us to be restored to the Father. And how are we restored to the Father? Through Jesus, through the cross, through his death and resurrection. So when Jesus was sent, he was sent to accomplish this work. And Jesus was preaching the kingdom of God and displaying the kingdom of God right up to the time that he went to the cross. Okay, so we are also sent in the same way to preach the kingdom of God to declare that sins are forgiven through Jesus Christ. But the response that people give is up to them, right? So the power to declare forgiveness to people is in our hands. We have the power to preach the gospel, to share this message that there is forgiveness in Christ. But the response of the people will determine whether their sins are forgiven or not. Okay, so that is one aspect. We are sent like Jesus was sent. The second thing is receive the Holy Spirit. So we go in the power of the Holy Spirit. We go as agents of God to represent Jesus Christ before people. Okay, so let's just turn to Matthew 18. Okay, we'll read verses 15 to 20. Matthew 18 verses 15 to 20. Moreover, if your brother sins against you, go and tell him his fault between you and him alone. If he hears you, you have gained your brother. But if he will not hear, take with you one or two more that by the mouth of two or three witnesses, every word may be established. And if he refuses to hear them, tell it to the church.  Assuredly I say to you, whatever you find on earth will be bound in heaven and whatever you lose on earth will be lost in heaven. Again, I say to you that if two of you agree on earth concerning anything that they ask, it will be done for them by my Father in heaven. Two or three are gathered together in my name. I am there in the midst of them. Okay, so the first aspect of forgiveness is in preaching of the gospel. So when we preach the gospel, we offer people the opportunity to be forgiven. If they reject the gospel, they have chosen to not receive that forgiveness. And if we read when Jesus sends out the disciples, he says, if they do not welcome you, what do you do? Do you try and force them to accept the gospel or what do you do? When you go from one place to another preaching the gospel, he sends out his disciples, right? In tours to go out and share. So what is our response when people don't receive the gospel? Yeah, so we dust the, we basically shake off the dust from our feet and we move on, which is meaning to say that you have chosen to reject. And so I've done my work. I'm leaving you to be judged by God. Okay, so that is one sense in which we have the power to declare forgiveness and to declare judgment. Okay, the second aspect is what we just read in Matthew 18. Here this is within the body of Christ, okay, where there is disagreement between two people. We try to address it between the two people. We go to the larger body of the church. And if that person is still unwilling to accept correction, then we treat them as someone who is no longer part of that body of believers. But this is something that is given as collective authority to the church. So it says here verse 18 says truly I tell you whatever you bind on earth will be bound in heaven. This is very similar to the verse in John 20. If we read it in the original language, it actually is whatever you bind on earth has been bound in heaven. Whatever you lose on earth has been bound, has been lost in heaven. Meaning to say that you are just doing what has already been done in heaven. What God has done in heaven you are executing on earth. Okay, so God has actually bound, God has actually lost and you are executing that in this context. Okay, in this context of somebody sinning. And so it's saying when you agree as a church on something like this, then you are executing the will of God. Okay, so I am there with you. I am leading you to act in a certain way. Okay, does that make sense? So we are agents of Christ and as a body of Christ we can make certain judgments against sin in agreement when we come into agreement with each other because we believe that Christ is present with us. Is that clear? So it's not as an individual that I can declare that you are not forgiven, but as body of believers coming agreement about a certain sin. Okay, and then the third one is also a similar example, but this is a practical example. So Matthew 18 is just giving it to us in theory. If we see a point C in under this question, it's mentioning the issue in the Corinthian church, where there is sin in the church and Paul tells the church to put this out of their fellowship because he is continuing to walk in sin and if they allow that to stay in the church, the rest of the church is going to be corrupted. Okay, so the point of putting that person out of fellowship of the church is to bring them to repentance. So even when we are passing this judgment against sin, our ultimate goal is that the person would repent, not that that person will be condemned or that person will feel this sense of shame or judgment. Okay, the point of that declaration of you have sinned and what you've done is wrong is to then give them the opportunity to repent and that example is given in the Corinthian church. So does this make sense? Any questions? Are you good? Yeah? Okay, the next one is three days and three nights. So we see in Matthew 1240 that Jesus says, for as Jonah was three days and three nights in the