The word advocacy to me means that you're thinking about somebody else, you're thinking about something else that is not necessarily always in your own interest, that you're trying to make sure that everybody's included. Advocacy is such a big, important term, and I'm glad it's the core tenet of our meeting this year. When it comes to the neurosurgeon's role in the patient care, it's the totality of their entire experience. Advocacy is so important in our field, both patient advocacy as well as governmental advocacy, as well as advocacy for our colleagues and for our profession in general. It's really important from my position that we advocate for health care of children throughout the United States, and particularly at our institution. We clearly advocate for our less disadvantaged patients. To provide guidance in so many different aspects about education, clinical care. Historically, neurosurgery has been a field, you could just summarize, that was predominated by white males. And if you look at programs across the country, including ours, the degree of diversity in the residency has really markedly improved. We have a greater number of women, a greater number of people of different ethnic diversities, racial diversities, from all walks of life. I also think that I do a lot of advocacy within our department and within our training program, and I try to ensure that our faculty are as successful as they possibly can be. I think we really need to put our best leg forward and support each other so we can do what's best for our patients. And so when I think about advocacy, I think about principles of DEI, of diversity, of equity, of inclusion, and how to bring everybody else in to what we're doing, and how to provide care to our greater community. And that has to do with being able to diagnose their problem, being able to get in to see the right providers and specialists, being able to get the right treatment, whether that's surgery or not surgery, not being hindered by a lot of the different roadblocks that prevent our patients from getting the right neurosurgical care. Providing neurosurgeons as advocates is paramount to being able to provide the comprehensive and best possible treatment options for all of our patients. And I think it's so important, and it comes from advocacy, it comes from an intentional effort to make this important and to make this happen. I think our field will be so much richer for it, and the downstream effect will be that patient care will be better. All right, thank you. Thanks to everyone for joining us this morning at plenary session number two of the American Association of Neurological Surgeons Los Angeles meeting. Thank you for being here, and welcome. We have a fantastic group of late-breaking abstracts and very good science to review this morning, along with our Cushing Medalists and our Cushing Oration, some of the top honors that our organization gives. I think it's going to be a fantastic session. Welcome, and let's get started. We'd like to start off inviting Dr. Nassiri up to the podium. He's going to be talking to us about combined oncolytic virus and checkpoint inhibitor for recurrent GBM. Good morning, everybody. My name is Farshad Nassiri. I'm from the University of Toronto. I'd like to start by thanking the organizing committee for the opportunity to present the results of the CAPTIV clinical trial reporting on combined oncolytic virus and immune checkpoint blockade for recurrent glioblastoma. I have no disclosures for this talk or any others. Think everyone in the audience likely knows these two graphs. The standard of care for glioblastoma has not changed in over the last 15 years or more. The median overall survival of patients from newly diagnosed disease is between 14 to 16 months, and recurrence disease is approximately six to eight months. There's been an explosion of trials over the last decade that have reported on the success of immune checkpoint inhibition in systemic cancers as well as other brain tumors like brain metastases. These molecules really work by inhibiting the interaction between immune cells and cancer cells that allows cancer cells to normally evade the immune system naturally within the host. But unfortunately, checkpoint immunotherapy, as a monotherapy at least, has been relatively ineffective in glioblastoma at primary diagnosis as well as at recurrent disease. So why is this treatment that's a holy grail for other systemic cancers and even some brain tumors like brain metastases ineffective or have low success in glioblastoma? Well, it turns out to be a very complicated question, but perhaps one of the main reasons is that glioblastomas are relatively immunologically inactive, meaning there's a low degree of immune cells infiltrating the microenvironment relative to other different tumors. This is results from Logan Walsh's group that has recently reported that essentially shows a low degree of immune cell enrichment and infiltration in glioblastomas compared to other brain tumors like brain metastases. So perhaps immune checkpoint blockade would not be as infective in such a microenvironment. Now oncolytic viruses can induce immune cell infiltration into tumors. DNx2401 is an example of an oncolytic adenovirus that has two specific genetic modifications that allows it to be successful in glioblastoma. There's a 24 base pair deletion in the E1A gene that allows it to selectively replicate within malignant cells that have defective retinoblastoma signaling, as well as an RGD insertion at the fibrinot that allows the virus's anchor into integrins expressed on glioblastoma and increasing its infectability. Fred Lang, Juan Fuego, and Candelaria Gomez were instrumental in developing the virus from MD Anderson and actually led the phase one clinical trial that clearly shows here a high degree of immune cell infiltration after a single delivery of the DNx2401 virus into the tumor. So could you combine the virus which allows immune cell infiltration with checkpoint blockade to augment response in patients with glioblastoma or any other tumor? Well, it turns out that Tony Rebos's group has looked at this in the setting of melanoma using a herpes virus, and you can clearly see from the immunofluorescent images here that there's an upregulation of immune cells or increased infiltration of immune cells in the melanoma with an impressive distribution of responses in patients with very advanced systemic cancers. And it also turns out that we actually see very similar effects of this in preclinical models with immunocompetent mice with glioma cells, showing improved survival with virus and anti-PD-1 therapy compared to monotherapy with virus or anti-PD-1 inhibitor alone. So this leads us to the CAPTIV clinical trial, which is really the first in-human investigation of a combined oncolytic adenovirus with pembrolizumab for recurring glioblastoma. This was a phase 1, 2 open-label trial, a multi-center trial, and a two-part trial. There was first a dose escalation phase in order to determine the safe dose of the virus in combination with pembrolizumab, followed by a dose expansion phase. Patients were eligible if they had histopathologically confirmed glioblastoma at first or second disease recurrence, univocal disease, and had at least a 1-centimeter tumor with a maximum diameter of 4 centimeters. Baseline dexamethasone use must have been kept to a minimum of less than 4 milligrams per day leading up to enrollment. And surgical resection, importantly, must not have been planned or needed for these patients. So these patients did not receive surgery in terms of resection as part of the treatment. They only had injection of the virus followed by systemic treatment with pembrolizumab. The objectives, primary objectives, were evaluating the safety of the combined therapy as well as determining the objective response rate, which was defined as the proportion of patients with complete and partial responses by the MRANO criteria. Secondary objectives were to determine the 12-month overall survival, the clinical benefit rate, which was defined as stable disease or better, as well as a median overall survival. Every patient essentially received injection of the virus at day zero, followed by systemic pembrolizumab every three weeks at standard dosing, starting one week after viral therapy. There are 15 participating institutions, and many of the co-investigators in the trial are actually members of the audience today, and we'd like to thank everyone for their support and participation. This trial would not have been able, would not have been possible without everyone's work together. I'll show you some of the results, and I'm happy to be able to share with you that these results and the manuscript has been accepted for publication within Nature Medicine and should be released within the next few weeks. There are 49 patients that were enrolled across the dose escalation as well as the dose expansion phase. The table on the right shows the demographics of the baseline and the baseline characteristics of the patients. Median age was 53 years, 41% of patients were female. All patients had histopathologically confirmed glioblastoma. Importantly, the majority of patients had IDH-Wild-type tumors, and the majority also had MGMT-unmethylated tumors, representing the group of glioblastomas that have prognostically unfavorable characteristics. There were no dose-limiting toxicities that were identified in the dose escalation cohort, and 5 times 10 to the 10 viral particles was selected as the final dose for the dose-declared cohort. You can see here from the tables that the adverse events were generally well-tolerated and as expected for the population, with the majority of events being grade 3 or lower. There were no deaths that were related to the treatment, and the most common adverse event was brain edema that was easily managed with a short course of dexamethasone or bevacizumab for most patients without the need for any surgical intervention. So the treatment was generally safe and well-tolerated for patients. Move on to some of the efficacy results. There were three patients who had a complete response to treatment and an additional three patients who had partial response to treatment at the target lesion. One of the patients developed actually a satellite lesion at the time of the complete response assessment, and so this patient was categorized as a progressive disease by the Embrano criteria. This led to objective response rate of 10.4% in the intent-to-treat population and 11.9% in the patients with the declared dose cohort. This is in comparison to pre-specified control rates of 5%. The clinical benefit rate to find a stable disease or better was 56% in this population, and the 12-month overall survival was 53%. This is in comparison to a pre-specified control rate of 20%. The median overall survival was 12.5 months in the cohort, as you can see from the Kaplan-Meier curve, and three patients remained alive at the time that the manuscript was prepared, with patients remaining alive at 60 months, 48 months, and 45 months after treatment. This is an example of a patient with an IDH-12-type tumor that was injected with the virus. As a reminder, this patient did not receive any additional resection of the tumor, just virus injection as well as Pembrolizumab. This patient completed a two-year course of treatment and now remains alive at 60 months after treatment. The objective responses resulted in significantly longer survival than patients who did not have objective responses, even after accounting for lead time biases, and you can see from the table that the clinical characteristics of the patients with objective responses was rather varied. Patients with older patients as well as younger patients, patients with larger tumors and smaller tumors, patients with both IDH mutant and IDH-12-type tumors, and MGM demethylated and unmethylated tumors. So if the clinical characteristics couldn't really help us select patients who might respond from treatment, we thought, are there other reasons that patients would be responding to treatment? So we looked at the dexamethasone use, as well as the degree of edema that was developed in patients longitudinally using volumetric analysis. You can see here that all patients had a slight increase in T2 changes and pre-lesional edema. This settled out by 20 weeks for patients who did not develop progression of disease, really showing data-driven support for the concept of pseudoprogression in immunotherapeutic trials. Baseline steroid use and steroid use throughout the study was not associated with outcome. We also then looked at the host response to the viral therapy as measured by IgG levels of anti-adenovirus antibodies. You can see that all patients had an increase in terms of their anti-adenovirus antibodies after treatment. And we thought that perhaps the variability in the response by the host could reflect the differences in outcomes. And you can see from these Kaplan-Meier curves that this was not the case. So it's not the host response. We thought that perhaps there's some innate tumor characteristics that could help explain some of the differences. And so we performed gene expression profiling of the patient's tumors at baseline, and we did deconvolution of the gene expression data to identify immune cell type scores. And we clustered that data to identify three different groups of patients, patients with low expression of immune cells throughout their microenvironment, patients with a moderate expression of immune cells throughout the microenvironment, but also some elevated PD-1, and patients with very highly expressed immune cells throughout the microenvironment, but also high expression of other immune checkpoint protein axis, not just the PD-1 axis. And you can see here from the immunofluorescent images that we called these the low, moderately inflamed and highly inflamed microenvironment tumors, and the immunofluorescent images support this description. And it turns out that all the objective responses actually occurred in those patients who had a moderately inflamed microenvironment with elevated PD-1 levels at baseline. The objective response rate in this moderately inflamed group was 29.4 percent, with a clinical benefit rate of 76.4 percent, and this was statistically significantly different than the other groups. And in fact, the overall survival of patients with a moderately inflamed microenvironment was statistically longer than those with a low or high degree of inflammation. We also had a subset of patients that had tumor samples available at recurrence of their disease after their treatment, and this allowed us to perform a matched paired analysis. I'm showing you a volcano plot of the gene expression differences, and when we did functional annotation analysis to look at pathways that these gene expression profiles were represented, we found an overwhelmingly large number of pathways that converged on leukocyte activation, migration of immune cells, and inflammatory response, and you can see from the immunofluorescent images that after treatment, these tumors have a high degree of immune cell infiltration. And indeed, when we look at the immune checkpoint proteins, not just at the pathways, we find high regulation of alternative checkpoint proteins that we see in these tumors, not just the PD-1 tumor, PD-1, PD-L1 access, potentially providing some insight into mechanisms of resistance. So, in conclusion, this is the first study reporting on the delivery of the oncolytic virus in combination with systemic checkpoint inhibition. The combination of the therapy was generally well tolerated and safe. There were notable objective responses and durable responses, and with improved survival in select patients, the objective responses were enriched in patients who had a moderately inflamed microenvironment and elevated PD-1 at baseline, and potentially an increase in alternative checkpoint proteins may be a mechanism of resistance, and we think that those moderately inflamed microenvironment patients are the ones that would respond best to treatment, and potentially alternative checkpoint blockade proteins in combination could be used for those patients with a high microenvironment. I'd like to acknowledge all of our co-investigators involved in the CAPTIV clinical trial, members of the Galleries Ades lab, and as well as our collaborators who all performed their investigative work, and, of course, all the patients and brave family members who were enrolled in the clinical trial. Thank you very much. Thank you. To discuss this abstract, I'd like to invite Michael Lim. Thank you, Dr. Lim. Good morning. Thank you for this opportunity to discuss this really interesting paper. I think it's a high-impact paper. So, as Dr. Nasseri mentioned, we're at a crossroads for immunotherapy. I think while we've seen much responses for checkpoints in other cancers, the results in glioblastoma have been disappointing. And I think in thinking about this paper, there are many different concepts that I think are interesting, but one of the points that I wanted to elaborate on that I think was important in this paper is the fact that they're addressing the gorilla in the room, which is what we call myeloid cells. These are the cells that are…they're macrophages that are in the glioblastoma, and as Dr. Nasseri mentioned, they are the predominant cells. And these cells can have a Jekyll and Hyde function. They can promote tumor growth, and they can have an antitumor function. And in glioblastomas, they actually suppress the immune system, and they're the major barrier to overcome. Now, I think what's neat about what Dr. Nasseri and his group did was they're addressing those cells. The oncolytic viruses are attacking those myeloid cells, which are immunosuppressive, and I think that is where the paradigm shift is happening. Now, if you look at their results, it suggests that there's a signal, right? They're OS12. Their overall survival at 12 months is 53%. The average survival for a patient with recurrent glioblastoma is only 6 months, and so it suggests that there's a signal here. It's very exciting, and I think the other point that he's made is that there is a potential biomarker. They found that this moderately inflamed tumor microenvironment could be a way to enrich so that when you move on to the next set of trials, we could potentially pick the right patients to find a signal. So I think that there are a lot of important points from this paper. First, we understand and appreciate that we have our work cut out for us because GBM is more immunoresistant. The myeloid cells are probably where we need to go, and I think this is one of the first papers to show that addressing the myeloid cells and overcoming them could potentially unlock the power of immunotherapy. The other point is that if you look at the viruses, we're in a paradigm shift with the viruses. We're not using viruses to be definitive in therapy. We're using them to essentially kindle an immune response to allow other therapies like a checkpoint blockade to work. Also, it's exciting because they have a potential biomarker from this trial to predict who might respond to this therapy, and I'm excited to see the randomized trial. The randomized trial has to be the next step, obviously, because, of course, this is a single-arm study and we need to know that answer, and I think that it's exciting that you don't need to have a tumor resection, that you can just inject the tumors. So we may be able to have broader patients for patient selection in this trial. So congratulations to the authors for this important work and excited to see the next steps. Thank you, Dr. Lim. We'd like to invite Dr. Ironside up to the podium, who will be discussing a novel AI for predicting hematoma growth in ICH patients. As we saw yesterday, the search for a therapy that improves functional outcomes in spontaneous interest reball hemorrhage patients is ongoing. Hematoma expansion is a consistent independent predictor of poor outcome, and biomarkers which stratify patients at risk for hematoma expansion represent attractive patient selection tools for therapeutic intervention. Deep learning methods which are able to learn from annotated data to provide automated analyses have gained popularity for modeling biologic and medical information. But they are severely limited by their black box processes, meaning that the internal structure of the algorithm is inaccessible to the user. And this results in a lack of connection with the underlying pathophysiology of the disease and a loss of confidence in their practical utility. So a big question that currently underpins the use of AI in medicine is how do we harness this technology in a way that is trustworthy, reliable, and safe for use in a critical system? In recognizing these limitations, our objectives here were to investigate relationships between non-contrast CT hematoma features at the time of initial presentation and subsequent expansion. And using this information, we sought to derive and validate an automated tool for predicting patients at risk of expansion. Our hypothesis was that non-contrast CT morphometric predictors of expansion could be detected in a fully automated manner using the mathematics of optimal mass transport. Optimal mass transport is a mathematical problem that in its simplest sense takes two mass distributions of equal size and seeks the most efficient way of transporting one to the other by minimizing a cost function. When images are normalized, they can be interpreted as probability densities. And this allows each pixel intensity to be represented as a mass. So solving the 3D continuous linear optimal transport problem maps the most efficient way of transporting the relative intensity of each pixel from a template to any given image. And this generates a representative transportation map of the entire information content within that image. Using segmented and normalized non-contrast CT hematoma images, we made assumptions that Hounsfield unit pixel intensity values represented relative measurements of blood density. That hematoma expansion occurs as a continuous process of red blood cell movement under the effect of unknown biologic and physical influences that can be expressed in partial differential equations. And that the mean of all the hematoma images in the dataset could be used as the template. These assumptions allowed us to compute a unique optimal transport map for each patient's presentation hematoma image in the dataset as a solution to the equation shown here. And we call this map the transport space representation of the hematoma image. So what does this mean? The framework allows us to simplify stochastic information by converting it into a linear embedding. And this allows us to use linear statistical analysis methods to extract trends in the image morphologies. And this is shown in the bottom right figure where the two different signals are easily separated in transport space. It is invertible, meaning that the data can be converted from transport space back to the original image space to visualize the trends that were captured by the statistical methods. And the mathematical model has a foundation in the biology of the disease. So we used two intracerebral hemorrhage patient databases. For the training data, we used the VISTA repository, which is a clinical trials database. And we manually segmented the hematoma regions and computed their volumes at presentation and at 24 hours. For the external validation, we used the ERIC study, which is an observational cohort study. And for segmentations, we used our previously described automated algorithm. This slide also shows the inclusion criteria. This figure shows the pre-processing protocol where we registered each CT image with reference to a population mean template. And after segmentation, we normalized all of the hematoma images. And shown here is an example of hematoma expansion on the left and relative stability on the right. So our first objective was to determine if a relationship exists between the presentation non-contrast CT hematoma morphometric features and 24-hour growth when measured as volume change in milliliters. And our analysis showed that there was a statistically significant correlation with a coefficient of 0.28 in the training and 0.24 in the validation data sets. When we inverted the transport maps, we found that there was a visually discernible trend with the hematoma features associated with growth being located towards the right-hand side of the figure. And when overlaid on the CT, showing less growth to the left and more growth to the right. The features that we visually identified, we retroactively tested and found each of them to be significant independent predictors of growth, which is data I'm not showing today. We then went back to the original segmented hematoma images and asked ourselves the question, between patients who experienced significant expansion when defined as greater than or equal to a six milliliter volume increase at 24 hours and those that did not, was there a statistically, oh sorry, a visually discernible difference in the appearance of their hematomas? And we didn't think that there was. So