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Hello, good evening. Good afternoon. Good morning. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm the professor in the Medical Education Research and Development Unit at the Faculty of Medicine at the University of Malaya. And we're coming to you tonight from Kuala Lumpur and I'm overlooking the patronus trials in production. The nation is 1/4 year medical student at the University of Malaya. If this is your first time joining the Black Academy, thank you very much. Indeed. And if you're returning and following, thank you and continue to spread the word. We've had over 4500 registrations from people in 100 and 33 countries. And tonight, we have 44 registrations from Bulgaria, Egypt, Guatemala, Japan, Kenya, Poland, Sri Lanka, Tunisia, UK and USA. That is only possible to the connection that we have with metal. We can literally reach across the globe. I had a pleasure of attending the Malaysian Surgical Student Society meeting at last Saturday. Fabulous to see everybody enthralled in Stitching and have been introduced to the Faculty of Medicine and The Silent mental program, the indelible signature. The idea is, is that from the Malaysian medical certificate requires that all students have level three knowledge of how to suture. But I think that is poorly taught. So we have deconstructed it and have now got the opportunity to practice on the Silent Mentor program. And I'm absolutely delighted that 105 students signed up within an hour and a half to attend a workshop on Saturday the 15th of February. This will be important. And I'm also delighted that surgeons from the plastic surgical department will be there to mentor and help. Now, continuing on from where we were last week, talking about evolution and hand movement. Humans have reached a high level of sophistication in the way they interact with the environment, particularly with the use of tools. And this has enabled us to extend the boundaries of possibilities. And of course, in surgery to explore the human body sensimotor processing that highlights how tools usually used is shaping the way we think. I, in essence, there's a plastic feature in our way, cognitive abilities that ensures efficient motor control its development and the use of skills throughout later adult life. And it's been shown that behind what seems an effortless behavior, many century motor transformations take place. For example, one aspect that seems to be increasingly important in the use of tools. And when I say tools, I'm thinking of this in surgical instruments as well is the ability to actually predict the outcome of actions. And lead me to think about visualization and seeing where you're placing this. So recent theories on motor control postulate that the central nervous system controls movement by generating a prediction of the outcomes of the action itself. And comparing this to the prediction that is offered by century feedback, there is a a loop feedback there and the relation between action performance and its consequences is acquired with experience and remains constant as long as the environment doesn't change. But there's a lot of literature to also say that the brain compensates from any change in the environment and movement that has been planned based on previous knowledge about the environment and the handheld object can be challenged by practicing the movement under the same conditions over and over. But then if you introduce an extraneous force to this, for example, pushing an arm or pushing an instrument, the brain has a fantastic ability to compensate and learn very quickly. The outcome and prediction of the movement that is required. And this capacity of the central nervous system to learn a map. Movements plays a very important role in our use of tools and surgical instruments. The other thing is think about it. I would like you to think about the shape of our finger. All right, there's a tip, there's a pulp, a nail, a hard bit and a soft bit. And we unconsciously choose the part of the finger for each daily function, picking up an object tanning a page or striking a surface. And the fingertip enables us to check the hardness and temperature. And what's also interesting is that the human fingertip can discriminate between tones differences and harmonic components. We literally can feel sound for a contact load of about one Newton. Two types of vibratory stimuli have different phase differences between the fundamental and second harmonic components. And this can be discriminated at a fundamental frequency of 40 Hertz. Now, the research into how we feel and explore our environment is in fact, with my reading absolutely enormous because people are trying to improve haptics of robotic arms and help patients with neurological deficits. You see the human fingertip consists of skin epidermis, dermis, subcutaneous tissues, the phalanx, the nail and of course, lots of sensory receptors. And we have the mesna core puzzle that detects vibration sensors of about 10 Hertz, the Merkel disc, which should touch and pressure sensations, Ruffini endings which are touch sensations in the pin corpuscle. Again, vibration sensations of about 250 Hertz. And on top of that, there are free nerve endings for temperature and pain sensation. And these area entities are about 1500 per centimeter square for me, carpus, 750 for Merkel cells, 75 per pin corpuscles and grain endings. So with all of this, it means that the surface resolution for the sensation of touch or the two