belly of the great fish, so will the Son of Man be three days and three nights in the heart of the earth. Now, this big question of how does Jesus' death to resurrection count as three days to three nights, because the way we usually celebrate it is Good Friday and Easter. So Good Friday you have Friday night, Saturday night, that's two nights. So even if we say the whole of Friday, the whole of Saturday, somehow Sunday morning may be three days, but we can only count two nights. So how can we account for these three days and three nights that Jesus mentions in Matthew 12? There are two explanations that are given here. We'll just look at both of these. So John 1931, let's just turn, we'll read these passages here just to help us. John 1931, someone can read that for us. Therefore, because it was the preparation day that the body should not remain on the cross on the Sabbath, or the Sabbath was a high day, the Jews asked Pilate that their legs might be broken and that they might be taken away. Okay, so John 1931 talks about this being a high Sabbath, which may be different from the regular Sabbath and we look a little bit more at what that means. Okay, and this we see also in John 737, the same high Sabbath that is talked about, the last day of the feast, the last and greatest day of the festival. So the feast of the Passover and the feast of Unleavened Bread, they were supposed to be celebrated on the first month of the year, the month of Nisan. And the 14th day was the preparation day for the Passover. So if we look at starting from the 14th day, you can look at that first table that is there. The 14th day of Nisan was the preparation day and that's when the Passover began. And if we look at the Jewish day and night, the day began in the evening. So it began from 6 p.m. the previous day and it would go into 6 p.m. the next day. So that would be considered as one day, one full day according to Jewish custom. Okay, so the Sabbath would begin at 6 p.m. on Friday rather than in the morning Saturday or 12 a.m. on Saturday. It would begin at 6 p.m. on Friday. That would be the Sabbath day till 6 p.m. on the Saturday. So we count that 14th day of Nisan the preparation day as the day when Jesus had his supper. That would have been a Wednesday. Okay, so he's arrested in the Garden of Gethsemane on Wednesday. On Thursday morning, he is crucified in the morning at 9 a.m. And he stays on the cross till 3 p.m. But he's buried in the tomb before 6 p.m. that day. And the Jewish Friday begins from 6 p.m. So Sabbath begins from 6 p.m. on that Thursday evening. The Jewish Friday begins on that Thursday evening at 6 p.m. So that's considered as the first day. So we're saying here that Jesus was crucified on Thursday morning based on this whole thing of the high Sabbath. Okay, where Friday is the high Sabbath and Saturday is the weekly Sabbath. So the normal regular Sabbath would have been the Saturday. But the high Sabbath was the last day of the festival. And so that was the day that they said that we can't take the body off. We can't have these bodies hanging on the cross on a high Sabbath. Okay, so Friday is the feast of Unleavened Bread. It begins on that Thursday evening and then ends on Friday evening. Okay, so that is the second night that Jesus is in the tomb. Saturday is the Sabbath. Again, beginning on Friday 6 p.m. ending on Saturday 6 p.m. That's the third night. And on Sunday, Jesus is raised from the dead. Okay, any questions that are a little confusing? Okay, so the only thing here is because of the high Sabbath and the weekly Sabbath, instead of considering Saturday as the Sabbath, we are saying that Friday was the Sabbath. That is mentioned here in John because it talks about a high Sabbath. So that means Jesus was crucified on a Thursday rather than on Friday. Okay, so that is one explanation. The other explanation is that we look at each night and day as one whole. Like we count that as one day. So on Thursday, that Jewish Thursday begins on Wednesday at 6 p.m. That's the preparation day. Jesus has his last supper on Thursday and he's arrested. On Friday, he's crucified. Okay, and then he's buried before 6 p.m. So that's considered as the first day because he's buried before 6 p.m. He dies before 6 p.m. So that when Thursday to Friday is considered as the first day and night. Does that make sense? Yeah? Okay, so that's the first day and night. And he's in the tomb on Friday from Thursday 6 p.m. Sorry, from Friday 6 p.m. to Saturday 6 p.m. That's the second night of his death. And then from Saturday evening to Sunday morning is the third day of... So we're considering that 6 p.m. till whichever the next day as one day and night. Okay, so those are two possible explanations. So the conclusion here is also important. We are not looking at this as this is a definite explanation. These are just possibilities for ways to explain. But the important thing is that Jesus died and was raised. Okay, these are just ways to understand how we get those three days and three nights. Any questions or confusion about those two ways of looking at it? Okay. All those online also? Okay. The next few ones, we have two short ones. We'll just look at that quickly. And then I wanted to do this group discussion. We may just only have time for that today. But yeah, and then we'll have to do maybe an hour next week. But we'll just, yeah, we'll see