our second question was, can we predict future expansion at 24 hours? And we found that we were able to separate the mean distributions between the growth and the no growth cohorts to predict expansion with an AUC of 0.78 in the training and 0.73 in the validation cohorts. The inverted transport maps again showed a visually discernible difference between the features that did predict hematoma expansion to the right and did not to the left. And these identified features were significant predictors of expansion. So our next question was to investigate the effects of location. By including location information in our model, we were able to determine the preferential locations associated with growth. And putting all of this together, we could start to form hypotheses like the heterogeneity might represent blood products of different ages. Intensity distribution towards the periphery of the hematoma might represent early phase of the continuous process of expansion. And the preferential direction of location towards the lateral ventricle might represent expansion through perivascular spaces. So our hope is that these hypotheses can be tested and then used to inform understanding of the pathophysiology of hematoma expansion. Finally, we compared our method to alternate scoring systems for predicting expansion and found it to outperform these. So the contributions of this work are that we derived and validated a novel and quantitative approach to fully automated non-contrast CT feature analysis in spontaneous interest-rebel hemorrhage patients. We also demonstrated the reliability of our neural network-based segmentation algorithm in an external population data set. We established that non-contrast CT hematoma features and location are predictors of expansion, and we've shown how they can be used to formulate new hypotheses to improve our understanding of its mechanism. The major limitations are the assumption of mass preservation in this method when analyzing hematomas of different sizes, the relative paucity of intensity information on non-contrast CT, the lack of correlation with clinical outcome, and the fact that we haven't yet used other clinical information in this model. And finally, the weak correlations found in the relatively small sample sizes preclude broader clinical applications at this time. In conclusion, we believe that non-contrast CT-based automated prediction of hematoma expansion may eventually be useful to select patients for therapeutic intervention. And we've shown that continuous linear optimal transport is a feasible and reliable approach for modeling hematoma expansion in non-contrast CT that outperformed currently available methods. This method is mathematically reproducible and affords insight into the generation of image features that are used for its predictions. Like to finish by acknowledging the many contributors that helped with this work. Thank you. Thank you. Good job. To discuss this abstract, we'd like to invite to the table, excuse me, to the stage, Dr. Eric Ohrman. Dr. Ohrman. First, I'd like to congratulate Dr. Ironside in this really excellent work and presentation of a very challenging technical topic. The fundamental technical problem, which I think her group has so elegantly solved, is that of featurization. How do we convert images into numbers or data that we can subsequently model or analyze? And as she pointed out in her introduction, there's several ways of doing this. There's fixed filter sets, which many of us are probably familiar with, Gabor filters, SILF filters, and so forth. And there's no necessary reason why any of these would work for any neurosurgical analyses, particularly of hematomas. There's many other techniques, certainly deep learning, it's the zeitgeist. But I think as we all know, deep learning is incredibly data-intensive and not suited to neurosurgical problems with relatively small sample sizes. I think her group has very smartly chosen this technique of transport-based morphometry. My best analogy for this for a neurosurgical audience is in some ways, this is like low-grade gliomas. In their native space under the white lights of an OR, a low-grade glioma can be difficult to distinguish from the parenchyma. But when transformed into a new setting under blue lights in the presence of glialan, it can be relatively straightforward to differentiate a low-grade glioma from surrounding parenchyma. In the exact same way, Dr. Ironsides and her team have taken hematomas on non-contrast head CTs, which can be difficult, dare I say even impossible, for neurosurgeons and neuroradiologists to predict which ones will go on to expand. Taking these hematomas, they transform them into a new space that they've learned, a metric space through transport-based morphometry. And they've demonstrated that on this new Riemannian manifold that they've learned from a relatively small training set, suddenly it is a straightforward process which they can predict in an interpretable manner, which hematomas will expand and not. I think there are many other things about this study which make it particularly elegant and are there to recommend it. It is a relatively large test set relative to its training set. And this, in my mind, is good indirect evidence that this is a technique that works. It will generalize. Even more impressive is their training set is sampled from the Vista study, while their test data set is sampled from the Erich study of intracerebral hemorrhage. And this out-of-domain generalization is strong evidence that the techniques that they have discussed and showed us today will work in other settings and in other practices. Their pipeline for processing it is simple and elegant. By using a auto-segmentation tool to identify the hematomas prior towards mapping them with a transport-based morphometry, it really is a fully automated technique, which is rare. I think there are many interesting questions which I'm excited to see what they follow up with. Certainly, the dependency of their TBM technique on the auto-segmentation, I think there's an interesting ablation study to be done there. Certainly, also exploring the full variation of their technique, does it work for small hemorrhages and large hemorrhages and across other data sets? And I think most intriguingly is the question, they've chosen a mathematical technique in TBM that is perfectly suited to a neurosurgical problem, and it raises the possibility that there might be other mathematical and machine learning approaches which are data efficient and well-tailored to neurosurgical techniques. So congratulations again on this work. Thank you to Drs. Wolff and Ratliff and the rest of the leadership of the AANS for giving us a few moments to give you the CNS update. My name is Elad Levy. I'm the president of the CNS. And before we provide this update, I'd personally like to thank President Anne Strzok and incoming President Tony Asher for their partnership over this past year, especially with the Washington Committee, the CSNS, the Joint Sections, and so much more. The theme in September for the CNS meeting is Imagine, Innovate, Inspire. Certainly three tenets that were personally important to me and probably for most of you through our journey in neurosurgery. And that's certainly on brand for the CNS as an organization that is imaginative, innovative, and inspirational. And we hope to see you there in September because we believe it will be one of the most innovative and inclusive meetings, and we look for you to contribute your knowledge. One of the things that we're trying to feature are future leaders, future academics, future practitioners, people that when you see them in September, five years from now, you're going to say, I saw them first at the CNS. The meeting team is truly incredible. It is one of the most diverse and energetic teams that I have seen. I've been around the CNSCC since 2006. I've been part of the annual meeting committee. And under the leadership of Lola Chambliss, our annual meeting chair, Garni Barkadarian, the scientific program chair, and Edja Ndum, the vice scientific chair, the meeting they've put together is nothing short of phenomenal. The honored guests are going to be Nick Hopkins and Drs. Doug Konzioka. At a time when our specialty is facing threats from other specialties, parasitization, blurring of lines, Nick Hopkins gave us endovascular. Think that residents coming into neurosurgery will now never know a world where thrombectomy wasn't part of the standard of care and radiosurgery wasn't the standard of care. These two luminaries were innovative, certainly imaginative, and definitely inspirational. Our speakers, Safi Bakal, author of Loonshots, will talk about how you can take innovative and imaginative ideas and bring them to fruition in order to change the world. Chris Cassidy, NASA astronaut and Navy SEAL, will be talking about adapting and leading through change. And certainly, our inaugural Nash lectureship, Dorothy Nash, the first practicing neurosurgeon in the United States, practiced at Pittsburgh, where I trained many years after she finished practicing, will be Amal Clooney, certainly a lawyer, advocate for human rights across the globe. We could think of no one more deserving for the inaugural Dorothy Nash lectureship. Martin Eberhard, the original founder and CEO of Tesla, and Justin Tuck, two-time Super Bowl champion and now managing director at Goldman Sachs. Certainly we are excited about this amazing group of speakers. In addition, we've developed a practice-based neurosurgery community. Many times at these meetings, you're hearing phenomenal science, and that's wonderful, but many, many of the constituents are private practice neurosurgeons, are practicing neurosurgery in more rural communities, and they have issues and problems that are certainly unique to their practices. So, we've created the practice-based neurosurgery community, led by Jason Ellis, and we hope to show you content that is unique and novel and germane to these practicing neurosurgeons. Finally, it's not just about the annual meeting. We focus on education 12 months a year. So certainly, the annual meeting in September in 2023. We have the Emergencies Virtual Course, which has over 100 participants this year. We have the Written Board Crush Course, which uses stems for the American Board, our Oral Boards Course, and our Leadership Institute. We are doubling down and investing in the precocious leaders of our future for our specialty. In addition, we know how busy you are, so we're creating content that is mobile and nimble. One of our most important products is CNS Guidelines, because that grounds us in our practice of the standards of care, and we want to put the CNS Guidelines on your phone so it is available for you anywhere, anytime, as well as publications, references, and products like Nexus that give you complex, beautiful anatomy tied into complex cases that you can reference very quickly, or students can reference and residents can reference prior to going into surgery. And finally, our family of publications. The Neurosurgery Publications is the fastest-growing family of publications in this space, with an impact factor greater than 5, and the newest member of this family is Neurosurgery Practice, which again, like the practice-based committee, focuses on issues of daily practice of neurosurgeons around the country. So please feel free to follow us on all our social media platforms, but more importantly, we'd like you to be part of the CNS family. We look forward to seeing you all in September. Thank you. Thanks, Dr. Levy. Thanks, Dr. Levy. For our next presenter, we'd like to invite Dr. Hutchinson to present our next late-breaking abstract, Decompressive Craniectomy vs. Craniotomy for Traumatic Acute Subdural Haematoma. Dr. Hutchinson, thank you. Thank you very much. I'd like to thank Dr. Stroink and the AANS for the opportunity to present this late-breaking abstract, a trial of Decompressive Craniectomy vs. Craniotomy for Acute Subdural Haematoma, on behalf of the Rescue ASTH collaborators. Acute Subdural Haematoma is present in one-third of patients with severe TBI. It is associated with underlying cerebral parenchymal injury and brain swelling, a high mortality and a poor functional recovery. Approximately two-thirds of patients with TBI undergoing emergency cranial surgery are having an acute subdural haematoma evacuated, and it is the commonest neurotrauma operation in high-income countries. There are various guidelines for the management of this condition through the American College of Surgeons, and the Brain Trauma Foundation guidelines state, if surgical evacuation of an acute subdural haematoma is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty. The recent update of the guidelines state that the current literature predominantly relates to secondary decompressive craniectomy, bone flap removal to treat refractory elevation of ICP, and there is a paucity of literature informing primary decompression, the practice of leaving the bone flap out following an initial surgery to evacuate a mass lesion. There are three multi-center trials of decompressive craniectomy for traumatic brain injury. For secondary decompressive craniectomy for raised intracranial pressure, there is the DECRA and RESQ-ICP trials, and I'm now going to present the results of the RESQ-ASDH trial, secondary decompression for a mass lesion and acute subdural haematoma. This trial was funded by the United Kingdom National Institute for Health and Care Research, was sponsored by the University of Cambridge and supported by a number of universities and hospitals across Europe and North America, supported by the Society of British Neurological Surgeons, Centre TBI, the Royal College of Surgeons of England, and huge credit to the trainees, the British Neurosurgical Trainee Research Collaborative, for helping deliver this study. So the research question, does decompressive craniectomy lead to better functional outcomes compared to craniotomy for adult head-injured patients undergoing evacuation of an acute subdural haematoma? The patients were randomized following evacuation of their haematoma to either craniotomy or decompressive craniectomy. The sample size was 440 patients. The primary outcome was the extended Glasgow outcome scale at six months, and secondary outcomes included the same scale at six months, and the quality of life questionnaire, the EQ5D. So for eligibility, we had adult head-injured patients over the age of 16 years who had an acute subdural haematoma on the CT with the admitting neurosurgeon feeling that the haematoma warranted evacuation via a craniotomy with a bone flap of at least 11 centimeters. It's important to note that the randomization during this trial actually occurred in the middle of the operation once the haematoma was evacuated. The patients were then randomized to craniotomy, bone flap replaced, or decompressive craniectomy, the bone flap left out, except if significant swelling prevented safe replacement of the bone flap. The trial randomized 462 patients. This was a major international effort. 40 centers in 11 countries globally contributed to the trial, and we are very grateful for the randomizations. In terms of the results, the patients were well-matched in terms of their characteristics at baseline, and you can see from this slide that approximately 65% of the patients presented in coma with the Glasgow Coma Score of 8 or less. In terms of the results, the median diameter bone flap was 13 centimeters in both the craniotomy and craniectomy arms. The mortality was the same, 30% versus 32%, and in fact, across all domains of the Glasgow Outcome Score, there was no statistical difference in outcome between craniotomy and decompressive craniectomy. The same applied to quality of life EQ5D. Additional cranial surgery within two weeks occurred in 28 of 192 of the craniotomy patients and 13 of 188 of the decompressive craniectomy patients. It's important to note that most additional operations, 18 of 28 were decompressive craniectomies in the craniotomy group, but actually very few patients who had a craniotomy with a bone flap replaced subsequently went back to the OR for removal of the bone flap. The wound complications were 3.9% in craniotomy and 12.2% in decompressive craniectomy. These are the results shown graphically. There does appear to be a tendency to better outcomes in the craniotomy group, but this was not statistically significant. The common-odds ratio was 0.85 with a p-value of 0.32. So to conclude, among patients with a traumatic acute subdural hematoma who underwent decompressive craniectomy or craniotomy, disability and quality of life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but actually relatively few patients went back for additional surgery, and there were more wound complications occurring in the craniotomy group. So what are the practical implications of these results? If the brain is not swollen, the bone flap can be replaced without compression of the brain. We would advocate replacing the bone flap, so surgeons may consider doing so as opposed to performing a preemptive decompressive craniectomy. It's also important to note that these findings may not be relevant for resource-limited or military settings, where a preemptive craniectomy is often used owing to the absence of advanced ICU facilities for post-operative care, including control of ICP. The views expressed are those of myself and the authors and are not necessarily those of the UK National Health Service, the National Institute for Health Research and the Department of Health and Social Care. The trial was supported by the NIHR HTA Programme. We would like to acknowledge patients and families, clinicians and research staff, the Cambridge Clinical Trials Unit, my co-CI, Dr. Coleus, Dr. Manny Rubiano, and the AANS, Dr. Stroink, Wang, Ratcliffe and Sam Lubering for their help with this presentation and also coordinating the presentation for publication in the journal, acknowledging the editors, Dr. Roper and Dr. Rubin. The full results for the trial will be released on the NEJM website, NEJM.org, at 1230 Pacific Time today. Thank you very much for the invitation and thank you for your attention. Thank you, Dr. Hutchinson. To discuss this important late-breaking abstract, we'd like to invite Dr. Rubiano to the podium. Well, thank you so much to the AANS for the invitation to discuss this important paper that was really expected from the neurotrauma community worldwide. So we need to remember that the cranial decompression in TBI and mass lesions have been discussed in the last couple of years. We have some review papers and also the guidelines paper reviewing many of the evidence that is available. For the general discussion related to that, we understand that the role of the primary they see when evacuating an acute subdural hematoma is currently undergoing evolution in the study that was presented. And regarding to the guidelines, we need to understand that the recommendations should not be extrapolated to primary they see in which the bone flap is left off or left out at the intracranial mass lesion after the brain injury. So this was the status of the evidence until this study. We also need to remember that in 2019, we have a consensus of experts talking about many aspects of the decompression process, including the mass lesions and some recommendations specific for each one of the type of the hematomas. So we have three basic recommendations related to acute subdural hematomas. After evacuating an acute subdural hematoma, if the brain is bulging beyond the inner table of the skull intraoperatively, you can consider leaving the bone flap out based upon the clinical and radiographic findings. After evacuating an acute subdural hematoma, if the brain is very relaxed and the preoperative computer tomography imaging is not keeping with a high risk of progressing brain swelling, you can leave the bone flap and should be replaced immediately in the same procedure. So there was an agreement on 87% of the participants related to this recommendation. And for the intermediate category of acute subdural hematomas, where the brain is not very relaxed, but it's also not bulging, surgeon judgment must be used to decide whether to leave the bone flap out or not. The agreement was 97% of the participants. So in order to fill those gaps that at that moment were in the evidence, we were generating this type of recommendation for the practice. So going directly to the study, we have a lot of likes from this study. The inclusion of center from different contexts, high income countries, and LMICs that regularly use both techniques, but sometimes different materials. This is very important because it decreased the possibility of bias due to the lack of experience to the surgeons performing the surgeries for selecting the patients for one or the other procedure. The use of block randomization and stratification according to the geographic region, age group, severity of the injury, and CT findings also is very important as generates an internal validity for the study that will produce reliable evidence about the impact of both techniques for different groups of patients. The outcome analysis performed centrally blinded to the trial group assignments that decrease also the bias, and with a modified intention to treat ordinal analysis, decreased the impact of the 8.8% of patients moving from craniotomy to craniotomy, and the 5.4% of patients moving from craniotomy to craniotomy, despite being assigned to different groups. The standardization of the minimal size of the bone flat for both techniques was also really important. The study have an evaluation of additional 12 secondary outcomes for each group, including the therapy intensity level scale, discharge destination, adverse events, surgical complications, admissions and readmission for cranioplasty, hydrocephalus requiring shown between others. So the issue of reporting no difference between these secondary outcomes in both groups is a key aspect for understanding the real impact of the results for the primary outcomes. The study methodologically heavily based on the surgeon's discretion or opinion for the surgical techniques, including the main intervention, leaving or not the flap, plus other aspects for the technical details like skin incision types, intracranial hemorrhage evacuation, cisternal drainage irrigation, dural closure method in the craniotomy group, and in the use of wound drains. So this can generate some sort of bias into the process, but as we mentioned, the use of the block randomization and the evaluation of each one of the groups decrease all these aspects. So definitely the variations in the technique, including a skin incision type, intracranial hemorrhage evacuation, dural closure methods, and use of wound drains can have some influence over some of the evaluated outcomes. So the final remarks are the finding of this study might not be relevant, as Professor Hutchings has already mentioned, for resource-constrained environments or military settings. So we still didn't have evidence of these specific areas. The study brings light into the decision-making point for emergency neurosurgery, considering the importance of the balance between reintervention requirements and surgical site-associated complications. This brings a lot of importance for a specific topic, and it is the care of the wound after the surgery. This is a great example of reconciling clinical experience with the clinical evidence, as you see, almost the recommendations for the consensus overlap with the results of the study. So I just need to say congratulations to the authors for generating this important study that will be adding more evidence to the neurotrauma care science worldwide. Thank you so much. Before introducing this year's Van Wagenen lecture, I have been asked to announce this year's Van Wagenen recipient. The 2023-2024 Van Wagenen recipient is Brandon Luckey-Wold from the University of Florida. He will spend his fellowship year at Fujita University in Japan under the supervision and mentorship of Professor Yoko Kada to pursue the research topic, promotion of aneurysm healing, biodegradable coils with chemokine release. Accepting the award on his behalf is his colleague Sandra Yan, who I think is here. Or may not. We're going to move on. All right. It is my absolute pleasure to introduce this year's Van Wagenen lecture. Before I do, however, I would be remiss if I did not reflect on the history of this incredible fellowship and lecture. In 1900s, Sir William Osler encouraged and accompanied Harvey Cushing to Europe so that he could learn about neurosurgery. There he was influenced by Sir Victor Horsley, Coker in Switzerland, Sherrington in London. Following these experiences, he returned to the United States determined to influence the world, the field of neurosurgery. As a neurosurgery resident, William P. Van Wagenen earned Dr. Cushing's greatest admiration. Dr. Cushing, much like his own mentors, encouraged Van Wagenen to travel to Europe. He told Van Wagenen that there is one last piece of the puzzle you have to assemble. You must study in the great neuropathology and neurophysiology laboratories in Europe