point threshold for the human fingertip is approximately two millimeters. And the brain recognizes the details of this contact information with all of these receptors. Now consider this yourself taking literally a pinch of salt. You can feel the pinch of salt in grains between your fingers. And what's interesting is that the Mesler corpuscles in humans compared to other primates of higher density, they're equal in both hands and distributed predominantly in the fingertips. But they also vary in a me structure. They have a special innovation with the distinct molecular physiological and ultrastructural properties responsible for perception but also feeding back to behavioral responses. In other words, it enables us to detect with the gentlest of horses and all these corpuscles shared a similar endoneural origin. The human skin itself is also fibroelastic and the frictional coefficient and contact pressures as you rub your hand together varies a lot. As you know, with lubrication or soap. And these affect sensation, the contours of your fingertips, the deformation of the finger pad, the forces the pushing and pulling as you rub your fingers together are all really high fidelity elements of sensation. What's also interesting with tools and hand and finger pointing, test, pointing one finger from an object to the other and then picking up a drumstick in this case, literally to place drums, not a chicken drumstick to point and pick up very quickly. The brain starts to recognize that the drumstick is an extension of the arm and part of the feeling process. So touch is predicted based on the anticipated position of the current effector. In other words, the tip of the tool or the tip of the surgical instrument rather than the body part itself and under controlled conditions, touch with a tool once observed to be akin to touching the fingertips. This is why when we hold an instrument, we need to be holding it with the lightest of touches using all that sent input, enabling the brain to control eye movement and focus at the tips. Now, in surgery, the high fidelity sensation of the fingers is further helped with an extension of the index finger because that affords direction, it affords pro perception and enables us to incorporate the finger and the instrument as part of our overall body schema. Learning to practice and being aware of these sensations is p part of deliberate practice and it's recorded this sensation or sensation and feel and lightness of touch is well recorded in the learning of musical instruments, but it's interesting that we do not actually discuss it in the learning of surgery. Now, of course, you would say of course, a gloved finger will affect the sensibility of your fingertips and certainly wearing the co correct gloves that fit closely and do not constrict. Your fingers will improve sensation provided that they are thin, but wearing the gloves. Although it might attenuate the feel to a little degree, it is more than made up by an increased awareness of the haptics and the movement. So combined with the proprioceptive movement that we said of the muscles and the upper limb, the central nervous system, perception and anticipation of the movement. Together with the lightness of touch, we have the perfect recipe to actually understand and use the surgical tool appropriately. And nothing could be more appropriate than the ubiquitous instrument that we use in surgery. The scissors and the scissors interestingly enough were considered or are considered the first essential tool in learning coordination at school. You remember taking an object, by the way, I love this. This is Mr D Ry and that's paint already on the coloring in card. Fabulous. But we remember when we were younger at school learning to cut out bits of card. And this was part of a developmental process. By the age between 2.5 years, between two and three Children should be able to snip paper and use the other hand to stabilize the cutting. At about 3.5 years, you should be able to cut lines and turn the paper around accordingly. With the alternative hand. And by the age of 51 should be able to according to developmental scores accurately cut out objects. So one of the things that I would like to, to introduce to the scissor skills is we are going to go back to cutting out paper objects. Now, I'm not gonna take making those scissors to this bit of card. But if you've got an object on a piece of paper, I would like you to put that on the table and with, and make kind those scissors and a pair of forceps cut out an object. And now it's much easier if it is piece of paper and this is card. But what we trying to practice using your forceps and card is accurate, cutting. It's not easy at all. And as part of our process and learning, perhaps we ought to go back to those developmental models that were used at school to assess our surgery skills. I want to preserve the scissors because this card is rather thick. But focus on how we hold the principle of all surgical instruments I think is to maximize the contact of the pulp of the fingers with the instrument. In this situation. You see that my fingers are not through the rings. I do not feel this part of the thumb, I feel with a pulp and therefore I apply the pulp of my fingers to the rings. The other thing is by putting my finger through the rings, I can't take it off. My thumb is quite big. My fingers are big compared to many. But if your fingers are small, don't put your fingers through, apply your fingers obliquely so that you f maximize the contact of the palp of the finger. I always have put the scissors on my ring finger because as a general surgeon, I used to PM an instrument, I could tie a knot and then bring my scissor down and cut, do not cut with the ma scissors, but it for fine sutures, that was fine. But I could pound my scissors and operate using this specialized group note, my thumb, my ring finger, middle finger and index finger are all applied to the instrument. 