how far we get today. So one Corinthians 13, we see at the end of first Corinthians 13, it says, when the perfect has come, tongues will end and prophecies will end. Okay. And so some people consider that the spiritual gifts are no longer for today because it talks about this time of perfection when there will be no need for tongues, when there will be no need for the use of prophecy and other spiritual gifts. So let's just turn to first Corinthians 13. Let's look at that in the context of what Paul is talking about. Okay. If someone can just read for us from verse 11 to 13. First Corinthians chapter 13 verse 11. When I was a child, I spoke as a child. I understood as a child. I thought as a child. But when I became a man, I put away childish things. But now we see in our mirror, Emily, but then face to face. Now I know in part, but then I shall know just as I also am known. Verse 13. And now abide faith, hope, love, these three, but the greatest of these is love. Yeah. Thank you. So before this section from verses 8 to 10, he's talking about prophecies. Tongues will be still, knowledge will pass away. And then he says, when completeness comes, what is in part will disappear. But that completeness is to come from what we just read is when we will see Christ face to face. And now we see only reflection as in a mirror. Then we shall see face to face. So it's at Christ's coming that there will no longer be a need for the spiritual gifts. So when he's talking about this perfection, it's that final day of us being with Christ. That's when we will truly see the kingdom realized. We will truly see all of heaven come on earth. And so it's not talking about gifts ending at our present time because we have not reached that time of perfection. Do you all think we've reached the time of perfection? No. We all continue to see, we see death, we see sadness, we see sin, we see sickness, all of that. So it's at this time of perfection that there will be no longer a need for gifts. So until that time of perfection comes, the gifts will continue to be in the church to be exercised for the benefit of the body and to be witnesses for Christ. Can women be in five-fold ministry? We want to read these passages Ephesians 4-8-11 and Matthew 4-4. But the word used is man. And so is our interpretation that only men can be in these offices? No, because that word man is just used to refer to humanity. So it can be a woman or a man who is called to be an apostle, a prophet, an evangelist, a pastor, a teacher. It's just that the word in Greek says man. It's translated as man into English but it refers to humanity. It refers to either male or female. The five-fold ministry is the apostle, prophet, evangelist, pastor, teacher which is like our offices that are given in the church. I think you all will learn that second and third year to really do each of those things. So we are not going to do head covering and headship because we already covered that in class. So we won't discuss that question. Let's just break up into groups and do can women teach the word? If you all have already read this in the time that we had, then you all can just go straight into discussion. But if you all still have to read it, I'll just give you all a few minutes to read it and discuss in groups what is talked about here. And we'll come back and just share. So I'll do the breakout rooms online as well. So we're just discussing the question on page 42, can women teach the word? Just for us to read what's given in our notes and come to a conclusion about what scripture's teaching is on that. For those online, I'll just start the breakout rooms. We'll just have about, I think, 10 minutes or maybe let's just seven minutes. So please get into your discussion quickly and we'll come back and talk a little bit about what we discussed in our groups. Okay, I'll just start the groups online. So please join your group when the pop up comes on the classroom on meat. Sorry.  Yes. Okay, great. Okay. Good job. Thank you. I think the in-person students are just finishing up. Okay. Anyone wants to share what was your conclusion on that question and why you all came to that conclusion? Sister, can I say something? Yes, please go ahead. Sister, see there are women in the Old Testament that is in Deborah Esther and in the New Testament also there are women with Jesus, especially Mary Magdalene. She was with Jesus till the end and she was the one who seen the resurrected Jesus first and she went and told the apostles. I think what Paul says is about the married women to keep quiet in the church and to take the husband's permission. So it was culture during that time. So the church has grown and according to Lucy said Galatian 328, you know, we have that neither male nor female. Everybody is equal in the eyes of God. Okay. Yeah, and anybody Sam would like to add something, anyone from Madhura? Go ahead, please. Yeah, I think I joined a little late because I'm actually in Mangalore. So when we're in the breakout rooms, I think what I was just saying is before we, when we're talking about the subject before we go to the specific passages that Paul writes in 1st Corinthians and 2nd Timothy. Where he's explicitly writing about women keeping silent. I think before we go to those passages, we need to broaden the picture throughout scripture. What do we see? And what we see is God has used women. We see in the gospels in Jesus' ministry that he first spoke to women after he got resurrected. And we see in Paul's ministry team that he had many women and he gives thanks to them.  