and then return to Rochester to begin your career. The rest is history. Valuing these experiences, Dr. Van Wagenen and his wife, Abigail, created the Van Wagenen Fellowship to honor his mentor, Harvey Cushing. The intent was to inspire the most talented young neurosurgeons to follow the Cushing and Van Wagenen tradition to travel abroad to gain new and unique skills to bring back to the United States to influence neurosurgery. This year's Van Wagenen lecturer, Dr. Odette Harris, was herself the recipient of the Van Wagenen Fellowship in 2003 and traveled to the University Hospital in West Indies. There, she studied under Professor Ivan Crandon, focusing on trauma systems in underserved environments. She then returned to the United States to influence the field of neurotrauma. Over the past 20 years, her accomplishments and accolades are many. At the age of eight, she immigrated to the United States, where she went on to attend Dartmouth College and then medical school and residency at Stanford. After five years at Emory, she moved to Stanford, where she has developed a world-renowned neurosurgical trauma program and is the Paralyzed Veterans of America Endowed Professor of Spinal Cord Injury Medicine. In 2019, she was recognized by Forbes and Ebony Magazine Power 100 list of the most influential African Americans. And in 2022, was recognized by Stanford University as one of Stanford's 13 women history makers. In talking to Odette, however, her most meaningful accomplishment is that of being a mother. Without a doubt, Dr. Cushing and Dr. Van Wagenen would be proud. Please join me in welcoming Odette Harris. Having technical difficulties. Let's say. Okay, sorry, let's, can we go back? All right. So thank you, Andy, for such a kind introduction. I want to thank all of you here today for coming to hear this talk and allowing me to share a little bit about my path and a little bit about my research. And I want to thank the Collegium for selecting me as the fellow. And a special thanks to the AANS and Dr. Stroink for their vision in choosing this focus, Neurosurgeons as Advocates. I think it's really a remarkable topic, and I hope to do it justice in this talk. And so I have no disclosures, except what I'm about to talk about is a true story. So I'm going to start with this scenario of an astronaut and a neurosurgeon being in a room. And I'm going to ask, like, what are the odds of that happening? An astronaut is fairly niched. Neurosurgeon is fairly niched. And what are the odds of those two individuals being in the same room? And then I'm going to challenge us even further and ask, what are the odds of either the astronaut or the neurosurgeon being a woman? What are the odds of the astronaut or the neurosurgeon being an underrepresented minority? And let's blow our minds even further and ask, what are the odds of either the astronaut or the neurosurgeon being both a woman and an underrepresented minority? And I want you to hold your thoughts on that and that scenario and the likelihood of that happening. And I'm going to pose two more questions, which is why were they in the room to begin with? And what was the impact of that meeting? And to answer that, I'm going to take you back to my undergraduate years. Andy alluded to, I was at Dartmouth College. And when I was there, I was invited to a dinner and then a lecture with May Jamison, Dr. May Jamison, who would go on to be the first African-American woman astronaut in space when she went up on the Endeavor. And I was lucky enough to have dinner with her. And then the next day I went to the lecture. Now, for those of you who know Dartmouth, you know that we are known for entertaining. And so a lot of my college experience is a little bit fuzzy. But I do remember this lecture, because to date this stands as one of the best titles I've ever heard of a lecture. What does E equals MC squared have to do with primping in the mirror on a Saturday night? And Dr. Jamison in her talk was taking something as complex as E equals MC squared. And she was translating it into something real, something quotidian, something sort of basic and simple that college students could relate to. And in so doing, Dr. Jamison was making science real. She wasn't dumbing it down in any way. She was keeping it nuanced. And as I looked around the room at my college classmates who were equally hungover, Dr. Jamison was making science accessible to all of us. And in that moment, when I thought about my path to date, I realized that that accessibility was key. And in preparing for this lecture, I realized that that accessibility piece was key to where I am today. And Dr. Jamison gave me that entry into science. And so my path, as Andy alluded to, I am an immigrant to the United States. I was born in Jamaica, the country, not the city in New York. I came to the United States. I finished high school in the US. I went to college in the US. I was at Dartmouth. I did my undergraduate at Stanford. I mean, sorry, I did my medical school at Stanford. I did my residency at Stanford. I completed a master's in public health at Berkeley and then went on to graduate from neurosurgery. You can see how happy we all are. And then I went on to receive the Van Wagenen. And as Dr. Stroink said in her presidential address yesterday, this is one of the most amazing fellowships. It is completely unrestricted. You get to do anything, study anything, and go anywhere. This is a rare finding in neurosurgery. And I encourage all of the residents and trainees in the room to consider this. This is a phenomenal opportunity. And for my Van Wagenen, I decided to marry my expertise then gained in epidemiology with my interest in accessibility. And I went to the developing world and I studied trauma systems and resource utilizations and whether or not access in fact limited outcomes. And of course, coming from Stanford, a fairly high-resourced environment to a fairly low-resourced environment, I had preconceived notions. And what I found in my research was incredibly unexpected. And so although a lot of it is beyond the scope of this talk, I will say that the main finding was despite the availability of advanced technology and more aggressive neurologic support, the overall mortality rates for traumatic brain injury in all of the sites, the university site, the public hospital site, the public hospital site and the developed world site was exactly the same. Now, there were more nuances in terms of morbidities and such, but this particular outcome was unexpected for me. And what it forced me to do was to ask the question, wow, what else do I hold true without challenging it? And when we do challenge it, what do we learn? And this became central to my future, both in my clinical work, but importantly, in my research. And so years later, when I came back to Stanford to work, I was coming back to work with the Department of Defense and the VA on a newly defined entity called polytrauma, which is essentially traumatic brain injury. And everything we knew about traumatic brain injury was being upended by these conflicts. For those of you who recall, OEF, Operation Enduring Freedom, OIF, Operation Iraqi Freedom, OND, Operation New Dawn under the Obama administration. And so everything we knew was completely turned on its head. We had been taught about primary and secondary brain injury, and now we were learning primary, secondary, tertiary, quaternary, and everything was different. And I was super eager to dive in and do my part in addressing the traumatic brain injury. And my mentor, Dr. John Adler, for those of you who know John, sat me down and said, listen, there are four stages in a neurosurgeon's career. The first is when you are unconsciously incompetent. You don't know what you don't know, and you are incredibly dangerous. The second is when you are consciously incompetent. You know that you don't know stuff, and you go on a path to try to learn. The third is when you are consciously competent. You know you were good, you're working at it, you're doing your best. And the final stage, being unconsciously competent. Everything you do is just great. You're completely unaware of it. It just comes very easily. And Adler said to me, I don't know where you're going to end up on this spectrum, but I can tell you right now, you are unconsciously incompetent. You don't know what you don't know, and you are dangerous. And I love Adler. And so I took what he said to heart, and I decided that I needed to learn. I needed to know more. And so I delved into the field, and I learned everything that I could about traumatic brain injury secondary to BLAST, and this polytrauma entity that was emerging as a signature wound of our conflicts. And what I gathered from that was the majority were mild traumatic brain injury. I gathered the majority were male. That was not unexpected, right? And what I also learned was the majority of studies were predominance of men, but that there were actually entire studies that were 100% cohort of men. So women as a sub-cohort were not included. And we were gathering information about the prevalence, information about the associated comorbidities, and information about the reintegration obstacles. And these studies were providing a broad description of the needs of this cohort, but importantly, these studies were data driving the treatment, they were driving the course of our management of these individuals, and they were driving future research and policies. And this was problematic. And as I reflected on what I had learned in my van wagon, and I thought, wow, what are we holding here without challenge? And so I asked, are these data applicable to everyone? Are the conclusions applicable to everyone, especially given that women were excluded entirely from much of the datasets? And there began my multiple years investigation and a research portfolio that would unfold. And so with broad support by the Clayman Institute at Stanford, which is our gender institute, with the VA, the Polytrauma System of Care, to the Department of Defense, and actually also some of our researchers funded by NREF, we decided to investigate this. And so I'm gonna condense years of research, years of research into several slides, and so bear with me. So our hypothesis was exactly as noted, right? That women were not wholly represented at all in the published outcomes. And what was the impact? Because these data were being used for data-driven decisions, and these data were used to guide management and care for these individuals. And so the first thing I did was the first level of investigation was a cohort analysis. I went to the literature, and then I went to our cohort, which at the time was 25% of the women in the country who had served. And we looked, and we said, okay, on the left of your screen is what the literature, the published outcomes are. And on the right of the screen, well, the right of my screen, sorry, are women and their outcomes. And you can see that demographically they were similar in terms of age, ethnicity, marital status, and even in terms of injury etiology with the exception of blasts because women were not frontline at that time. But what was incredible to me was that despite having higher levels of education than their male counterparts, women had significantly deleterious impact. They were less likely to be working, more likely to be unemployed, and less likely to be housed. And this was unexpected. And when we looked at psychiatric diagnosis, you see the red on the screen, women were suffering far more than their male counterparts, more likely to have depression and PTSD and cognitive impairments. And when we looked at their post-concussive symptoms, similar outcomes with women having more chronic pain and more sleep disorders than their male counterparts. And so we know that there, and we looked at, sorry, newer behavioral symptoms. Again, we saw these trends as well with women having more somatosensory and more vestibular complaints. And so again, women were diagnosed with more often with PTSD, depression, et cetera. They had more difficulty with community reintegration and more severe somatosensory and vestibular symptoms. And we know that there are issues with cohort analyses. And so we decided to also to go deeper and to do a matched analysis. And again, we were comparing apples to apples. We were using the published literature to guide what domains we investigated. And when we did, the findings were again supported. Women were having more difficulties with vestibular complaints, and women were having more difficulties with reintegration indices. And so overall, these data supported the cohort analysis. And now we were at the matched analysis. So reintegration and symptom reporting were greater for women in the cohort. And so we decided to take it one step further and to look at the brain behavior interface. We wanted to understand the relationship between neuropsychological measures for executive function with brain regions. And so we included both civilian and military in these cohorts. And a lot of what we found was expected, right? Sex differences in cortical thickness and TBI and controls. So for instance, we found that on average across the whole brain, women and female in the cohort had greater reports of cortical thickness. That is not unheard of. That is actually to be expected. And when we looked at the demographics, again, we found that women, there were no differences between TBI and control except in two very specific areas. One that was measuring brain injury and the other that was measuring post-traumatic stress. And so again, that was to be expected. And when we looked at the correlation, again, we found what we expected, that those suffering traumatic brain injury would fare worse on battery of neuropsychological tests. But in this scenario where we tried to correlate, this is where we found the unexpected, that the female patients with traumatic brain injury showed several moderate negative correlations, whereas the male in the similar findings showed positive correlations. And so this was concerning to us. And again, very unexpected. The sex differences, the greater cortical thickness, expected, right? But what we most definitely did not expect was that the female patients would have poorer neuropsychological outcomes and that those would be correlated with moderately negative correlations versus their male counterparts. And in publishing this, we wanted to make sure that people understood that sexual dimorphism could in fact necessitate more precise clinical profiles and targets and rehabilitation strategies. And so the challenge for us, right, in terms of trying to understand these cohorts was we set up these studies. We had this first level, second level, and third level evaluation. And what we found was that there was in fact a significant need, right? We absolutely needed more advanced analytical methods. We absolutely needed to be studying these sub-cohorts more clearly. But by excluding them, we were not understanding their plight and we had no prospects of improving their outcomes. And so we realized that the impact was that we needed to change our approach and change our methodology. But what was interesting to me is during this time and since that the literature continues to not focus on this, that the literature that keeps coming has an absence of women in the cohort. And this for sure remains concerning. And we have done our part to try to publish for sure, but we also recognize that more people read Stanford Medicine than they do Journal of Neurosurgery. And so we have been focused on trying to get the word out in the lay literature to make sure that people have a full understanding. This research has also gotten a lot of attention in our colleagues in the Department of Defense and our colleagues in the Department of Labor and the NIH and some of the work that we have done. And one of the key questions we receive is we don't understand this because they receive the same treatment. But as neurosurgeons, we recognize that precision does not, same does not mean equal. And in fact, receiving the same treatment might indeed be the problem. And so you have to ask yourself, why is this not studied? Why are we not more concerned about this? And I think it comes back to this. We recognize in this study that science is very nuanced, but the key is accessibility. And so if you look at this picture of my graduation, which I'm truly proud of, you'll notice the absence of women. There's one other woman in the photo and she's actually a member of our neurology department, not neurosurgery, and then there's me. And I think that that accessibility we have to own. And so when we come to this question, what are the odds? And when we ask the question, why do we not study this? Accessibility is key to that. And so when we look at our discipline as neurosurgeons, you'll see that we've made a lot of strides, but we've also been stagnant and in some areas regressed. So for instance, for African-Americans and American Indians or Alaskan natives, you'll notice that those numbers have been stagnant and actually declining over the last 10 years. And when we look at gender, you'll see that we've made a lot of strides and we are now a significant increase, 10% increase over the last, I don't know, two cycles of residence, but you'll notice that 21% or 22% is not 50%. And we've also been looking at age and other areas of access and inclusion, which are beyond the scope of this talk, but know that these are all areas that we need to be thinking about when we think about our future workforce and the patients that we serve. And when we think about faculty, who are the individuals that train these individuals, train the future of our field, right? We know that nationwide, all departments in our country, women are still not at 50%, but there are significant gains. But at the level of professors, you'll notice that there is a lot more to go. We are only 25%. And in neurosurgery, right, we start at 25% of women faculty. And if you will also look closely, underrepresented minorities are all lumped together, and it is about 9%, which we know is far below the real data of the population that we serve. I'm proud that the number at Stanford far exceeds these national data, but we work as a collective of a body of neurosurgeons, and so we must heed these data. And that brings us to this year's topic, neurosurgeons as advocates. I think it is an incredible and bold choice, because in order to have impact, we really do have to serve as advocates to increase access. And when we think about advocacy, we have to think about it in these three parts. It is about outreach and mentoring, it is about research, and it is about advocacy beyond ourselves and for our patients that we serve. At Stanford, we've been heavily focused on this. We recognize that the pipeline is key. And so we have programs that reach as far back as eighth grade. I spoke of my experience in college, but I think it is important to ignite that spark in very young individuals. I'm proud of this slide, which is tooting a little bit our own horn, but this is our neuroscience journal club, which we do with our neurology colleagues. And these kids enter our journal club at the age of 13 and 14, and this is their recent graduating class. And take note not only of where these individuals are going, but take note of what they are studying. This is our future in science, biomedical engineering, aerospace engineering, molecular biology, and of course, neuroscience. By being advocates, by being mentors, we have shaped the future of science. And when we think about research, because again, we are researchers, this is important. Colleagues such as Karina Zagarrakis and our chief resident, Paris Fatemeh, who are studying health disparities. When we think about our basic scientists who are making access for those who are traditionally underrepresented in the basic science, and setting up the first women's center under the auspices of neurosurgery at the VA, these will make lasting impacts. And of course, our work, a traditional work in peer review, but also recognizing that many societies and collaborating with those outside of our field is also important. So with NASEM, and American College of Surgeons, and many of my colleagues in the audience who have worked arduously on these efforts to make sure that our advocacy is represented. And again, advocacy beyond ourselves, because our patients, these are our patients, these are real lives. And so when we talk about women and the impact that brain injury has on them, particularly in the military, they're more likely to be unhoused. They're more likely to suffer from all of those symptoms. Their reintegration indices are impaired. And so this research has real life translation into their outcomes and the lives they will lead. And so on our path to advocacy and impact as neurosurgeons, it's important that we continue to ask ourselves, what do we hold true without challenge? And to guide our research and our clinical practice in that vein. And Dr. Van Wagenen held that. He held us to the highest standard, right? And he was focused not only in the advancement of academic knowledge, but as it would benefit mankind, our patients themselves. And his career stands as a roadmap for advocacy and for impact. His military service was incredibly laudable. His work with Cushing on the trauma registry and standing as the first president for the Society of Neurosurgeons, impact through advocacy. And I would also add that the many fellows for the Van Wagenen, those individuals who have taken up that challenge, who have focused on impact and advocacy, the work that they have done, they stand as heavily funded researchers, as chairs of faculty, as chairs of departments of neurosurgery, and their work has really truly redirected our field. And true to the fellowship, I can't believe that it's been 20 years. I'm still only 27 for the record. And so I cannot imagine that this path. And I wanna say that I have been fortunate. This foundation has served, the fellowship that I received from the Van Wagenen Foundation has served as a roadmap for my own career. And I am truly proud of all that I have accomplished. And I recognize that it would not have happened without the support and advocacy of organizations like the AANS and my mentors, some of whom I've named, and my department and my friends. And although I'm proud of this, I also recognize that much more needs to happen. And so I'm gonna close where I began, with the astronaut and the neurosurgeon in the room, and the challenge that I put forth, which is what are the odds? And I'm gonna focus for the purposes of this discussion on the neurosurgeon, and the likelihood that the neurosurgeon would be a woman and a minority. And in this scenario, I wanna say, I wanna hold that we as neurosurgeons over the arc of my career, we have enhanced our roles as advocates with a focus on impact, such that the answer to this scenario of the neurosurgeon being a woman and a minority is not a hypothetical. And that the answer to this scenario will never be considered a joke. And that the answer to this scenario is increasingly a reality. And although I am proud of what we have accomplished, please, let's all continue to take this challenge. Thank you. So, I'm really honored to be able to present the Washington Committee update. As many of you know, the Washington Committee really serves as an advocacy arm for both the WNS and the CNS. The agenda is really driven through the Washington office, which is headed by Katie and her outstanding staff as well as all the volunteers that touch on the critical subcommittees, which represent our advocacy for our specialty. It's the only place in all of neurosurgery where everyone is at the same table. We have liaisons from all the different houses of neurosurgery. The 2023 advocacy agenda was really generated by member input, and it includes critical issues that all of us are facing, including prior authorization hassles, reducing those, fair reimbursement, GME support, liability reform, biomedical research, reducing the burdens of the electronic health record, as well as improving competition within health care. And for brevity, I'm going to just touch on a few of these and show progress that has been made over the past few months to years. Prior authorization is a huge issue. This bill was passed by the House of Representatives. This bill would have created profound and important changes within prior authorization. Unfortunately, it had a $16 billion price tag, and so the Congressional Budget Office, it stalled at that point. Nevertheless, Secretary of Human Health Services and CMS administrator began to, started with Medicare Advantage reform in order to reduce this cost. By doing this, they can reduce or eliminate that $16 billion cost and move it into permanent legislation and law. These regulations that they're imposing on Medicare Advantage, and these will ultimately go into Medicaid managed care chip and the ACA plans, will begin January 1st, 2024. It will also add things like electronic prior authorization, and this should hopefully reduce that $16 billion cost, if not eliminate it, allowing that previous bill to go and become passed into law. Medicare