1234 pulps. The other thing is I can take it out of my hand and put it in my hand. I'm not gripping it. I'm feeling the instrument and it's that feel and that extension of the fingers, it now becomes part of my arm and movement. Note also that it's 123, there's a triangle, a base on which the scissors are being held and my index finger is extended down the finger, the shaft giving me that sort of cant appropriate se direction and feel in holding it. This way. It is important. Also to note that the curve of the scissors fits the curve of my wrist because as I look down the scissors, I can see the curve of my wrist, curve of the blade and curve of the tips. These are mcindoe scissors, the Fatah cousin in the Mets and bars, but they come in all sorts of lengths the same principle. And these are Nelson scissors and you can see the handles are longer for reaching in the cavity. You have correctly identified mayo scissors, pot scissors, bandage, scissors, and simple scissors. The scissors that we use in surgery have this curve. And my preferred scissors are mac and we have discussed the history of Mackinder previously, the curve of the wrist. The curve of the scissors means I can see the tips and I can see the belly if I hold it this way, that's the curve of my wrist, that's the tip. But underneath here is the belly and I've actually seen the pulmonary artery cut by the belly as somebody's focusing on the tip. So what models do we have? And I enjoy going round a supermarket, Lawrence, who's the manager of the G supermarket downstairs said to me. So what are we operating on this evening? I've got some sausages here and what I like about the sausages and you can get different thicknesses of sausages is that the meat is actually wrapped up in the skin and the skins come with different thickness depending on the sausage. The important thing is is that the scissors can be used as a gentle probe and I'll take it this magnification down. I just take this out a little bit more so I can send over the camera so you can see this dissection and this is feeling the tissues I've developed a plane there. And this is very similar to all the adventitia and tissue planes that actually run over vessels. Now, I've got my scissors partly open there and this is you've done this with wrapping paper, partly up the scissors. I've got the plane and there you go. I am able to dissect out the plane. The scissors itself. I can use gently tease the tissue away as a blunt probe. When I feel resistance, I need to explore it further and determined if this was a dissection. Is there anything underneath that it between my scissors and that is the condensation of tissue I need to decide, is that a vessel, is it a nerve or in this case, just a folded bit of sausage skin and cut it off? And that scissor ability to actually find a plane, this is very similar to cleaning off fascia layer on the long of venous vein. But if you do any vascular surgery at all, it's important that you find the plane on top of the vessel. And since all the vessels invaginate into the endoderm, it carries layers and the layers to be honest, are not too dissimilar to this. And in many organs, knowledge of the blood supply will help direct your dissection in the lung and the liver to do segment dissections. So we did ask you how far do you open the scissors? You noticed that I actually to do that, had the scissors opened just a couple of millimeters. You do not have to open the scissors anything more than that. And certainly no more than five millimeters. And at five millimeters, I think that is quite a, a big scalp. I'll just get out the scalp will break here because the handle has got a, there you go. Five millimeters. One centimeter is far too much. And to be honest, I think three millimeters or five or less is the perfect amount to open up the scissors for fine dissection. There are many objects, um, food produce in the supermarket and I'd love to hear from you your examples and cutting the skin. It's giving me haptic feedback of cutting something fine. So if you haven't done or you wouldn't have done hernia repairs or herniotomy in pediatric cases, I can assure you that the hernia sac that you find doing a herniotomy in a child is a lot thinner than that. But in neurological surgery, epididymal cysts about the same thickness. So it's a fabulous example of tissue. So what else can we use? I personally love tangerine. I have got some thick rind on the outside here. So I am gonna use thicker scissors to develop these planes and I like the Nelson scissors one because they're rounded at the end and they do not cause any damage. Also, they don't, are not regularly used in theater because Mac and those are the ones that are usually pulled out. So I found from experience that these Nelson scissors do offer a better dissection because they're less used and they're not blunt, as we said last week, a razor is only effective if it's sharp and I think the same could be said for scissors. When you hold them up to the ear, you can hear that scissor motion, there's a one blade slide over another. So