So I was just saying that before we attack those passages just to broaden the picture first and then we can go to those specific passages and kind of give our perspective and interpretation. Okay. Yes. Thank you. Yeah. Thank you sister Gertrude and Sam. It's important to like we talked about when we are interpreting difficult passages that we don't interpret. I mean, we never interpret scripture without taking into account what the rest of scripture is saying, but especially in such cases. We understand our conclusion should be based on all of scripture first informing how we read the passage. So normally what we'll do is we take a passage, we understand the context, then we look at the rest of scripture. But here we know that this is something that is a little difficult to understand. And so we look at, okay, what does all of scripture first say about women? And then, okay, scripture says this about women that God was already using women in the Old Testament that Jesus accepted women as disciples, which was actually very, very counter cultural to have women disciples. And Jesus appeared to women first when he was resurrected. If all of that happened, then how do we understand what Paul is saying here? So we know that the rest of scripture definitely doesn't teach that women are not to be part of ministry or to serve God in this role of teaching. Is anyone else wanting to share something online or in person? The anointing and the spiritual gifts, what is there is the same. There is no disparity between receiving it because if you're male it's different or thing. And what Paul primarily identifies here is about women having to be suppressive only in a house. It is not very specific in the church as such. So male can only have a responsibility. It's not like an authority that he has over a woman. But where we were actually personally stuck in a group is like the verse where it says in Timothy, I do not permit a woman to teach or have authority over a man. That's where we were stuck. Because the Corinthians we understood the concept in the context and the culture in which he spoke. But only in 1 Timothy 2 verse 15. 2 verse 12, right? To teach or to assume authority over a man. So we'll just address that before we close. Was anyone else who want to share online or anyone else here at class? See the Galati chapter 3 verse 28. There is a name Jew and Greek. There is a name for three. There is a name male and female. You are all in Christ Jesus and Roman. This says you are the Jesus Christ of one body. So emphasizing the equality of men and women, there is no difference in terms of our position in Christ. Right? You were going to add something? These human and males on Jesus Christ of one body is equal to preaching. What's that sorry? Human and female is one body of Jesus Christ. These are human preachings. Okay. So both women and men can preach about Jesus Christ. So why does Paul talk about this specifically about women? I don't permit a woman to teach or to assume authority over a man. She must be quiet. Right? So one thing like we looked at in our notes is the first aspect of within a husband wife relationship. Not assuming authority over the man, which is what he talks about in the second half. But the first half of I do not permit a woman to teach. Now if we look at this is not in your notes, but I'm just going to add some background. If we look at the context, women were not really educated in the law in Jewish custom. Okay. So that was it was very, very rare for women to actually be knowledgeable about the scriptures about the Torah. But it was very common for men as they were growing up when they were children to be taught the Torah. So they were well versed in scriptures. And if we read in this context in First Timothy, there were false teachers who were coming in and targeting women, especially because women lack knowledge. Okay. So what Paul is actually saying, if we read the previous verse verse 11, a woman should learn in quietness and full submission. So he's not saying a woman shouldn't should actually what he's saying is advocating for them to learn, but first learn before you're going to teach. Okay. So don't because these false teachers were targeting women because women didn't know the scriptures and they were using that against them. Paul is saying learn in submission, learn in quietness and don't too quickly be or too quickly assume the position of a teacher. Okay. So that is the context. So we're reading it within the context of the rest of First Timothy, as well as in the context of the early church where false teaching and heresies were coming in. This is Paul's encouragement. Women learn first before you before you think about going into a position of teaching. Okay. Is that satisfactory answer? Yeah. Okay. So we will end here. And I think we'll have to just address these last few questions next week. But thank you all for being here. I think next week we'll just need to do a one hour. So maybe we'll start with the second hour instead of doing the first hour. We won't meet then. We'll meet in the second hour and then we'll do our third hour as well. Okay. Thank you all.


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