payment's a huge issue, as you all know. This year, in 2023, there was an expected 8.5% cut. That was virtually eliminated through advocacy over the next two years. Just to put this in context, the ANS, CNS, Washington Committee, over the past three years has prevented Medicare payment cuts totaling $181 million. Additional support is coming for Medicare changes, and this includes this act, which was introduced on April 2nd of this year. It provides annual physician payment updates based on a Medicare economic index. GME funding for our trainees is absolutely critical, as many of you know. The Consolidated Appropriations Act now included an additional 200 Medicare-supported GME slots, as well as $385 million for children's hospitals' graduate medical education. In addition to this, this act, which was introduced just last month, provides for 14,000 new Medicare-supported residency training slots over the next seven years. Telemedicine is also another critical issue. The COVID-19 telehealth waivers are now extended through December 31st, 2024, removes geographic restrictions, increases flexibility of the originating sites, as well as permits now telephone and audio-only visits. The Federal Trade Commission has also put a proposal for eliminating non-competes. This will help many of our members that are in hospital-employed models. But Katie and her team have also been working to understanding that a number of our members also have private-owned groups and working to navigate that so those groups are protected as well. You heard this and you see this on the slides before. Help us shape neurosurgery's advocacy on firearm safety and injury prevention. You'll have the surveys. We need to understand your feelings and how we can move most effectively forward. There's minute-by-minute updates on social media, newsletters, and the Washington Committee website. I'd be happy to provide any information as Katie has been a stalwart of the Washington Committee. She's really why we have neurosurgery advocacy and the extent and power that it exerts through medicine. So thank you very much. Sorry. It's my pleasure to introduce the 2023 Hunt-Wilson Lecture. Fred Meyer. Fred's a giant in our field, as you all know, and Fred's a dear friend of mine. And he's going to talk to us a little bit about what we're going to do next. So I'm going to turn it over to Fred. Thank you. I'd like to introduce the 2023 Hunt-Wilson Lecture. Fred Meyer. Fred's a giant in our field, as you all know, and Fred's a dear personal friend. Many of you know that Fred's the dean of the Mayo Clinic School of Medicine. He's also the enterprise chair of the three departments that are in the Mayo Clinic system in neurological surgery. He's also a professor of neurological surgery at the Mayo Clinic. By way of background, Fred was born in Massachusetts. He attended the University of Pennsylvania, where he obtained his undergraduate degree in biology, went on to get his medical doctorate at Boston University, and then he went on to the Mayo Clinic for his training, where he's remained for the entirety of his career thus far. There he was trained by Thor Sundt, which was a mentor that is incredibly and indelibly positive on his career. Fred's truly a triple threat. I know that's a term we use often, but he really epitomizes that in neurosurgery. He's an expert surgeon and clinician. He's also a researcher as well as a mentor. Clinically, he's really changed and shaped our views of vascular disorders, neoplasia, and epilepsy through his expert technical skills and publications. On the research perspective, he's remained federally, industry, and foundationally funded throughout his career. He has 372 peer-reviewed publications, two patents. He's had hundreds of invited talks. He's been a visiting professor at 45 universities around the world. He's also a tremendous mentor. He's been a program director at the Mayo Clinic for a number of years. He won the Teacher of the Year Award in the Department of Neurosurgery 15 times. He's a distinguished educator awardee for the Mayo Clinic, which is an incredibly high honor across their system. He serves as the executive dean for education as well. I've personally seen him not only mentor the medical students at Mayo Clinic, but medical students from around the country. Because of his abilities and background, Fred's a remarkable leader across our specialty. He served as president of the American Academy of Neurological Surgery. He was a director, secretary, chair of the board. He's also currently the executive director of the board. He's on the board of directors of NREF. He served on the editorial board of the Journal of Neurosurgery and served as its chair. Fred's an avid fly fisherman. He's also, on top of all these outstanding professional commitments and successes, he's a devoted husband to his wife, Irene, and six children, Jenna, Ilana, Jake, Thor, Ben, Bobby, and Monet. Please join me in welcoming the 2023 Hunt-Wilson lecturer, Fred Meyer. Thank you. Thank you. I can't say I've ever walked in with music playing. Usually, when I walk into a room, there's, you know, turmoil at times. So, Dr. Monzer, thank you very much for that amazing introduction. Not warranted. Not. But thank you. Coming from you is most meaningful. And Dr. Strank, I'm so grateful of the honor to provide this presentation. You're inspirational to me. You've broken many institutional societal barriers, along with our other women and diversity leaders. So, congratulations. And really, I'm so impressed with you. It's not easy for a neurosurgeon to give a non-surgical talk, right? And so, I hope you bear with me. I know I stand between you and coffee. So, I'll try to be quick. I'm going to try to touch on some of these points. Each one deserves much more attention than I'm going to give it. Career development. My definition of leadership. Challenges that I've experienced. What I've learned. Joy and not joy from the position. But this young woman summarizes where I'm headed. So, she's one of our first-year medical students on our Arizona campus. We have three campuses that I'm responsible for. And she's the first individual in her family to attend college. Now, she's at our medical school. This is our step ceremony. And imagine the beam and her mother in the audience. She knows where she's going. Very meaningful to me. So, we all talk based on our experiences. I'm indebted to three groups in particular for whatever I might say. First is my colleagues in neurological surgery at Mayo Clinic in Rochester, Florida, and Arizona. They're great surgeons, clinicians, very creative. They're inspirational to me, quite honestly. And I've had the great privilege of working with a host of board directors for the American Board of Neurological Surgery. These are the individuals who give their time voluntarily, uncompensated, for weeks on end each year to guide the best progression of our profession. They also are inspirational. And then a lot of my comments are based on my experience as being Executive Dean of the College of Medicine and Science and the Dean of the Medical School at Mayo Clinic. Ultimately, I'm responsible for about 4,500 students and learners, five schools, graduate school, 10 Ph.D. tracks, for example. Our GME has 305 programs, which makes us one of the largest GME programs in North America. You can envision all the financial, all the challenges with that. And I've learned a lot from that. And the teams that I have that really help me, I've learned so much from them. And those comments and what I'm going to say is based on what I've learned from these folks. So when we finish our residency and fellowships, all of us face this dilemma, right? Most of us want to be a great physician. We want to be a great surgeon, a great diagnostician. Some of us perhaps want to be a researcher, like a Dr. Lanzer, for example. To be a successful NIH-funded researcher, in my opinion, you have to have 50% protected FTE time and at least $800,000 in startup funds for the first three years from your department if you're going to be successful. That's what it takes. But the point is it's a tension, isn't it? I want to be a surgeon. I want to be a researcher. Maybe you want to be an educator. It's very hard to balance that. Now, Dr. Lanzer said, well, I'm a triple threat. I don't really think so. But when we used to be recruiting individuals to a department, we would look for the triple threat, someone who would excel in clinical practice, research, and education. And in my opinion, for what it's worth, I don't think that's realistic nowadays. So my opinion for young physicians, young neurosurgeons starting to develop your professional career, you should choose two, not three. And excel in those two and focus on those two. And then you'll be successful. I, for example, was a surgeon, still am, fortunately, and a researcher, but I had difficulty maintaining my research and I shifted that time into education. That's how I evolved. The other tension that we all appreciate, of course, is this. Neurosurgery work is greedy. It can be all time consuming, totally all time consuming. Then, on the other hand, you have your family, you have your physical wellness, your spiritual wellness, your mental wellness. And it's continual tension, in my opinion, between these. And I'm sure everybody in this room agrees with me. I think being a parent is harder than neurosurgery, quite frankly. I certainly tried my best. I don't know if I was completely successful. I worked in a gentle institution that afforded me time to try to build a great clinical career but do these other things. But it's very hard. And looking back, I'm on sort of the back 18th hole of my professional career, in a sense. I would suggest you focus on the other side, the family and the wellness, as opposed to work and what it's worth. So at some point, you may decide you want to become chair of a department, dean of a medical school, president of a university, whatever it might be. And so you start to think about those balances. You reflect on what you're trying to get in your career, right? If you're going to lead something, odds are you're going to do less surgery. I mean, I'm a good example of that. The fact of the matter is, though, you have to decide what is most important to you and reflect on that. Once you do that, you have to decide, to lead whatever you're going to apply for. I've been on many search committees, searching me and then leading others, and you look for people who have passion and energy, who are really committed to that job that they're applying for, because if you don't have that passion, you're not going to be successful, right? So you have to decide, does that speak to you? Does it really speak to you? And then lastly, you have to build up that legacy of, that person has hard work, that person is credible, that person is intellectually honest, has a high level of integrity, communicates well, team builds, has delivered outcomes. So for those of you who are in your early, middle years of your careers, you send up your academic promotions, if you think, I'd like to be a chair, whatever, you need to think about, how am I going to build that reputation so when I apply, I have tenure, I have gravitas, I have credibility to be competitive in those internal and external searches. So I'm a big believer in what we call servant leadership, and I want to distinguish that from leadership. Many leaders do it for their ego. Servant leadership is, I want to lead something because I believe in the mission, the values of the organization or a committee or whatever it might be, the church. I want to make it better, so when I leave, it is better. That's servant leadership. Very different and very important. And I can assure you on search committees, you can easily tell who's really doing it for them versus who's doing it because they want to make that better and they believe in the mission and the values and they have passion for it. Of course, it has to be intellectually challenging, right? Because if it's not challenging, you're not going to be that excited about it. You're not going to put 100% effort into it. Time here is a double-edged sword. You have to make sure you have time to commit to that endeavor. Time also is a timeline of how are you going to deliver those outcomes. At my institution, we have term limits in every leadership position. Term limits because we believe in refreshing leadership. It brings vitality to the organization. So as Executive Dean, I know, okay, I have X amount of years before. Thank you very much for your service, Fred. So that gives a sense of urgency. It also means, by the way, that you have to build your succession from the very beginning day you walk in because you know you're not that important. They played music for me walking in. Wow. Not that important. None of us are. So these are, I've written down here, we all know these things, skills for successful leadership. I'll comment on a few of these for you. Obviously, you have to think critically. You are handed issues that, my gosh, as a neurosurgeon, you don't really know what to do with it. I mean, think about it. In the end, neurosurgery is not that hard, right? I mean, you have to understand anatomy. You see a tumor, you take it out. Disc rupture, take it out. But in these type of positions, you're a little fish out of water. You have to think critically. You have to get support and advice. You have to seek that advice from people who are smarter than you, more knowledgeable than you. I completely recognize that I'm not the brightest light bulb in the rooms I walk into, but I'm okay at organizing teams to help advise me and to lead an effort. And it's important to identify that talent that can support your vision, your initiatives, your strategic plan. For example, AI, GPT, and, of course, there's many other AI advanced programs that are right around the corner, and you read the newspapers, and there's a lot of platitudes. AI is going to do this. AI is going to do that. For neurosurgery, what's AI going to do? I don't know. We won't need neuroradiology. They're going to look at X-rays, and maybe AI is going to drive a stereotactic biopsy, et cetera, et cetera. Anybody can say that. But how about digging deeper? What does AI really mean about how are we going to deliver education in my realm? How are we going to do research better in my realm? And I can't answer that. So what I've tried to do is create a team of AI experts from very different domains to say, okay, here's the problem. Come back to me in six months and tell me where we should go and where we should put our resources and finances. That's what I mean by team building and thinking critically. Obviously, you have to inspire and drive meaningful change. That's obvious. You know, I mean, if you come into a room and you're not passionate, boy, you can look in the eyes and they're lost. I've heard a lot about, you know, before you have a meeting, you want to go around quietly and tell this person, hey, I'm doing this, and that person doing that. I want you to support me. I confess I don't really do that. I go into a room a little blind and say, this is what I really think. Here's the data. Here are the metrics. Here's the outcomes. Here's the timelines, and it's my job as executive dean to say, I want to get there. Help me. Help us. Help our students. Help our institution. Don't micromanage speaks without saying. I'm blessed to have a lot of great administrators and physicians and other deans who support me, and they're great. Let them do their stuff, right? Build your knowledge is just reminding me that I try to read things that are not neurosurgical, because there's only so many hours a day, right? I mean, you know. So I try to read futuristic writings in reading. I try to read economics, not that I understand it so well. It's been a long time since I've read a neurosurgical article other than coming to, like, this great meeting to learn, because there's only so many hours in the day, and I have the responsibility of understanding things beyond that, more on a societal level. Like, for example, Supreme Court has huge implications for us, us, and for my college on affirmative action. Huge implications. How are we going to deal with that? Create accountability, timelines, all clearly cut. Celebrate accomplishments. You know, when small things happen, or big things, you want to celebrate it, because a lot of bad things, a lot of good things don't happen, so to speak. And you want to call out the people who do the work, you know, the secretary, the education coordinators, the administrators. It's really important to recognize the small people. It's so meaningful when you recognize them in public. And on the other hand, you don't take it for yourself, by the way. And then, on the other hand, you have to own failures. A good example, some of you heard me talk about a few years ago, through a computer glitch, we sent 300 acceptances to the waiting list at Mayo Clinic School of Medicine, 300. Our class is only 100. We only accept about 150 to fill that class of 100. We're exceedingly competitive. We have thousands of applications, and 300 on the waiting list said, welcome, congratulations, you're accepted. What a nightmare. I didn't push the button, but I'm the dean, right? So I owned it. I called every one of those students over four days and apologized. You have to own these things. You have to have strategic planning, right? And we have about 28 pages of all these columns of strategic planning. It's very hard to communicate that to the staff. It's very hard to communicate strategic planning to benefactors. I have to do a lot of fundraising, unfortunately, with my colleagues. My colleague, Dr. Spinner, does a great job at that. All of you, some of you have to deal with that, right? I do. So I have to market it. And so I've marketed and reduced our strategic plan to PLATO. I can remember that platitude. It's easy. I like that acronym. But notice P. P stands for attract the best, the brightest, and most diverse learners to advanced science and clinical care in medicine. Because a firm believer, education and the people are the platform for your academic medical center or for your hospital. If you don't train the next generation of surgeons, scientists, educators, your institution is going to fail. So platform is one of those things you read about. Everybody says platform is a da-da-da. I turn it around and say platform, for us, we are the platform of Mayo Clinic. Education is training the workforce of the future for Mayo Clinic. And I justify everything under that. Now, it's not uncommon to run into, you know, hey, we're okay. We're good. And I would say good is not good enough. You never can accept mediocrity. Would you accept mediocrity in your operating room? Heck no. That's how I convert it. When I run into this, which is not that uncommon, if I was taking out your tumor, would you want me to be just good? You'd want me to be great, hopefully. So you've got to push X once. You've got to drive X once. This is what keeps your dean and CEOs awake at night. It's a long list and I don't have time to go through it, but you know, neurosurgeons go to deans and they say, we want this, we want that, we want to buy five microscopes out there, which are really pretty expensive, especially if you start to add the contracts for repairs and service. Hey, neurosurgery is not that important for an academic medical center. We're not the big dog. We're important, but we're not the biggest dog. So when you present something to your dean, you got to build a business plan. If we build this research program, it's going to attract top of the pyramid surgical patients. That's what he wants, he or she wants to hear because that's revenue, right? So you got to be strategic when you talk to your dean. I think Dr. Strang wisely and brilliantly chose the mission of this meeting to be advocacy. So I'm going to briefly talk about three points of advocacy that come to my plate. The last one's going to get people upset, I have no doubt. So diversity. How do we increase diversity in neurological surgery? And my comments, by the way, are true for most surgical subspecialties, ENT, ortho, urology. Do you know that the number of neurosurgeons in residency and practice who are African-Americans, about 5.5%, that stayed flat over 12 years now. Hasn't made any advancement. Same is true for Hispanics, 7%. And there are almost no indigenous Americans who are neurosurgeons. That's a problem for neurosurgery, right? Now, women, we've done better at 19% of women in our RENCs are, 19% of the RENCs are women, but 19% is okay, but 55% of your medical school graduating class are female. So we're still missing out. So why do you care? Well, you care because it's evident, it's been published that diversity improves patient outcomes. It's also the right thing to do for our country and society, which is terribly polarized, right? And we're neurosurgeons. We can contribute to the repair of our society. I really believe that. So I just want to give you, I'm sure many of you are doing these things. I can give you a taste of what we do at my institution. We have 27 pathway programs that we've started over the last four or five years. Takes a lot of funding. They're high school, they're college, they're medical school, they're indigenous Americans, African-American, Hispanics. We're across the country. The goal is to attract kids, give them an opportunity to see what medicine, to see what science is all about, because my goal is to get them to think about, hey, maybe I'm interested in applying to their allied health school or their medical school or their graduate school. That's my goal, right? Ultimately, beyond doing the right thing. So last summer we had 324 students of diversity on our campuses. Pretty cool. My medical school is ranked in the top 10 nationally in the number of underrepresented medicine entrances, particularly in students this year, 30%. We have partnerships with historically black colleges and universities, five actually mentioned. This is a photograph of a neurosurgery mentorship program I sponsor. In fact, some of these students are here, so if you see them, reach out to them. They're going to be applying to some of your programs and they're great. You got to give them an opportunity. If you visit some of these schools without, you look and they say, I want to show you our organic chemistry laboratory. I'm telling you, in some of the schools I've been to, their organic chemistry laboratory is not as good as the one in our high school. It's painful to see the lack of resources. So we have these programs and these mentorship programs. When you get some of these students to come to your school, like on the right there, you got to give them scholarship, of course. You got to mentor them. The one, Bella, on the right there, I nominated her for a Soros Foundation scholarship, which she won. She was written up in the New York Times about nine months ago. These kids have great potential if you give them the opportunity. When you have diverse students in your residency programs, you got to watch out for them, quite frankly. There's published data that African-American residents get dismissed at a higher rate than Caucasians, fired. That's the fact, especially in surgical subspecialties. Well, that's not acceptable. We've created a program we call CITE, as you can see there, where if we identify a diverse student who we want to keep at Mayo because we want to add diversity to our workforce to improve patient outcomes, we create a pathway. We say to the clinical department, do you need someone who's special on this? Say, I don't really need that additional staff. We go to leadership and say, we want permission to create that position for this student, even though there's not a clinical to meet. And, of course, when you have young staff, all staff, not diverse, but all staff need a lot of mentorship, right? I've listed there. They don't really know how to manage time, how to build clinical practice, research support, academic appointments, a lot of obstacles in some institutions for academic appointment. You have to be careful for our diverse colleagues because they have something called the minority tax. They're tagged to represent minorities on every committee in an institution, which takes away their time to build out research. You've got to look out for them. Now, this is a beautiful story here. This is a colleague of mine who, again, was first student in her family to go to college. She applied and was accepted to our MD-PhD program, which she completed. She then matched into our anesthesia program and then a fellowship. She was recruited on staff, and I put her on the admissions committee. Full circle. Beautiful story. Second advocacy. Neurosurgery health care disparities. I've listed some there. Do you know in rural America, people don't have access to acute stroke intervention. They don't have Dr. Levy's hanging out there ready to do a thrombectomy. Same is true for traumatic bad injury. We heard a talk about decompressive craniotomy. In rural America, they don't get that. Same is true for inner city. That's a disparity. Do you know if you're an African American kid, at least it's