I've got a tangerine here held on the plate with a bit of blue tack. What I'm wanting to do is develop this plane. And when I develop a plane I open with draw close, open with draw close. And this is the one occasion where I am opening the scissors more than that one centimeter is to explore planes. Open the draw close. You never ever close an instrument or scissors within the tissue, you have no idea what you could be cutting. So as I dissect this out, I am using heavy scissors. Is that one together the skin off and this is not too dissimilar to the cortex. I'd find in a pericarditis or a cortex over the lung. But now, now we have a lovely challenge. There is a segment of orange. Now, the questionnaires in my dissection, am I able to dissect out the section of orange? Can I find the plane? I do not get the right plane. You see it is starting, you see juice appearing. So what my challenge is is to open this up, developed the plane without actually spilling too much juice and I can tease, tease the, the segments are apart. I don't want to be too forceful because otherwise I'm going to be breaking the flesh of the segment again, like all the models that we have actually introduced into the Black White Academy. I find myself at this stage totally engrossed. I have to actively think about communicating what I'm doing with you watching because I not only is it challenging, but it is requiring concentration as well. And you know, when you're concentrating to actually be able to talk and chat at the same time, I've always thought was a indication of how comfortable a surgeon was with an operation. And standing opposite trainees for many years, I had noticed that when you first start operating, that the trainee was holding their breath because they are so tense. Well, that's counterproductive because holding your breath means that you're now c two retaining and your tremor is going to increase. So breathe gently in, through the nose and out through the mouth. And in fact, in training sartorius, I got him to sing as he is operating to sing a song so he could focus, breathe normally and sing a song in operating. You appreciate that some tangerines are easy. Other segmented fruit like orange or a grapefruit would be even more difficult. But the important thing is to persevere and in this sort of dissection, we cannot afford to hurry. It, it comes out when it comes out. What I'm trying to do is gently persuade this mindful that you will see at the present moment that I am getting and losing some tangerine juice. And this is sometimes exactly what is happening in dissection and surgery and the pain is there, but it is not fully developed. And you'll find that one side will end up a little bit raw area. Was bleeding. Well, bleeding will stop with a swab on it. And a bit of time at normal temperature reminds me of that joke is what's the bleeding time? And you'd say at 9:32 p.m. actually, the bleeding time could be anything from five minutes to 15 minutes depending on the situation. So there you go almost out. I still got and depth here. Really snap a little bit of the p this is hoarding it here at the bottom. And to be honest, I think this is a wonderful model for t practicing your dissection skills. Mm I felt a dive at the bottom there. I think the problem is I think I need to actually take off a little bit more of skin down to the bottom. So if I was scoring myself here, I'd say not bad, but definitely as with all things room for improvement because I've certainly got tangerine juice being spilt and there you go. I said I had something give at the bottom. If you look at the bottom of that, I haven't followed it all the way down on the segment. My hand got to the bottom and indeed, I've cut through the segment at the bottom, but there you have it. There is the tangerine segment and I was caught at the bottom there trying to scoop it out and that's what I did there. But see the next level of dissection as we're talking about layers and skin is. Now, what about the flesh itself? A segment? There is a thin segment on top and I must say this is very difficult, it's better in a grapefruit. This segment scan is more defined and in fact, that's why in restaurants and breakfast. There you go. You see that little soft bit of skin there of the segment and grapefruit is more defined in good restaurants or breakfast. They would actually cut this off for you and se and serve it without the skin because it is quite thick. But it's an opportunity to see if you can I sake out the thin membrane. I improve the lighting here. You see that that's a very thin membrane. Can I actually take that off? So we've gone from taking the cortex off with the thick scissors to dissecting the segment out at depth to now dissecting out inhaler. It can actually remove the pips as well or with a simple exercise that you can do at home on a very simple low fidelity model which brings us to another of my favorite models. Uh pro there is one question. Yes. Yeah. So there is a question from participant. Do we sharpen surgical scissors if it's blunt or just change it. Uh Yes, the scissors and all surgical instruments are, are part, should be part of a, a inspection repair and maintenance program. And in, in part of that all surgical instruments, they should be go through cycles and they should be pulled off before they require serious repair. So they do require inspection. Part of that inspection is to look at the joints to see that there's no play or movement. There's a little play on this, that that