published, if you're an African American kid, you have craniosynostosis, you have five times more likelihood of having a craniotomy as opposed to an endoscopic repair. DBS. If you're an African American person with Parkinson's disease, five times less likely to be referred for DBS. Tumor surgery. Ample data published that if you're African American or Hispanic, your brain tumor, whether it's an acoustic meningioma, glioblastoma, has to be significantly larger before you're referred for surgery. Those are health care disparities that we own. We can improve upon. And then the third, I apologize, is patient advocacy. I think that the needs of our patients should come first. That should be our primary mantra in neurosurgery. The needs of our patient come first. And I've listed on the right what I would call really pathetic surgeries. I have patients who get called or contacted by certain institutions where they're told, we always cure, we routinely cure glioblastoma multiformes. Oh God, they cure GBMs like all the time, Dr. Meyer. All right, well, I've seen older patients, not male fortunately, with like a three millimeter MCA aneurysm. So what's the odds of a 73 year old woman with a three millimeter MCA aneurysm rupturing? It's like zero, zero. So explain to me why that patient had a craniotomy. And oh, by the way, the OZ had another surgeon's charge. Really? And the list goes on and on. I mean, you see these big cavernous sinus transitional aneurysms. I mean, I used to operate on them all the time, right? Fun surgery, difficult surgery, challenging surgery. Well, if that was in me, I'd rather have one of my colleagues just place an outpatient diversion stent and be done with it. Why are we operating on them? And the worst, of course, is spine fusions. At the board level, we see case records. We review cases of young people having front back operations with normal MRIs because of back pain. We own that. It's just wrong. I don't know what drives that. Is it greed? Is it because we're arrogant? But I'm telling you, it's not right. And I see that on many levels. And I just throw it out to you. And I apologize if I'm offending anybody, but it's how I feel. So does being a dean bring me joy? It does. I mean, a lot of it. I mean, this is one of our group that just matched. I asked them for a photograph, and it's what they did. That's a happiness. Another happiness would be be invited to the Poor Bear Club and say, hey, Dean Meyer, you want to jump into this pond in February? No, not really. But I'll watch you. I'll drink a beer. Down below is I like inviting our medical students in Rochester, to my house, the traditional world famous Meyer Pina Colada. You have to have a glass as the entry. I like those things. I also like other things that up on top there is we formed an association with Ibsen Foundation in France. So we published children's books where the author is a child working with a artist to teach a kid about the disease they have. So we have books on autism, bullying, lymphoma, leukemia, onward smoking. That brings me, it's translated into four languages now. That brings me great happiness to see that come to fruition. But obviously, the thing that I enjoy the most, which I think many of you do is mentorship, right? Nothing gives me greater pleasure than, you know, a bypass for Moya Moya and Senior Resin. Just watching them do the bypass. It's like beautiful. I don't need to do another one. It brings me great joy to watch them put those stitches in. Great joy. I like a lot teaching. And when I say I now, I'm talking about us as neurosurgeons and us and our decanal staff and us with our faculty, us for our residents, teaching students and fellow residents, all the way down, us. We enjoy teaching integrity and empathy, teamwork, scholarship, excellence, and most importantly, in my opinion, values. Teaching values matters. I've made so many mistakes, I can't even begin to list them. We could, you wouldn't get coffee for three days if I started talking about my mistakes. These are broad categories. I'll give you one example. Ignoring my inner sense. So sadly, under my watch, I've had two suicides. You may say, well, 4,500 students learners, two, it's awful, right? Even though I didn't know one resident. But the story here is that a certain medical student, you know, I was at the medical school, talking to the kids, da, da, da. Hey, how are you? He said, I'm okay. But this, he was the type of kid who said, I'm great. Never a bad day. I'm great. But he said, I'm okay. And my inner sense should have keyed in on that, right? I should have said something's not right. I should have gone back and talked to him and I didn't. I failed him. Terribly sad. Anyway, there's a lot of things here. But I see we're running out of time. What have I learned? I've learned that a value-based mission is most important. Doesn't matter what it is. I love being on the board of neurological surgery. There's a value-based mission. How are we going to elevate the standards of neurological surgery? How are we going to create a system that is inclusive to neurosurgery? How are we going to create an MOC that is educational and not antagonistic like ABIM? A value-based mission. I've learned that it all comes down to very hard work. I keep saying I'm not the smartest person in that room or this room for that matter. It's all about work. It's all about work. Don't sleep much, honestly. Integrity is important. Teamwork is important. Innovation is important. We innovate on all sorts of levels, whether it's our sim centers. We have, you know, we have thousands of learners in our sim centers. So we have infused augmented reality and virtual reality to teach better. We have all sorts of reverse classrooms where we're giving a course in Arizona where our Minnesota and Florida students are learning it, etc., etc. We innovate all the time. Never forget about innovation. Commitment, and most importantly, belief and purpose. So if I can say anything to anybody here, I'd say believe in purpose. If you decide you want to be a great surgeon, then do it. Do it with great technique. Do it with values, with integrity, and do the right thing when you take care of patients. Do the right thing. If you believe in education, learn about pedagogy. Learn about how to teach. Try to build that. And research, my gosh. Discover the cure for GBM. That's a passion for you. So I hope that was of some interest. I really appreciate your attention. Thank you. What neurosurgeons do, oh, sorry. What neurosurgeons do is great. I mean, we're a community of great, great people, right? We really are. We really are. Think of what we do every day. We drive patient care, research, education, innovation. So honestly, I applaud you. Thank you. Thank you, Dr. Meyer. Thank you so much. We're going to take a 30-minute break and then be back for our plenary. Please go and visit with our industry collaborators in the exhibit hall. Yeah, our outstanding industry supporters helped make this meeting possible, and they'll appreciate you saying hi. Thank you. Neurosurgery PAC was founded in 2005 because our leaders understood that to be the best advocates for our profession and patients, we must be bigger players in the political arena. Neurosurgery PAC is the most powerful tool we have to gain political clout in Washington, DC on issues that uniquely affect our specialty, since it's the only political action committee dedicated solely to neurosurgeons. With the pandemic behind us, we are turning the corner to step up our fundraising. Neurosurgeons face significant practice challenges, and we must grow our political imprint to achieve legislative victories. As a member-driven PAC, we urge all neurosurgeons to join our crusade and support our Why I Give campaign. We want and need to hear from you. Do you give because of the significant pressures that dictate how you deliver care to your patients? 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Good morning, and as editor-in-chief of the Journal of Neurosurgery, I'm pleased to give you this update this morning. I think you'd all agree it's great to get a cover article for yourself on the Journal of Neurosurgery. And this one's special because what you see on the image of the cover is about a thousand women whose faces adorn this cover. And we're delighted to present this to all of you at this meeting, and please pick up a copy at the Journal of Neurosurgery publishing booth on your way out this morning. I'm very happy about the impact factors of the Journal of Neurosurgery. We continue to climb in all of our journals, and not only with the impact factor but with our citations as well, which keep improving. Under the leadership of Bill Caldwell and his assistants, Jason Sheehan and Aaron Cohen, neurosurgical focus and focus video continue to thrive. You think you can see from this that it's been 10 years now that video has been active in the space of video journals, and it's been a complete success for JNS. Out of the pandemic, the Journal of Neurosurgery Journal Club arose. You can see some of the topics that have been presented, and this provides enduring educational content that you can look back at and review at your leisure once these are filmed and recorded. We now have a freely online and open access journal called JNS Case Lessons. It's a wonderful opportunity for both residents and fellows to submit their works for publications related to case reports, and it's now listed on PubMed newly. We have a very active social media team led by Faith Robertson from Harvard, a neurosurgery resident, but then you see listed here the faces of the medical students and the young neurosurgeons who are neurosurgery residents who are actively involved in sending the messages out there for the Journal of Neurosurgery on social media. If any of you have published an article in the Journal of Neurosurgery in the last 30 years, you will have spoken to and have worked with Margie Shreve. I guarantee it. She's been the voice and the backbone of the JNS over the last 34 years. She's announced her retirement in her name and honor. I'm really pleased to tell you that we have an Honor Your Mentor fund for Margie now, and I'm also pleased to tell you that all members of the editorial board of the Journal of Neurosurgery have contributed to this fund in Margie's name. In keeping with the priorities of the AANS, we also have a mid-career opportunity for ad hoc reviewers for the Journal of Neurosurgery. This is the second cohort now. You can see them listed here, and automatically they and their predecessors become the pipeline for future reviewers for the Journal of Neurosurgery. We also have a new diversity, equity, and inclusion subcommittee led by Bill Ashley and Sonia Eden. We're delighted that in conjunction with Aviva Abash of the same committee in the AANS, we will have new eyes looking at journal articles through the lens where race and ethnicity are involved in journal articles. Okay, you can't open a newspaper today without seeing something about CHAT-GPT. This is Michael McDowell, who's a pediatric neurosurgeon at the University of Pittsburgh, and we're publishing this shortly in the journal, but he asked CHAT-GPT, write a letter to the editor advocating for prenatal closure of myelomeningocele within five seconds. Here was the response. I won't read it, but you can see it. It's actually pretty good. He also asked, write a letter to the editor advocating against prenatal closure, and it was also pretty good. So anyway, we're going to discuss this in the Journal of Neurosurgery. You'll see it in an upcoming issue, but along these lines, because it's a train that's way out of the station now, and you can either get on the train or the train's going to pass you by. This artificial intelligence, we had a great lecture, the Louise Eisenhardt lecture, you remember at this meeting, but Fred Barker, associate editor of the JNSPG, wrote this piece, and it'll be published shortly. Everything you need to know about artificial intelligence, CHAT-GPT, and so many other things related to scholarly publishing. And then finally, you know, a journal's only as good as its editorial board, and I think we have the best editorial board on the planet working for the Journal of Neurosurgery. I'm delighted when they travel throughout the world, as you can see on this slide, that they not only take their work with them, but they take their Journal of Neurosurgery caps along with them, and here represented in various cities and countries around the world are some of the editorial board members. So with that, I thank you for your attention. I particularly want to thank Anne Stroink, and also congratulate her on the success of this meeting. Thank you very much. Thank you, Dr. Rutka. We'd like to continue our science by inviting Dr. Patel up to the podium. They're going to be talking about the two-year outcomes in a randomized controlled trial for spinal cord stimulation. Thank you. On behalf of the investigators, I would like to thank the AANS for allowing us to present our work today. So this was a national 15-site trial. Each institution received industry research support. The trial is registered on clinicaltrials.gov. So spinal cord stimulation has traditionally been used for intractable, chronic, post-surgical back and leg pain. Until now, efficacy has not been demonstrated in an RCT specific to a surgery-naive population. This study was designed to evaluate the clinical and cost-effectiveness of 10-kilohertz spinal cord stimulation to treat non-surgical refractory back pain. We define non-surgical refractory back pain as pain that is refractory to conventional medical management, including injection therapy, physical therapy, trials with oral medications, and pain psychology. The patient had not had any previous spine surgery. Surgical evaluation indicated that the patient was not an acceptable candidate for surgery. In other words, they did not have a structurally identifiable lesion that, if treated surgically, would have likely led to symptomatic improvement in their condition. The 12-month RCT was published in JNS Spine last year, and here we present 24-month data for all implant patients. The trial design was published in 2021. This is a QR code for those interested. This was a one-to-one randomization of conventional medical management versus 10-kilohertz spinal cord stimulation plus conventional medical management. This was non-blinded, as we would have had to perform a sham procedure on the conventional medical management group, which we felt was not ethical. The graphic in the upper right-hand corner shows the trial setup. The primary and secondary endpoints were evaluated at three and six months, followed by an optional crossover if pain relief was not achieved on treatment, with patients followed out to 12 months post-baseline and an additional year if they consented to the study extension. Patient-reported outcomes included pain, function, quality of life, and sleep. Objective outcomes included a 50-foot walk test and evaluation of opioid usage. So the patient population had a mean of eight years of chronic moderate to severe low back pain. Age and sex in the two groups were similar. Most patients reported multiple pain etiologies, with 91% having degenerative disc disease and joint disease. Most complained of non-mechanical burning back pain. Some complained of neuropathic leg pain without clear structural cause. But again, all these patients were evaluated by a spine surgeon and felt to be non-operative. So both cohorts started at an average of over seven on the VAS. The 10-kilohertz spinal stimulation group experienced a 72% reduction in pain on average through 12 months, which is depicted on the green line on the left-hand side. The conventional medical management group, seen in dark purple, continued to report above a seven on average. The response criteria was at least 50% pain relief. So the primary endpoint was met by only 1.3% of patients in the conventional medical management group versus 81% of the patients in the 10-kilohertz spinal cord stimulation group. Seventy-five percent of the conventional medical management group crossed over at six months and received a 10-kilohertz spinal cord stimulator implant. That's the light purple line on the left-hand side. They achieved the same outcomes as the original implanted group with improvements in their VAS scores. We now present the 24-month outcomes for the entire cohort of patients implanted with 10-kilohertz stimulation. That's a total of 125 patients. Missing data was handled with last observation carried forward imputation. All implanted patients achieved an average reduction of five and a half points on VAS or 74% pain relief, which was stable through 24 months as seen on the left-hand side. On the right-hand side, at baseline, 73% were considered severely disabled as assessed by the Oswestry Disability Index. And that reduced to 26% after implant, and that carried through to 24 months. These tornado plots show each individual patient's response at 24 months in terms of pain relief on the left and disability on the right. On the left side, the blue lines represent patients who achieved greater than 80% relief. The green lines represent those that achieved between 50% and 80% relief. And the orange lines represent those patients that achieved less than 50% relief. So as we can see from the plots, 82% of patients responded well to the stimulation with greater than 50% relief. 58% of patients were profound responders and had greater than 80% relief. On the right side, the blue lines represent patients who achieved the minimal clinically important 10-point reduction in disability as measured by ODI. 75% of the implanted patients achieved and maintained that 10-point reduction at 24 months. In terms of quality of life, quality of life as measured by the EQ5D5L on average improved by more than twice the minimal clinically important difference, and this was stable through 24 months. The average change in the Utility Index is shown on the right at all time points. And as we know, this is an important parameter when measuring cost effectiveness. Cost effectiveness was achieved at just over two years, and that was published in JNS Spine in October of 2022. Sleep was significantly improved in the implanted population as measured by this pain sleep questionnaire. There was a 67% reduction in frequency of pain interference with sleep at the 24-month mark. We know sleep impacts quality of life. There's a negative feedback cycle where pain negatively impacts sleep, which can in turn worsen chronic pain. Patients often complain that not enough attention is paid to their sleep dysfunction by their physicians. In addition to patient-reported outcomes, an objective functional test was also performed by the patients at each follow-up. The patients' walking speed for the 50-foot fastest walk test increased significantly. In the patients maintained on opioids during the study, 62% of them were able to decrease or stop opioid use altogether. So we see favorable results in both objective measures. In terms of safety, a total of 145 trials were conducted, followed by placement of 125 implants. There were five procedure-related complications, including three infections, and those three infected patients were explanted. Two were then replaced when the infection cleared. There were also three explants due to dissatisfaction with therapy on 24-month follow-up. Increasingly, in the pain management field, clinicians are moving away from UD dimensional management and measurement of pain intensity. A patient's response to the therapy can better be measured by looking at different domains of patient status and therapeutic goals, including function, ability to perform daily activities, perception of global improvement, and sleep quality. Here we see the success of the stimulation therapy in a more holistic way, across multiple dimensions. 90% of patients achieved significant improvement in at least one dimension, and 84% in at least two of the dimensions. So, to conclude, these patients have tried nearly everything available to try to improve their chronic severe back pain. 10-kilohertz stimulation improved pain, function, and sleep in most of these patients, with durable results at two years. In addition, opioid reduction or elimination was seen in many patients. We believe that 10-kilohertz stimulation should be considered as an option for this difficult patient population. Thank you to all the investigators, without whom this work would not be possible. And a very special thank you to all the patients that were involved in the study. Thanks. Thank you. To discuss this abstract, we'd like to invite to the podium Dr. Patil. Well, thank you very much to the committee for inviting me to discuss this work and place it into context. We all know the saying that when all you have is a hammer, the whole world becomes a nail. And so the question posed by this study is, do we have a new hammer for our rustiest nail, which is non-surgical lower back pain? These are my disclosures. So in terms of background, spinal cord stimulation has been traditionally indicated for chronic, medically refractory back and lower extremity pain of spinal ordrine. If you will, it's non-mechanical burning back pain. Although spinal cord stimulation is well established, it's not the only way to treat spinal cord pain. It's non-mechanical burning back pain. Although spinal cord stimulation is well established for the treatment of lower back pain, some recent studies have cast doubt over the efficacy and value of spinal cord stimulation. For example, database studies have concluded that the costs and benefits of spinal cord stimulation are not what we expect. And other randomized trials have concluded that spinal cord stimulation is no better than placebo. So how do we reconcile these with the study that was presented? In fact, a Cochran review, which reviewed data up to the 10th of June 2022, so did not include this study, concluded that for people with low back pain, we are moderately confident that at six months, spinal cord stimulation probably does not lead to lower pain, better function, or higher quality of life compared to placebo. It's quite damning criticism of our field. In fact, the review looked at 13 studies that were included and then criticized many of them on the basis of bias. In terms of these sorts of meta-analyses, we must remember two caveats. First, that lack of evidence does not equal evidence against a therapy. And second, that if we include flawed studies in our meta-analysis, then we're going to arrive at inaccurate conclusions. What the study presented by Dr. Patel and colleagues does is provide solid data for spinal cord stimulation. As reviewed, it compares 10-kilohertz spinal cord stimulation against conventional medical management, allowing for a six-month crossover with one-to-one randomization. It should be noted that each of the patients underwent a trial of up to 14 days and only then was permanently implanted. And the primary outcome, of course, was 50% reduction in the VAS. The findings are really quite remarkable. To put this into context, when I began practice in 2005, we would routinely tell patients that they would only expect 50% to have improvement with a spinal cord stimulator trial, and only 50% of those implanted could expect long-term benefit. In this study, it was found that 94% of spinal cord stimulator trials ended up in success, and that over 24 months, 74% of the patients achieved a 50% reduction in VAS, as well as reductions in opiates. So let's examine this study in terms of the biases that are often quoted in the literature. The study did an excellent job of randomization to prevent selection bias and also did a remarkable job in terms of following patients over the duration of the study. As mentioned by Dr. Patel, it was not possible to do blinding in this group because of the need to perform sham surgery, and this was viewed to be unethical. And therefore, issues of performance bias and detection bias, meaning the bias in evaluation or self-evaluation, are present in this study. There are several potential criticisms for discussion. One is that it's notoriously difficult to identify which patients with lower back pain, in fact, have neuropathic pain versus nociceptive pain versus nociplastic pain. And after eight years, it's not even clear what these terms mean. So if you will, what was being treated were patients who had non-mechanical burning back pain. In addition, what makes a patient non-surgical? This can be quite subjective and uncertain. And in this particular study also included 13% of patients who self-selected against surgery. Of course, with the crossovers from the chronic medical management to spinal cord stimulation arms, it wasn't possible to follow patients over time. But as you could see, only 1% of patients in the chronic medical management group reached the endpoint, whereas some 80% in the spinal cord stimulation group reached the endpoint. In addition, there's a great deal of additional analysis that can be done on the data that was not presented. And we look forward to seeing these analyses in the future. For example, did the length and the success of the trial of stimulation prior to permanent implantation make a difference in terms of the outcome? Meaning, did a patient who had a 50% improvement in pain do worse long-term than a patient who had a 70% improvement during their trial? These are questions that we look forward to seeing. So let me return to the original question. Have we found a new hammer for this rusty nail? And what I would claim is that the data presented are solid, the evidence are favorable, and perhaps, hopefully, the answer is yes, at least for non-mechanical burning back pain. Thank you. For our next presenter, we'd like to invite to the stage Dr. Furey, who's going to present the next abstract, Longitudinal Cerebrospinal Fluid-Liquid Biopsy in a Clinical Trial of Newly Diagnosed Gileoblastoma. Thank you, Dr. Furey. All right, good morning. My name is Shruti Furey, and I'm a PGY-5 neurosurgery resident at the Barrow. Thank you for this opportunity to share some of our work from the laboratory of Dr. Nader Sanaei that's centered on tracking glioma evolution in the context of a Phase 02 clinical trial of norepirib for newly diagnosed glioblastoma, and I have no relevant disclosures. So tissue-based surgical trials are underrepresented in our field. In the last 50 years, only 22 glioblastoma trials examined pharmacodynamic or pharmacokinetic endpoints, and this means that the vast majority of our trials were deploying experimental therapies without really knowing and proving to ourselves the drug, one, actually gets past the blood-brain barrier to tumor, i.e., pharmacokinetics, and two, if it gets there, is it actually doing what it's supposed to, or pharmacodynamics? And so early phase clinical trials are helpful in trying to assess these concerns. In our program, we like to think about Phase 0 trials as being trials where there isn't any therapeutic intent prior to surgical resection of tissue, and window of opportunity are then described as where there is some kind of therapeutic intent prior to surgical tissue acquisition. We also deploy what are called PK-PD trigger trials, and so here's what they generally look like. We screen patients, in this case with newly diagnosed glioblastoma, and they're given a non-therapeutic dose of experimental therapy, and then they undergo surgical resection. Here, what we're doing is we're checking for tumor, blood, and CSF, and evaluating the PK and PD endpoints within this tissue. We then have any number of three triggers, pharmacokinetic, pharmacodynamic, or PK-PD combined triggers. If they meet these criteria, they then undergo therapeutic expansion, which is where we're evaluating safety and efficacy. As a refresher, PARP1.2 is critical for DNA damage response, which is essential for cancer cell maintenance. We all know a lot about these drugs and their mechanisms, including their downstream effects. Within the medical oncology literature and community, there's actually specific interest in exploiting all of these downstream effects from the standpoint of synthetic lethality, with one of the most important mechanisms being related to BRCA mutations. Outside of our field, these drugs have revolutionized oncologic care, and they've worked their way into standard of care for various cancers, including ovarian, where there's been tremendous survival benefit. Some medical oncologists will even say that they're seeing things that are consistent with what resembles a cure in a BRCA mutant subset of patients. Naturally, the industry has responded in kind and developed a number of PARP inhibitors that both block PARP enzymatic activity and trap PARP1.2 to prevent DNA repair altogether. This is a phase zero study with an expansion arm of norepirib in newly diagnosed GBM. The patients get four days of norepirib, followed by surgical resection. The pharmacokinetic trigger is for unbound, active drug in non-enhancing GBM tissue to reach concentrations that are greater than five times the biochemical IC50, which is an important pharmaceutical measure of potency. Patients that meet that pharmacokinetic threshold and are MGMT unmethylated then go on to the expansion phase. 35 patients were accrued into the phase zero component, with 14 going on into the expansion arm with treatment. And so what you see here are the newly diagnosed patients, one through 35, and every one of those vertical bars is effectively unbound, enhancing concentration of norepirib in the non-enhancing GBM tissue. And that horizontal dotted line is the five-fold biochemical IC50 for each patient, so as you can see, norepirib performs rather admirably from a pharmacokinetic standpoint. And so interestingly, we actually have several PARP inhibitors within our preclinical trial portfolio, and their pharmacokinetic data demonstrate that norepirib actually penetrates the blood-brain barrier and tumor tissue at a much higher level. Now, from a pharmacodynamic standpoint, what we care about is whether or not these PARP inhibitors are actually radiosensitizing cancer cells to radiation. And so what we like to do is utilize an ex vivo assay. So we take out the tumor, half of the tissue is radiated ex vivo, and the other half is kept as a control. And so what you're looking at here are individual PAR-fold changes, and in short, the lower the PAR-fold change, the more effective a drug is at radiosensitizing tissue. So here in aggregate, what you're seeing is a statistically significant decrease in PAR-fold change in ex vivo radiated tissue after four days of norepirib treatment relative to control. And so here are the swim lanes from our ongoing PK-triggered study expansion phase, where each lane corresponds to a patient. And a median progression-free survival has not yet been reached at a medium follow-up of 8.4 months. And so you can see, though, that a couple patients are starting to develop and demonstrate progression, but we have no ability to molecularly visualize why they're progressing. And so this underscores how resistance mechanisms go undetected due to the morbidity associated with obtaining tumor tissue within our experimental trials. So we interrogate tumor biology when the patient comes in at presentation. Then they get their experimental therapy, and it remains a black box until the patient recurs. And in our IV center experience, less than 15% of trial patients returned to the OR for re-resection. So this motivated us, and in order to address this, we utilized a liquid biopsy paradigm within this clinical trial. So 14 patients underwent placement of an Amaya reservoir into their tumor resection cavity. Their blood was also drawn at that time and sequenced to differentiate germline variants. And tumor tissue was also collected for DNA and single-cell RNA sequencing in order to establish concordance with paired CSF liquid biopsy samples. So monthly outpatient CSF samples were then collected to longitudinally examine glioma genomic and transcriptomic evolution. It performed these minimally invasive liquid biopsies in clinic with no adverse effects or complications to date. And then after collection, we go right up to the lab. Apologize. So after collection, we go right up to the lab and spin it down. The cell pellet is used to perform single-cell isolations, and then the supernatant is used to isolate circulating tumor DNA, which is sequenced using our 293-gene IV brain tumor panel. So we were able to detect circulating tumor DNA in 96% of liquid biopsies. Further, radiographic volumetric tumor burden was found to correlate with CT DNA concentration per cc of CSF. CSF-based liquid biopsy also demonstrated good concordance with gene profiling at the time of paired surgical resection. Interestingly, liquid biopsy also seemed to capture more of the heterogeneity mutationally than standard open tissue biopsies when sampled within samples where we have fixed biopsies within tumor tissue. And so here's a representative snapshot of single-cell RNA sequencing liquid biopsy surveillance of a patient with early signs of recurrence. And so here you can see clearly a progressive change in the patient's cell cluster distribution. And when you analyze these transcripts further, what you start to see are elucidated resistance mechanisms, which in this case was a known CDKN1A-mediated PARP resistance mechanism. So overall, our single-cell analyses also demonstrated a shift in the GBM cell state in the context of PARP inhibition. So this cell state change was a transition from the astrocyte-like Neftal cell state during treatment. And so this is an EGFR-mediated process and a known PARP I resistance mechanism. So in conclusion, Niraparib reaches pharmacologically relevant concentrations in newly diagnosed GBM and demonstrates favorable pharmacodynamic radiosensitization properties. During the ongoing PK-triggered expansion phase, a median PFS has not yet been reached at a median follow-up of 8.4 months. And so this is one of the first reported experiences of serial intracavatory CSF biopsy to monitor DNA as well as RNA-based glioma evolution in the context of an experimental therapy, demonstrating that it's both feasible and safe. And additionally, we demonstrated that these minimally invasive liquid biopsies are concordant with open tumor biopsies and may even have the potential to capture more of the mutational heterogeneity better than our typical local core biopsy. And finally, longitudinally tracking a patient's tumor evolution during clinical trial offers us fundamental insights into the mechanisms that dictate treatment response, tumorigenesis, as well as therapeutic resistance in the setting of experimental therapy. And so these genomic insights that until now have generally remained undetected during clinical trials have the potential to advance the clinical development and use of genotype-driven therapies for glioblastoma. So this trial and research would not have been possible without the interdisciplinary efforts of our team at the Ivy Brain Tumor Center. This includes over 50 employees across multiple departments that are all unified together for improving outcomes for our brain tumor patients. And in particular, I'd like to highlight the contributions of these investigators and laboratory staff that are instrumental to this trial, our funding support, and most importantly, the patients and families that participate in this trial that make research to improve treatments for glioblastoma exceptionally fulfilling. Thank you for your time. We'd like to invite to the podium Dr. Zadeh to discuss this important paper. I'd like to congratulate the authors and in particular Dr. Furey, because I know that she did all of this work during her residency training, which is quite an accomplishment, because as you could see, the data set is very impressive. I don't have any conflicts for this. I think if we summarize the presentation, there's a wealth of data that Dr. Furey showed us, but most importantly, I think it's important for us as oncological surgeons to appreciate that we need to shift practice and use biomarkers integrating into our decision-making for managing patients with brain tumors. And in particular, the shift really has to happen for where we can obtain CSF safely from our patients, whether it's through reservoirs that you see through the study or lumbar puncture. And that's not a minor change in how we approach our patients. And hopefully, we can, with such studies and publications, really shift our practice. And they've demonstrated that this can be done safely. And as you saw, nearly 100% of the patients had CSF that could be used for analysis because the circulating tumor DNA was present. The second, of course, noteworthy finding that Dr. Furey showed us is, interestingly, the number of mutations that they could see in the circulating tumor DNA within the CSF was higher than that was seen in the counterpart of the tumor. So a very noteworthy finding worth further investigation as to what we would do with that information as well. And then, of course, the bigger picture of this study is the phase zero component, where I think, as oncological surgeons, we are key drivers to being able to determine whether the many therapeutics that we test with our oncological partners, the neuro-oncologists, and unfortunately fail, is the failure due to the fact that the drug, in fact, did not reach the tumor. It did not reach sufficient levels. And most importantly, perhaps, it didn't actually do what it was intended to do. And you could see that they very nicely did. And you could see that they very nicely shown that though PARP inhibitors have, for a long time, held promise to have an effect on GBMs, that it really depends on the type of PARP inhibitor we use for penetration and effectiveness. So that's also one of the key discoveries. The question remains, really, what platform do we use? Because in the literature now, there is considerable hope for using biomarkers in integrating into our decision making, whereas you could see in the right circle, currently, we require tissue biopsy to be able to understand the genomics of the tumor at diagnosis and recurrence. We like to shift it to the green circle, where we avoid needing to have a biopsy, not necessarily for the diagnosis, because we play a major role in cytoreduction from surgery, but really to be able to determine whether at recurrence, the genetic composition of the tumor has changed. And most importantly, have an earlier detector, rather than MRI alone, as to the recurrence for the tumor. The question then becomes, what biofluid is important? You could see CSF is presented by the authors, and there's also plasma information that could be used and ultimately analyzed through multiple different genomic platforms. There are studies from our group and others that show, for example, plasma is a key biofluid that can be used for determining the methylation signature, excuse me, that can match to the tumor and with very high accuracies of almost approximately 90%, we can discriminate different tumor types, as you can see in the curves on the left of the screen. And so this is an invaluable technique. We can also similarly apply the same technique in CSF. And so although the authors have looked at mutational and single cell data, methylation provides additional information that matches very nicely to the diagnosis. And you could see an example at the bottom for CSF methylation signature, where the images, perhaps you would have difficulty distinguishing the three different tumor types, but on CSF sampling with very high accuracy using the methylation, you can make the diagnosis. So in summary, I would say this study has, in fact, shown to us the importance of collecting CSF, the invaluable cutting edge of where we need to be as surgeons for neuro-oncology change and practice to be able to integrate all of the biofluids to the different platforms that could be analyzed, to then be able to importantly classify the tumors, but more impactfully be able to determine early recurrence and response to treatment. So I would propose that most likely it's a composite score that we create from plasma, CSF imaging, combine the various platforms of mutational methylation and RNA expression to come up with a score that we could offer the patients earlier intervention should they not be responding to the treatments that they need. Again, thank you for the opportunity to discuss. And I'd really like to congratulate the authors, and in particular, Dr. Furey. I apologize. The writing seems to have cut off. Thank you. This is the worst. Dirt. ♪♪ ♪♪ Good morning. I'm delighted to have been asked to present this global neurosurgery update to you this morning, and I thank AANS President Anne Stroink and the Scientific Program Committee for the opportunity. I'd also like to congratulate them on the great leadership and the choice of the theme for this meeting. So let's start on the moon as we look back on our globe, and we'll start with a definition that was actually coined by our African colleagues, notably Ignatius Essene from Cameroon, who defined global neurosurgery as the clinical and public health practice of neurosurgery with the primary purpose of assuring access to safe, timely, affordable, and quality care to all who need it. And I think, as we all know, we live in a globalized world, and part of our globalized world is that I believe we now have taken on an additional core responsibility, and that means that we all need to have, as our default position, a support for all those efforts that bring what we do, which is so important, to everyone who needs it. So you're all probably familiar by now with the Lancet Commission Report, the landmark publication of 2015 that had these five takeaways, and I want to draw your attention to the top one, that 5 billion people, two-thirds of the world's population, lack access to what we do and what all of you do so well. So that's a challenge for neurosurgery, and we've been newly aware of that challenge just since 2015. It's estimated, thanks to Duin and others, that there are over 5 million urgent, emergent neurosurgical operations not being done every year because right now we need 23,000 more neurosurgeons around the globe to do it. That's a big challenge, and that might seem to be too big a challenge to tackle. But there are others within the global community who've met a challenge, and it's recent. In fact, it's ongoing. This is the book Moonshot, written by the CEO of Pfizer, who describes doing what was thought to be impossible. We all thought it was impossible just three years ago that a new type of vaccine could be developed and developed on a nine-month timeline, but they were able to rise to that challenge, and they were led by him as being a self-described Greek immigrant, the child of Holocaust survivors, and Dr. Bourla is a veterinarian. So why do I say that global neurosurgery is our moonshot? Well, I have been very inspired as someone who grew up in America in the 1960s by President Kennedy, who famously coined the term moonshot for anything that is a big, bold idea and a big challenge. So I'm sharing with you some of his words from that landmark speech. His words are in italics, and I've just altered them a little in bold for our purposes. And Kennedy said, as you can see, while there is strife, prejudice, and national conflict in the world, these should not exist in health care. And you could read that. So let's go on to hear President Kennedy's famous speech and think about how it applies to us. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard. Because that goal will serve to organize and measure the best of our energies and skills. Because that challenge is one that we're willing to accept, one we are unwilling to postpone, and one we intend to win. Because it is hard. That attracts neurosurgeons. It doesn't stop us at all. And that's why I think global neurosurgery should be our moonshot. Kennedy goes on. We cannot be deterred, he said. No specialty and no nation which expects to be a leader can expect to stay behind in the quest for the highest quality of health care for people. And our instruments must include shared knowledge and advocacy, the theme of this meeting, advocacy for enlightened scientific and social policy. So neurosurgery has assets in common with those that JFK identified when launching the space program. Kennedy cited vast scientific knowledge, rapid progress, mental strength. And he concluded that moonshot speech by saying that this unanswered challenge and the unfinished work this represents must stimulate our collective energy and resources and indeed our imagination. That is why I think global neurosurgery is our moonshot and that we're up to the challenge. So let me just share with you a few of the things that we already have as arrows in our quiver to attack and surmount this challenge. We have shared knowledge. We have great educational programs and even more global ones since the pandemic. We have rapidly improving simulators. We have new health care delivery systems. We have all kinds of things. I want to just highlight a couple of them. Issues we've been working on such as expanding our training and skill set to create the public health experts of the future from our residents to find new ways to deliver global neurosurgery clinical skills on a shared basis. Now you've heard from Jim Rutka. The Journal of Neurosurgery has been absolutely wonderful in this regard. And Neurosurgical Focus has in fact devoted three issues to global international themes. And neurosurgery has also shown great leadership in this having started a global neurosurgery section just last year. I'd like to share with you that there is now for the first time ever a neurosurgeon inspired resolution that will come to a vote at the 2023 annual meeting. This was a joint effort of the ISPN and the G4 Alliance and was driven by major papers that you've seen throughout the world. And I want to give a special shout out to a pediatric neurosurgeon from Colombia, Kemal Ghotme, who was able to get his government on board so that that will pass in Geneva next month. There's so much work to be done in TBI, but we have so many like-minded surgical specialists working with us. Intersurgeon is the mobile app for working together also developed by neurosurgeons. So as neurosurgeons, as I wrap up, we have access. We're granted the great privilege of having access to many places, to WHO, some of you see yourselves there, to countries that don't have neurosurgeons but are eager to have us help them with how to develop neurosurgery in their countries. And yes, even the Vatican is starting to get involved. So we have great resources. Not only have we traditionally worked with NIH, but new sources of funding, USAID, the U.S. Congress is working on a line item in next year's annual budget for this, and World Bank and so forth. And my own institution is involved in this. So I'd like to conclude by saying the best resource that we have to meet this challenge is the neurosurgeons of tomorrow, the young people, many of whom are leading the way already. So with that, I'd like to leave you with this moonshot, Apollo 11 going to the moon, and I hope that we can do that as well. Who doesn't love a moonshot? We have a liftoff, 32 minutes past the hour. If JFK and NASA can do it, so can we. We're neurosurgeons. Thank you. Born and raised in Michigan, Dr. Anthony Asher received his bachelor's in religion and biology from Kalamazoo College, followed by a medical degree from Wayne State University, where he was a member of the original class of Howard Hughes Medical Institute NIH research scholars. After two years of general surgery, Dr. Asher served as a fellow at the surgery branch of the National Cancer Institute before returning to Ann Arbor to complete his neurosurgery residency under Dr. Julian Hoff. After residency, Dr. Asher joined Charlotte-based Carolina Neurosurgery and Spine Associates, where, for the ensuing 28 years, he has maintained an active community-oriented practice focused on neuro-oncology. He founded the neurosurgery residency program at Carolina's Medical Center, serves as president of Atrium Health Wake Forest Baptist Neurosciences Institute, and surgical director of the neuro-oncology program at the Levine Cancer Institute. He holds academic appointments at Wake Forest, Mayo Clinic, University of North Carolina Chapel Hill, and Vanderbilt. Dr. Asher has also held numerous senior leadership positions in organized neurosurgery, including president of the Congress of Neurological Surgeons, vice chair of the ABNS, and he is a member of the American Academy of Neurological Surgeons. Dr. Asher has extensive experience in surgical quality improvement and clinical data science. He has been the driving force behind the development of several unprecedented national databases, including the Quality Outcomes Database, the American Spine Registry, and the ABNS Practice and Outcomes of Surgical Therapies, or POST. He has published widely on these efforts and capably represented neurosurgery in front of national quality care and safety stakeholders, including the Joint Commission and the FDA. Dr. Asher met his wife, Jill, in Ann Arbor, and together they've raised three wonderful children. It is an absolute honor to present to you the next president of the American Association of Neurological Surgeons, Dr. Tony Asher. Thanks, Peter, for that kind introduction. Friends, it's an incredible honor to be given this opportunity. I'm approaching the responsibilities of this coming year with a deep sense of humility and humility based on the sober recognition of the contributions of Dr. Stroik and the 88 other extraordinary leaders who have come before me and have helped the ANS achieve its current recognition as an international leader in neurosurgical education, advocacy, and science. Consistent with this long history, the present leadership of our organization also includes remarkably talented and dedicated individuals, all of whom are committed to a team management approach emphasizing common purpose. In that regard, I am personally committed to continuing implementation of strategic platforms led by Drs. Timmons and Stroik while working to expand the impact of our signature programs and examining unique, hopefully high-yield opportunities for this organization to have a positive impact. In