would have to be tightened by looking at that screw there. That instruments need to be washed and these joints need to be free of water because this is where the dirt and this is where rust actually comes from. Then part of the thing is actually you can feel when operating with good scissors, you can feel the blade slicing together as cutting and you can put it up to your ear and you can hear that for want of a better word. I can't think of one, the scissors sound as one blade sweeps against the other. So in this position, now we are going to be operating at depth. And the problem is when I hold the decision as I've described and I want to get down there. You can see my hand is in the way I can't see it, you can't see it. So in this circumstance, now, we would use an inverse grip of the scissors and the inverse grip of the scissors is frequently used by our ent colleagues and that is literally turning it the other way up. But the principles of holding it are the same in this circumstance. My thumb and index finger are obliquely through the rings. My ring and middle finger are applied to the shaft and my index, my fifth finger is down the shaft. Now, now if I hold this up, you can, you can see the tip of my scissors and I can rotate my wrist round at depth. So it means when I'm operating at depth here, I can literally cat these little bits off. Now, if you want to practice dissecting your depth as well, simply put a sausage in a glass and depth and try to take your scissors down and dissect the skin of the sausage at depth in this circumstance. Also, I can use open my scissors up again as I did taking the skin off the sausage just a little bit. So 1.5 millimeters and I can use that as a scraping tool. There you go. I can scrape it off, scrape it off, but I can also practice in my dissection. So in practicing dissections, remember with much of what we're doing, we're operating at depth. So putting it on a table in front of you and sitting on a stool is not actually giving you the opportunity to play at different depths with different tools. And as I'm walking around here, I am literally moving as previously described my right foot, my left foot and changing my position such that I can get down to and depth and it's a very effective way of dissecting and cutting as well. I can see the blade belly and I can see the tips. You have to remember there are many surgical instruments, even though that is a blunt tip, can spear and damage tissue. So those plant there you go, can damage and certainly scissors, that of points are lethal as a stabbing instrument. I would not commend that at all. Just to demonstrate the one skill that I'll demonstrate next week as we combine scissoring knife and assisting in dissection. First of all, just to prove to you, I can tie not the scissors is on my ring finger. I can tie a knot in this situation. This is my finger. But in cardiac surgery, we don't advocate doing that. Kate's empty hand. Now, why I've got this knot up like that? I want to point out that when asking somebody to cut a knot, you'll be reaching into the chest with the scissors. I don't want to see the scissors flying in from the side and swooping out like that. That is dangerous. Put your scissors where you are going to cut open as far as necessary to do the job, make a cut and withdraw if needed. Use another instrument like a forcep is a fob. Now, when dissecting and fine dissection and when you are happy using Neiss I have and this is enable to cut the suture and I'll put it on a white background, shall I? So cos otherwise you won't believe me. And you think it's green background trickery. I'll put it on there. I'm gonna pass the suture underneath and I'm going to cut, pick it up and my forceps. So the feel of the instrument I can actually use this in one movement to pick the suture up. I don't have to actually put my scissors down to do it again. That just comes with practice. And that's understanding and feeling your instrument. Why? Because I've got a lightly balance to my hand and has now become an extension of my arm and I'm focused on the direction and the intent and all of that is improved with practice and getting to know your instruments. So I'm very happy to take observations from my esteemed colleague and fellow sense, Mr Caddy who's online. Oh, just before I do, I always bring in another piece of material and this is the experiment section inviting you to think about how you can practice at home. So I wondered what could I do with a mango and of course, I can't break the skin at the moment with a mango, but I might just puncture the skin here and see having made that puncture. Am I able two is a mango a usu model? So I thought I'd try it live to stimulate thought and creativity and invite you to think about what food product, animal or vege vegetable you've got at home that will enable you to perhaps think about how to develop and cut. And I'm not sure that the mango is going to be the perfect example. No, I'm gonna enjoy the mango later on. That has not come off as well as I'd like. And therefore my vote still is for the trustee Tangerine. So Mister Keddy, Fellow Sense Manish. Any observations and questions from the audience, please? I think my biggest observation was your discussion about the fingertips and the uh the the nerve input in there and the plasticity of the brain in integrating this into using tools. So it, it's applied anatomy. Um and you're taking it to new heights. So thank you for that. Well, I think as I'm reading this and I'm speaking