that regard, our core organizational priorities have been extensively reviewed in various forums for this meeting. I will not elaborate on those further today, but what I do want to mention is my personal desire this coming year to double down on our commitment to partner with any individuals and any groups that might help us advance our mission and advance the interests of our patients. To complement that priority, I also want to expand our capabilities to share knowledge across generations, across the professional spectrum, and I fully recognize and I celebrate the fact I learned as much from my younger colleagues as I do from my contemporaries. Finally, I'd like to say a word about next year's meeting in Chicago. The theme of that meeting is What Matters. This theme is intended to simultaneously represent a question, a statement, and a challenge. This theme, particularly now, means a lot to me personally as I, like many of you, am deeply concerned about growing disharmony and sometimes outright acrimony in society. I'm thinking a lot these days about how I might, even in a limited way, as a single individual, start to positively influence the trajectory of our dialogue and perhaps even our collective progress. So, while I was considering this issue several months ago, I was asked to participate in the development of a research grant, one that was responding to a proposal to empirically examine the relationship between neuroscience and society. I thought, wow, that's an incredibly intriguing concept, and it caused me to reconsider my appropriate role, our appropriate role, in the broader fabric of modern civilization. As a physician, I naturally, at least initially, perceived this issue from a medical perspective, and I found it convenient to imagine society as a patient. From that viewpoint, I came to believe that the health of that patient, of society, is dependent on its ability to protect the interests of its most vulnerable, to balance personal agency and liberty with the common good, to create opportunities for all, and to recognize and promote basic human rights, importantly, including the universal right to essential health care. I furthermore came to believe that such societal health is largely dependent, perhaps solely dependent, on the maintenance of the cognitive, psychological, sensory, motor, and communication health of its citizens, and that society, in turn, as we've seen here this week, particularly a society that is creating technological innovation at breathtaking speed, exerts profound effects back on human neurophysiology. All of this considered, my friends, we surely have to conclude that we, as neuroscientists, as neuroclinicians, and as thoughtful, caring professionals who have dedicated ourselves to the art and science of medicine, have as much and likely far greater potential to improve and preserve the health and well-being of individuals and of society as any of its citizens. Now, that is simultaneously a tremendous opportunity and an awesome responsibility. Therefore, it's never been more important for us to contemplate at this moment in history what matters, what constitutes the common good, what values and rights do our fellow citizens universally hold dear and are willing to defend and promote? How do or should those considerations influence our priorities and our actions? How, friends, do they frame our fundamental responsibilities, our proper role in society? To me, this is profound and important stuff. I'd like to say to my colleagues who might suggest that we as caregivers should focus on care and divorce ourselves from such discourse, I respectfully disagree. I disagree precisely because we as neuroscientists and, as Dr. Stroeing so readily and eloquently expressed this this week, as societal advocates simply don't have the luxury at this stage in the evolution of humankind and given our unique place in that evolution to disengage from conversations of such consequence. And so, friends, I ask you to start considering these considerations in the following year. What matters to you? What matters to your friends? What matters to your patients, your associates, to the individuals and communities large and small that you're in? What should matter to all of us? In the coming months, we'll attempt to facilitate a global, specially wide dialogue on this topic. Through that and other efforts, we hope to achieve in Chicago the corporate home of our organization and a city symbolic of both strife and progress and enhanced collective wisdom and a shared understanding about our proper place and role in the modern world. Colleagues, thank you for your attention. Thank you for the opportunity to serve this great organization and remarkable specialty. Thanks for everything you do. Your actions every day matter. Please enjoy the rest of this great meeting in the great city of Los Angeles. I look forward to seeing you in Chicago. Thank you very much. It is now my pleasure to offer the Cushing Medalist to Regis Haidt. This award was established in 1977 at the recommendation of Dr. Lester Mount. The first recipient of this honor was Frank Mayfield. As the Association's most prestigious and most highest honor, the Cushing Medal is awarded to an AANS member for outstanding services to the AANS and the neurosurgical community. Given annually, the AANS Board of Directors selects the recipient and recommendations from the Executive Committee for his or her extraordinary accomplishments and efforts to advance our field. Throughout his career, Reg has committed his time and efforts to well-known professional development courses on cadaveric cervical and spine surgery and instrumentation, his multiple scientific discoveries, presentations, publications, and frequent appearances as visiting professor, including his robust invigoration of our NREF and contributions to the NPA are really noted. But most importantly, most importantly, has been his outstanding commitment to the AANS and the members that we serve. And he has done this through unselfish servant leadership skills, which is a rarity. And his deep commitment to service. So as a true advocate, he's a servant leader, providing service, which he considers a calling, a lifetime commitment. Reg is not going away, okay? He's Reg here, Reg there, Reg there. And that's what we can count on because he's still committed to this for a lifetime. And he has a knack for saying to everybody with his favorite motto, he's paying it forward. So I want to say thanks to Mary Ellen and her entire family of children and grandchildren who adore Reg and for their ongoing commitment to neurosurgery because we know sometimes we can't always be home with our families and spouses. So thanks for letting us borrow Reg. The AANS is proud and I am enthusiastically honored to bestow this year's medal to Regis Haid, whose actions and commitments to the AANS and neurosurgery as a whole has left an indelible mark on the progress of our association and the patients we take care of. Reg, please accept this most prestigious award as we honor and thank you for astonishing work and service that you have given to our AANS and our specialty. You guys have the medal. Just so everybody sees it. Now we'll go over there. Thank you. Thank you so much. A few remarks. This is a team award, right? This is not an individual award. It's a team award. What this represents is actually what the AANS is able to accomplish on a multi-generational basis. And what's interesting is when I look at the, I call them kids, I apologize, when I look at the young adults today that are younger than my children and I see the diversity, I see the talent, I see the intellect, I see the commitment, it just brings me tremendous hope again of the multi-generational advancement. The team starts, you know, when you're in medical school, it's the team of your co-residents, it's a team of your fellow faculty, the team of your partners, a team of the fellows and residents that I teach, and the team of all of my colleagues out here that as a team, what we're able to accomplish and as a team what we're able to continually accomplish. I'd like to borrow a few of the things that Fred said this morning. So Fred and I met in 1991. I was offered a job at the Mayo Clinic. It was too cold for a southern boy. Fred had a full beard. We both had a full head of dark hair at that time. And I told Freddy after his talk, I said, you know, in 30 years we've come to the same place independently, or maybe not independently, but there's a book, The Purpose Driven Life, and the opening line is, it's not about us, right? It's not about us. And Fred talked about a level five leader or servant leader and he talked about that that's what we do is we serve others. And this is a couple of comments of the younger people out there. You do it one day at a time by staying in the present. So I'm a big sports guy. It's called the process, right? Saban calls it the process. So when you're, you don't think about the game, you think about lifting weights, you think about doing the push-ups or sprints or whatever you're doing to get ready. If you're behind by 20 points at halftime in basketball, you think about cutting it to 10, then to 5. If you have 99 yards to go for a touchdown, you don't think about the touchdown, you think about a first down, but then you think about that play, but then you think about making the block on that play. It's the same as surgery, right? You can't get ahead of yourself, and I teach that to the residents and fellows, you know, you do the positioning, you do the opening, and so you go A to B to C to D. And to the younger people out there, don't think about the journey, just think about what you're supposed to do right here today in this assigned task, and to get that task done well. That's what it takes. So it's servant leadership, it's process, then after you do the process, Jacques and I talk about this, right, Jacques, it's the flow. And after you develop the process and develop the habits, you find yourself in the flow of surgery and the flow of patient care, and that brings joy. Lastly, in 1759, Voltaire wrote a fable called Candide. There's a line in there I think is kind of interesting, it says, first we must cultivate the garden. What a simple turn of the phrase, right? First we must cultivate the garden. And I take that in two different ways, so I'm probably interested in how you take it. The first thing is I grew up on a farm. You got to do the work. The garden doesn't grow without going out there every day and cultivating the garden. It's daily work forever. And the second way I interpret that is mentorship, what Fred said. It's our imperative to give back the generations that follow us, right? That's tending the garden, that's cultivating the future. So again, I'm just humbled beyond belief. It's been an honor in my life. The greatest team that I've ever had is my family. I'm honored. Thank you. ["Pomp and Circumstance"] J.J. Abrams is one of the most sought-after directors and producers in Hollywood today. Born on June 27th, 1966 in New York City, Abrams began his filmmaking career as a teenager, creating super 8 millimeter films with his friends. After graduating from Sarah Lawrence College, he started writing screenplays and became a successful writer and producer for television series like Alias, Lost, and Fringe. However, it was his first release, however, with the release of his first film, Mission Impossible 3, that Abrams, as a director, achieved mainstream act success and became a household name. Since then, Abrams' unique style of storytelling and visual effects have been seen in films like Star Trek, Super 8, and Star Wars, The Force Awakens. He's also produced films like Cloverfield and 10 Cloverfield Lane, which have been critically acclaimed for their originality and suspenseful parts. J.J. Abrams' success is rooted in his ability to combine his love of science fiction with relatable human stories. Like J.J. Abrams, we as neurosurgeons must mix humanity as well through patient care, while driving innovation and advancing the science of neurosurgical practice. Please give a warm welcome to J.J. Abrams as he joins me in a conversation as Cushing orator. You are fully capable of deciding your own destiny. The question you face is, which path will you choose? In this world, you can be whoever you want. You can settle for a less ordinary life. Do you feel like you were meant for something better? Something special? We can be anyone. We can do anything. It's only a matter of going. You have a decision to make. Are you in or not? Of course we're in. I'm ready. So much happened here. So much is about to. The belonging you seek is not behind you. It is ahead. So we have a few questions for you today. And I know that, you know, we do a lot of technology in neurosurgery. It's really important to us. And obviously you do too. What are the most game-changing aspects of technology in the movie industry? And where is it now and where is it going? And then we kind of want to know how you stay on top of these trends and then master them in your movies. Well, thank you. First of all, I just want to say thank you. Thank you so much. And thank you all for having me here today. It's entirely unacceptable to me that you're facing me and listening to these words right now that I'm speaking. I'm in a room with the greatest minds. And my mother, who passed away almost 11 years ago from a glioblastoma, I got to witness firsthand the remarkable work of some remarkable neurosurgeons. And my gratitude to them and to you is limitless. So thank you for having me. It's an honor to be here today. In terms of technology, it's funny, there's all sorts of technology. There's the cameras that are being used. Obviously, digital filmmaking is most of what happens now. There's the technology that is involved in visual effects, as you mentioned, in special effects, things that happen on set. And the thing is, it's all about teamwork. It's all about having the people that you work with who know and are well-versed in everything that is new that's coming out. And it's also about your own passion and your own love. They say you are what you attend to. And if you love this kind of work, I think you find yourself, you can't help it, but you're researching all the time. You're always looking into what's happening. You're always finding what's new. One of the latest trends, and again, to any and all of you who already know all these things, I apologize. But there is a trend. I actually brought a little clip. There are these giant LED screens that allow... Let's see if this works. It used to be sort of like rear screen projection. Let's see if this works here. Nope, it's not that. That's for later. That's a fun one. Stand by. Let's see if it works now. Hold on. Come on, friends. No, that's me again. Here we go. Look, that's an LED wall. So what's cool about this is you can actually have characters or sets or props that are actually being lit by the environment. So instead of doing rear screen projection, having a volume and being surrounded by LED screens allow for you to do in-camera shots that used to involve and require green screen and blue screen. So that's like one of the latest and greatest kind of pieces of technology that's being used. But the truth is, it's all thrilling. And my favorite tricks are the old school ones, the ones that are the sort of tried and true, but sort of used in ways you don't expect. And a lot of times, using technology that exists that's new to sort of mitigate some of the things. For example, if you're doing puppetry, sort of painting out the puppet, the puppeteers, or if you're doing, you know, certain types of things that are, you know, where there are strings or wires or, you know, all the kind of old smoke and mirrors stuff is my favorite. But a lot of times the new technology allows you to add things. So, for example, if you have a character that exists as an audio animatronic, but you want to add some more life to the face, you can sort of augment things in post. And that's kind of cool. Okay. Then speaking of technology, it is so spectacular when technology and human motion come together at the same time in the film to kind of create a pinnacle of a dramatic moment. And I always think you're the king of this. The other piece is that in there's human drama people, you know, people feel that they're a participant in the movie and not just in the audience when that can happen. Could you show us a couple examples of how you maintain the importance of displaying emotional drama through an actor's character and at the same time be able to, you know, deal with flashy technology? Well, I have to say, I'm not going to name names, but there is a director who is a really wonderful action director, very, very well known. And his name rhymes with, no, I'm not going to tell you his name, but be rude. But I will say that he, I was shooting a movie and he happened to be on the next stage over. And I kept hearing these giant explosions that sort of kept ruining takes. And I walked over to see what was going on. And this person was, you know, blowing things up. And I mean, for the movie, not just for fun. And so I was talking to him about, you know, what he was working on. He showed me this long clip of this thing he was doing, and it was visually spectacular. But I found myself, to be totally candid, sort of unmoved, which is to say just, I wasn't, and it really got me thinking, why wasn't I feeling anything? And it all gets back to the things that we all know. And again, this is stuff that is sort of fundamental, but to say it, it's about the eyes. It's about the people, the behavior. And sometimes, you know, the technology doesn't need to be super flashy, but the technology is really important. It reminded me of a time not long after that, I went to go see a screening of Safety Last, which is the clip I'm going to show. And it's a Harold Lloyd silent film for the 1917. And he's climbing up the side of this building to the clock up on top. And it was at Royce Hall at UCLA. And it was about a thousand people, and the audience was screaming. And partly they were screaming because it was so much fun, and it's such a sweet film, and it's so good. And partly it was because of just what you were talking about. The humanity, the undeniable humanity of Harold Lloyd, and how he portrayed this character, and this technology that they were using. But I wanted to show this clip, if you don't mind. This is from Safety Last, I hope. See if it works. There it is. So this is the thing that we were watching. And when I tell you that the audience was screaming, it was the sweetest thing, and it was the most fun. And I remember, you know, this is before I sort of knew anything about Harold Lloyd. An interesting detail, by the way, about this movie is that this was 1917. He had been a very successful silent film star before, and he was doing a promotional shoot. And so he was doing this promotional shoot, and he pulled out this bomb, this prop bomb, and they lit it, and he was holding it in his hand, his right hand. And he said, you know, this is never going to be, no one's ever going to believe this. And the bomb exploded. It was an actual bomb that had inadvertently been put into a prop bin. And not only did it temporarily blind him, but he lost his thumb and first finger on his right hand. And this film was done years after that. And if you watch that clip, his right hand, he's wearing a glove, and the thumb and first finger don't exist. And he did this entire stunt doing that. But the beauty of this, to talk about the technology piece, was he didn't do this by hanging off a building the way it seems. He was actually across the street. And they built a facade of the building and shot it at an angle that gave you the illusion that he was actually risking his life. But the point is, it had the exact impact that any director aspires to, making an audience lose their mind and get lost in a sequence, believing it. Which, of course, is harder and harder to do, as we know that anything and everything can be fake. There's another clip I brought that is sort of in a similar vein. This is from a Modern Times chaplain. It's one of the great movies. So obviously, you watch that clip, and it's like, the performance of it, I don't know if it's the mirror neurons or what, but the thing that makes us feel and connect and click to that moment is his performance. And the technology there is similarly clever and of the era and low tech. It was a matte painting painted on glass. And it was a nodal pan, meaning the camera was just panning left and right so that it matched every time. But it's a remarkable thing to think about ways to perform the magic trick. And that's really how I see storytelling and filmmaking. And frankly, what you all do, which is to say, how do you create something that is impossible? How do you do something that is not possible? And what piece of technology do you need to do it? And then what element of humanity is required so that it works and you get the audience's involvement and investment? And that is always the balance that you're going for. Well, you know what's amazing? I've seen those since I was a kid, these clips, right? In fact, sometimes my husband and I look at stuff like this. I always get that feeling that, oh, I don't want to fall. There's an empathy each and every time with that drama, too. That's pretty cool. Yeah, agreed. All right. So we as neurosurgeons think of the final frontier as the brain because it won't ever be completely mastered. It just won't be. But Captain Kirk called space the final frontier, promising to explore new worlds, seek out new life and new civilizations to boldly go where no man has gone before. Do you think there's a correlation between the two phenomena? You know, I think that it is. First of all, what does Kirk know? I think absolutely. I mean, it's no accident that the search of outer space and inner space, there are constant discoveries. And that speaks more to the idea that I think anywhere we look and search and and and explore, the more we'll find. I mean, it's why, you know, junk DNA is constantly, you know, teaching us lessons that it's not, in fact, junk DNA. And and the idea and this is as, you know, obviously very much an outsider, but to see that that there are discoveries seemingly constantly about what's what happens with the brain and and the idea of whether it's silent synapses or or or the way, you know, memory is coded or, you know, there are things that are always being discovered, it seems. And it feels like as an outsider as well. Similarly, you know, and certainly the news, the James Webb telescope, the idea of what we can see now, how we are discovering what's beyond us. I think that it just speaks to not just the human need to understand more and to to search out and seek, whether it's civilizations or machinations. I think that anywhere we look, we're going to discover that not that we're in the dark ages, but that there's so much more beyond what we know always in any direction we look. Yeah, because somebody is going to sit here 30 years from now and think, wow, that was really, really primitive, right? I think that's true. But, you know, the other thing I was just thinking when you asked the question, too, it it's funny because even an episode or a film of Star Trek, for example, you know, for every Klingon, you know, or Borg that's discovered, it's like if there's nothing that's happening in terms of the characters and development and depth and discovery of who these people are, the film isn't isn't successful. The film isn't I'm not saying it can't be successful in the box office. I mean, the storytelling isn't as good. So the dream is not just that you discover something beyond you externally, but the dream is that you discover something inside. Sure. OK, good. Your role. Your role requires both creativity and logistic problem solving. How do you find ways to balance these two? And doesn't that often conflict conflict with each other in terms of characteristics? Well, you know, there's always something that goes wrong. And obviously, like in any profession, any profession, you do everything you need to to to put out the fire to solve the problem and to mitigate whatever damage might be possible. There are some that are sort of funnier than others in situations in my experience. One that was less funny was we were shooting a scene in Force Awakens with with Harrison. We were on the set of the Millennium Falcon. And just being on the set of the Millennium Falcon alone is just such a weird feeling. And, you know, and I was still kind of getting used to it. But we were there and the cast was there. We rehearsing a thing and Harrison was walking past and the door, the main door that slides open, goes down, which had been constructed as a fairly enormous and wildly heavy hydraulic door, was somehow inadvertently triggered as Harrison was walking under it. And it pushed him down and his left ankle snapped to the left and he pushed him down and it almost killed him. And he was literally pinned down and I was there and literally the guy who's playing Chewbacca without the mask on in the suit, but without the mask, he and I are trying to lift this door. Harrison is pinned down. It was the scariest, craziest, most traumatic and insane experience ever, which, of course, he recovered from. And eight weeks later, literally ran at me across the stage, you know, and I was like, Harrison, stop running. Please don't run. But he is an unstoppable force. But it, of course, screwed up everything. And that kind of a thing where it's a scheduling thing, those are the kind of things that, as you well know, it hits a million different dominoes. And yet there are often, when things are tragic, there are often upsides to delays and unexpected things that come your way. We were doing the Lost pilot. I remember there was a sequence where I storyboarded and figured out a certain way I wanted to reveal the discovery of the pilot of the plane. And in Hawaii, it rains all the time. And as soon as you have acclimated, it's not raining anymore. And then just as you take off, it rains again. And so we were shooting there and we got to the location we had scouted when it was dry. And it was a giant puddle, essentially. And then I thought, oh, you know, what we could do is we could use the reflection of the tree in the water. And anyway, it just triggered a thing that I ended up really liking and was a much better idea than what I'd had before. But it would never have presented itself, had that thing. The other thing, and I brought a clip from this, too. There's a sequence in the Star Trek movie, the first one that we did, if we can go to the screen. So there's a sequence where three of the characters, one of them is a red shirt, so you know he's about to die, are jumping out of a transport and diving towards this drill platform. Good luck. Away team is entering the atmosphere, sir. 20,000 meters. Approaching the platform at 5,800 meters. Kirk Enterprise, distance to target 5,000 meters. 