to the biomedical department and at the University of Malaysia um next Tuesday on the 28th. And I suddenly looked at this and thought really and truly, we haven't applied any of this thinking and any of this direction and knowledge and, and how to actually use our instruments. So I have two papers at the present moment, one on the functional anatomy of the upper arm, but also on the sensory motor input we get from our fingers and what can we do to actually improve their practice that rehearse it and understand it for the benefit of surgeons. And I think it's a wide open field, to be honest, what does the audience think? Well, it, it's without looking at it, you don't see what you don't see. So, I appreciate exactly what you're doing. Yeah, exactly. So, I haven't taken out one segment. I'm now better prepared to me all being well, take out the next segment right at the bottom. There you go. I think that's what you call practice makes better. So I've got less damage to that and that has come out better now. So tangerines, bananas, peppers, you name it perhaps next time you will peel some grapes for me. So take the skin off a grape without uh pressing the, the grape juice out of it. Oh yeah. Yes. Uh Yes, of course. Yes. No, we can definitely do that. I, what I, what I'd like to what II really have appreciated, been looking at some of the videos that we see on linkedin about the advent of instruments and particularly robotics. More and more people are using bananas. Fantastic. Please get rid of those suture pads. They don't give you haptic feedback, but certainly for the microscopic work, I've seen Da Vinci robots take skin and off uh grapes and actually put stitches in as well. There is a new endoscopic instrument that actually catches the needle and automatically rotates it as well. Wonderful. So all of this is in the pipeline until then you're gonna have to be able to use these. Indeed. And to be honest, to be honest, I would like a study and I was thinking of this the other day, everybody's gone into laparoscopic hernia repairs and meshes. You've got the risk of a general anesthetic and a pneumoperitoneum. And I think back to my days in general surgery when we did hernia repairs under local anesthetic challenges, tissue handling challenges, respective tissue. I think you get an as good if not better repair without a general anesthetic pneumoperitoneum and a lot of mesh inside. I wonder if somebody would do a randomized study on that. But also you have to have a communication and teamwork both with the patient and the rest of your team. So a lot of it is the knots, the non technical skills for surgeons. Indeed, and the patient is awake. So your usual surgical banter needs to be refined and involving the patient. Maybe you have a patient communication officer at the top chatting to them about other things to distract them from the survey, but we have digressed and it's interesting to free thought. Thank you very much indeed. For joining the Black Belt Academy. We look forward to seeing you next week where we're going to combine our knife skills, our scissor skills in dissect out the femoral canal of a chicken leg. And I'm actually going to assist my son doing it. He's on half term. He's developing his surgical skills very nicely. Although he doesn't want to do surgery, but we're going to combine all of this and show how you as an assistant can help the surgeon dissect and talk about when you use the scissors and when you use a knife, I look forward to seeing you next week. Please give us some feedback. There are CPD certificates with the feedback and all of this is free on demand and available for you to review again. Thank you very much. Indeed, for your attention. Have we missed any questions from the audience? You've been awfully quiet. Uh No problem. I think I've cleared up all the questions, but I just have a question. Uh Yeah. So basically we decide to use the curved scissors or straight scissors or is it up to the surgeon's preference? I, to be honest, the curve scissors because of the direction with the hand and the curve. I think these are the optimal dissecting scissors. You would not have. I have not. Well, I have not used straight scissors ever for dissecting the straight scissors I used for cutting bandages or uh dressings or sutures in general. I prefer to use curve scissors. Mr Ca is a plastic surgeon. We have different scissors of different sizes of course. Um for microsurgery, those are sort of forcep based and finger based. But again, in holding them, remember the principles of maximizing fingertip on that and, and, and they on spring mechanisms and pot scissors in particular are an unusual scissors because they are short pointed scissors and they're angled between 30 degrees, 45 degrees and 90 degrees, particularly to open vessels for vascular surgery. But one has to remember, they too have got sharp points. So one has to be careful in using them. Have you ever used? What's your favorite scissor for dissection? Uh, Steven's Tenotomy scissors, which are finer than the mcindoe and you just use them in certain areas. Um, but they've got rounded points to them rather than sharp points on their leg. And, and the blade is curved, is curved here at the tip. The blade, the blade is curved at the tip. So I think most dissection scissors varying in size do have that curve and I think that fits with the curve of the wrist. We'll see you next week. Have a good week. Thank you for joining the Black Belt Academy. Good night. Good day. Good afternoon.