4,600 meters from the platform. 4,500 meters to target. 4,000 meters. 3,000 meters. 3,000 bases. 3,000 meters. Pull and shoot. 2,000 bases. Come on. Pull your chute. All set. Not yet. Not yet. Hold your chute. All set. Pull your chute. 1,000 bases. I told you he was going to die. But anyway, so we were shooting that sequence. And it was, we had to do these shots of these characters diving towards this, the close-ups of their characters diving towards this platform. And we set this whole thing up and we hung them on these harnesses. And we had all these wires, which were, of course, in camera because they were being hung from this enormous apparatus. And as a group of esteemed neurosurgeons, you'll understand that when you're being hung upside down for a long period of time, it's not ideal. So these actors, and in fact, some of these stunt people who all fancied themselves, you know, incredibly strong and able to get through everything, started getting incredibly sick. And they were getting headaches. And some people were throwing up. And it was awful. And we tried and failed. So we tried it again with a slightly different harness and thinking we could hang them upside down for less of a period of time. And there was a very similar situation where it just wasn't working. And then I stopped and I thought, well, what the hell are the shots that we need? What does it need to look like? And I had this idea. And I went to our special effects people and I said, do you have any mirrors, like giant mirrors? And they said, well, we have these big Mylar sheets. I'm like, that'll work. So we set up these Mylar sheets on the parking lot floor. And we had the actors stand in the middle of the Mylar sheets. And we put a camera on a crane and looked down. And the sky was behind them. There were no wires to have to paint out later. We could just shake the camera a bit and they could just stand there. And it was the same shot. And it taught me a lesson, which is that sometimes the thing that you need, instead of looking at the thing so literally, how are you going to achieve the thing as you might expect, to almost remove yourself from it sometimes and ask yourself, what do you need? What do you need to look like? And how can you get that thing in an unexpected way? And we ended up having these actors who, of course, could stand there for hours and no one was throwing up and there were no headaches reported. And it was just the easiest way to do it. And, of course, later they added the chain that was holding the platform in post. But it was a good example of how sometimes, again, the lowest tech technology can sometimes give you the results that you need. Yeah, kind of a surprise too. Yeah. So neurosurgeons generally consider neurosurgery a team sport and no person is as good as when all our team is working together. What do you do to inspire your team to work together and keep them engaged throughout the entire project? And how do you work with, you know, we have different personalities too, so maybe you could explain that. Can you elaborate? No, no, no. I think that, you know, and this is me, you know, giving myself a compliment. I think that we do have quite a bit in common in that regard. I feel like what I will say is when I start any production, and this is really important to me because I just, I know that it all ultimately comes down to the golden rule of just treating others the way you wish to be treated. But I start every production with a group meeting with all the heads of production and that can be, you know, sometimes upwards of 100 people. But you have a meeting and it's always about reviewing various specific technical going through the schedule type things, which are, of course, critical and important meetings to have. But I always start by telling everyone as much as I desperately want to do something that we are all proud of and I want to make something that, you know, everyone feels like was worth their time and the audience's time. That perhaps even more important than that is that we all treat each other with respect and that we all approach everyone as a colleague and that we are all there to serve the story. No one is there to serve anyone else. And it helps especially when someone who's number one on the call sheet, which is to say the person who's sort of the biggest character, the biggest role, usually the biggest name in a film, when that person is a person of some decency and has a sort of ethical and moral compass, which is usually the case. But that meeting of just reiterating it's not. And I know, by the way, that now there are certain requirements that people do this, which is great. But I can't tell you how important it is that not only do that in the meeting, but then every day on set, you make sure that you are following that code. And I have to tell you, I have seen people when the sun is going down, when we're losing time, when there's a shot we need to get. I've watched crew members hauling equipment and I've, of course, hauled the equipment myself. But doing going above and beyond in a way that I think it does not reflect their paycheck. It reflects the culture. And I cannot tell you how important I think that that is to create a space where people feel like they aren't working for you. They're working with you to achieve something that you're proud of. Yeah, well stated. And that works for us better in the operating room team to, you know, developing a super hierarchy. And it just leads to problems, you know, so thank you. So how often does it happen when you're almost you're getting at the finalizing of your film and you go, oh, got to change a scene? Do you have to weigh the cost versus your artistic belief? Or do you think about this way ahead of time and you film something a few different ways and then choose later? And do you have examples of maybe how this has happened? And I know these are a lot of questions. OK, but also, can you have any serious regrets about a film, too? So, well, I have nothing but regrets. I don't know how much time you got. But beyond that, I will say that the you know, when I saw that question, I made me think of working on the The Force Awakens. And on that movie, I was lucky enough to get to write that film with Lawrence Kasdan, who wrote, among other things, The Empire Strikes Back and also Raiders Lost Ark and was an incredible director and has done just unbelievable movies. He was a real hero of mine. So to get to know him and work with him was an honor. But it was funny because he and I had a very different thought about not a different thought, but we had a different approach to this main character of Rey in the Star Wars movie. And I would always say to Larry, like at the beginning, when you first meet her and she's on this desert planet, what does she want? What is she thinking? What does she, you know? And Larry, who is again, I couldn't love and admire this man more. But he just he was like, very like, it doesn't matter what she wants. She's the star of the movie. She's the main character. She's going to just go. And I'm like, Larry, but like when I'm on the set and I'm talking to the actor and I need to be able to say something, you know, what do I? He's like, she's there. She's going to get caught up in the adventure. And she's going to end up like, oh, my God. But anyway, we never answered the question. And we were like there. We were shooting the movie. I'm in Abu Dhabi. And the actress says to me, so what does Rey want? You know, I'm like, call Larry. I didn't say call it, but but I was like, I, you know, I thought this is like so I brought a clip of this. If we could just put the screen back up. This is from Force Awakens. Very small clip. Don't give up hope. He still might show up. Whoever it is you're waiting for. Classified. I know all about waiting for my family. They'll be back one day. Come on. OK, so when she's telling BBA that she's waiting for her family, that was shot on the roof of our building in Santa Monica and everything else was done in Abu Dhabi. And that was one of the things that, you know, we realized I knew I needed something. We'd shot the whole movie and there were a number of things. There's probably 10 minutes of the movie that we shot at our building in Santa Monica and building small sets here and there, doing some green screen extensions. But that was which was just shot on the roof, bringing a little piece of the speeder and having some off camera dust and a fan. You know, it's one of those things that, you know, you have this giant production of literally thousands of people. And you're in our case, we're in the Middle East and it was just an insane situation. And then you suddenly realize you need to do something to answer a question, to plug something in, to do something important. And then you've got suddenly a couple dozen people and you're just shooting, you know, a few blocks away from the Pacific Ocean. And you're filming something that is a seamless piece of that puzzle. And again, I think it speaks to, at least in what I do, it doesn't quite matter where the piece of the puzzle comes from. And it's like being in the writer's room on a show. Like I don't care what someone's experience or credit or anything is. If they come with ideas that are working like they should be, they should run. They should be given as much responsibility as they can handle. Because I just feel like it doesn't matter where the puzzle piece comes from as long as you can find a way to make it. So what do you think about critics? Love them. I thought so. Here's the thing. There aren't really critics anymore. I mean, they exist and they're out there and there is Rotten Tomatoes. But the truth is, I don't know. I mean, it's the anomaly almost to not be a critic now. Everyone has the platform. So the word of mouth, the word of social media, it's like there is nothing but reaction. And the only thing I will say, and as someone who is, for better or worse, you know, waded into these waters of such passionate fan bases. There are people who, no matter what you do, will hate what you do. No matter what you do, will love what you do. And I don't think that either of them are right. But I get it. But there's so much, because of the anonymity, there's so much vitriol and so much anger. And I get that people are hurting and people are sort of afraid. And it's seen in so many different ways, you know, in our society. But I feel like there is an incivility that is, you know, this is not just about me, though certainly I've been the target of these kind of things. But that to me is the thing that is the worst. I have no problem with critics. And when they are known in accountable quantities, great. But when they are, you know, when there are these handles of unknown people who are saying things about wanting to kill people who have made things only to entertain. Or wanting to get revenge against them and their families because they made a choice that was an attempt to create something that hopefully they would enjoy with their families. It's just that is I think hurtful for everyone. And why you hear so many people saying I just don't look at, read or take seriously any of that stuff because it's a din. And it's hard to, so those critics I have fewer kind things to say. That makes sense. That makes sense. So anyway, movie going is a unique experience for viewers, of course. But what do you think is going to be the next movie watching experience? Both in the theaters or at home for that matter. I mean that's the big question. I mean obviously I love movies. I love going to the cinema. My wife is from Maine and we go to the movies in Maine. When you go to a movie theater that is not in a major city as I'm sure many of you have experienced. It's, you're hard pressed to find reasons to go other than oh that movie is not available anywhere else. And which is to say that this one particular theater makes things so uncomfortable for you that I'm convinced that their secret cabal is that they hate movies. And they are trying to like turn you off to going to, like you go there and it's cold and it's, and there's like no one there. And the sound is awful and the seats feel horrible. And it's just, it's so like to me I think the experience of movie going is in our DNA. That we need the communal experience. We need to be in dark rooms together. We need to hear stories together. And I think by the way you're seeing I think increasingly in young people a desire to have experiences that are real. Even some music. It's like people are going back to more deconstructed, less produced music. I think that there is a hunger for something that isn't virtual because so much of our lives are. And so I think movie going is going to I hope continue and I do believe that there are some companies that can afford to do so. That are going to be helping to make the actual movie going experience something that actually rivals the experience you can get in your living room. Because we all have big TVs with pretty decent sound and it's something that, it's sort of, that's sort of ubiquitous now. So we have to make sure that the movie going experience is, gives something, you know. It exists in a way that is comfortable enough that it can seduce people to leave their homes. Right and maybe give a little bit of different dimension than just a movie theater at home? I think so. And again, I would argue the communal experience, if the place is comfortable and the sound and picture quality is good, there's a thrill. I would say this. I don't know about you, but I can remember not all, but most of the movies I've gone to see, where I was when I went to see them. I can't tell you where I was when I watched movies on my phone or even at home or at friends' houses. When you go to the movie theater, it's an experience. It is an experiential thing that I think, and again, you would know this better than I, I think it creates memories in a way that something that is more habitual doesn't. Absolutely. So we have concerns about how technology is going to be changing neurosurgery. And I think some of us are concerned, is this going to potentially take away our basic skill sets from us that have been so fundamental? Even AI, we had talk about artificial intelligence Is that going to take something away? So the question is, do you find that the technology enhanced film production that we're experiencing now comes at the expense of possibly losing native instincts and creativity? Not yet, but it definitely is a concern. And I think it's probably a reality that there is going to be attempts at, I'm sure, successful ones. There will be attempts at, I'm sure, successful ones of storytelling that will be AI responsible. AI will be responsible for. It's not possible yet, and certainly within 10 years it will be, and probably much sooner, for someone to put in a prompt and then get back a piece of media, whether it's 30 seconds, 30 minutes, or two hours. It seems, though, that I was just at a conference and there was a lot of talk about AI. And one of the people who was there said to me, he said, yeah, but we get this too. And what he meant was, the people who are doing the work already are going to also have these tools to use. And it was kind of like an encouraging thing to think that that's true. I love the idea of democratizing creation, the idea that someone who has an idea for something can do it. I do think it's a little scary if they're saying, I want to see a movie that is, you know, and they put in a sentence or two and suddenly a two-hour movie is spit out. That is a vaguely horrifying prospect for anyone who does what I do. But I will say that the use of technology, one of the people in this conference was talking about how, at every critical stage, he believes that humans are going to be there and it will be the use of these tools to not just facilitate, but to, in some cases, perhaps improve upon or deepen or expand upon what the intention was. I do know that, as a writer, I've been using ChatGPT for research. It is often a lot easier, but a lot of times the answers you get aren't right. So when you actually question the ChatGPT, it then apologizes and says, yes, you're right. That's not true. And you're like, well, this was a waste of my time. But I do think that sometimes, I actually brought one more clip, the technology beyond AI, the technology is, I think, both threatening, but also something that's actually kind of inspiring. I just want to show you a quick clip here. CSRP. Cool. Two taco burgers and one regular. Thanks. Man. Hold on. That's cool, Doc. That's cool, Doc. So I brought that clip for this reason. It looks like something that perhaps Ridley Scott was doing for a new movie, some fairly giant production, something that was done by a major studio. But it was actually done by a guy named Ian Hubert, who lives in Seattle. And he used free software that you can just download called Blender. And everything that you just saw, he did with Blender. And everything that you just saw, he did himself. I will just show you, if you watch this, this is the clip you just saw on the bottom. And on top is what was actually shot. So everything in the clip below is in Blender, which is free software. And if you watch that guy who's on the sawhorse in the back, if you're wondering why he's there, you'll see in a second. The only reason that I'm showing this is that when I saw it, and this is something that I'm fairly familiar with, he's also the guy who's in that little booth that she goes to. I brought it because it was so inspiring to me that someone who had a vision for something was able to use software that didn't cost anything and create something that looked, that rivals what I think a major studio would do. And this is a whole series he's doing. This is just one shot. But it was so inspiring to see it. And what I love about this is the idea that technology is putting into the hands of people who, certainly, 10 years ago, 20 years ago, it would be unheard of for Ian Hubert to be able to realize a thing that he wanted to do, unless he was as lucky as I've been and actually get into the business that allows for this. But now everything allows for this. So I do think technology is a frightening thing. And I do think it is also wildly inspiring. OK, so as surgeons, we plan our surgeries in advance. And as a storyteller and a film producer, how do you envision a full story before you start your production? Or do you envision a full story? Yeah, but we have a script, which is the blueprint. And then we have the first AD, who's the first assistant director, who he or she goes through the script and helps with the director figure out how you're going to do it all. And then that gets scheduled. And inevitably, the studio says, no, it's too much. And you have to cut it down. And then you go back, and you deal with the box that you are given to, and you push back, and the box gets a little bit bigger. But then you want the box to be smaller, because there's no fun in it. I've been involved in movies that were way too overproduced and way too expensive. And that's no fun either. But I think that the plan is the script. And once you believe in the script, which is critical And I have been involved in a few productions where that was not the case. And then you're just doing constant. Then you're on the roof of our company's building a lot, shooting things that you wish you had done originally. But I think that the plan has to rely on the script. And then it's about having a great schedule to make sure that you know what your every day is. And then it's just, it is that weird thing. And it's probably very much like what you do in this regard, which is that it is entirely about the gut and instinct and knowledge and wisdom and a sense of things. And then an absolute sense of practicality. And whereas what I do, it's not life and death. But it is critical that you stay. I mean, it may be career, life, and death. And you have to make sure that you're sticking with the plan to some degree. But if you're not allowing yourself, it's not controlled chaos, but if you're not allowing yourself to, within the moment, call an audible or to know, you know what, I know that this was a plan. But I think something else, I don't have the clip. I didn't bring it. But there's one clip that is remarkable that it's from Poltergeist, which it says Toby Hooper directed it, but Steven Spielberg directed it, for real. And I've talked to Steven about this one shot in that movie that is this amazing shot. It's a three minute shot. It's in the hallway, and you start on a tennis ball. I recommend, just for fun, that you go and watch this clip because it's so good. But it starts on a tennis ball. And someone's writing a number on it because of the thing they're going to do in the house. And then there are, I think, seven people in the shot. And it goes three minutes all the way down this hallway until the very end. And it ends on a close up of this doorknob. And I watched that shot. I thought, this is just one of hundreds of examples of what Steven has done, where he had a plan. It was to shoot all these things, multiple shots. He got to the set. Everyone knew their lines. And he thought, screw it. Let's just do it as a one-er. And so he did this one shot. And because he's Steven Spielberg, he can and knows how and was able to. And it was brilliant. But when you watch it and you think, oh, my god, there are like seven or eight shots in this one shot. And it's three minutes long, which is considerable. It's so inspiring. And I'm sure that there are situations where you assume all of these steps are going to be taken. And you get to something and you realize, you know what? There's a better way. Or there's another way. And it may not happen often. But I feel like having that ability, and it probably should never happen with brain surgery. But my instinct is that that ability to always allow yourself to see the better way is probably a helpful piece of advice that I think I certainly need to remind myself of. OK. All right. So last but not least, as with other industries, neurosurgery has been diligently working to improve our diversity, equity, and inclusion in our field. I understand in the wake of the hashtag OscarsSoWhite controversy, and your production company, Bad Robot, instituted a policy to ensure people of color and women always make the final short lists for openings. Can you elaborate on how your efforts are going? And do you think Hollywood is making strides in DEI? And particularly, as it relates to female directors, especially given that the Oscars failed to nominate any women for directing this year, following two consecutive years of women actually winning in a category? You know, I think it is so important. And the idea of people who, at least historically, have not been given the chance to express themselves and tell their stories has only hurt the offerings that Hollywood puts out. And luckily, with streaming, and if anything, there are too many shows being made now. And my guess is that that sort of corrects itself, too. But that has given an opportunity for a lot of people to tell stories that, at least in terms of the films, they might not have been given a chance prior. It's very weird, though, because I think movies have become TV, and TV have become movies, in a way. Like, when you think about the movies that are typically made by studios, and there are, of course, exceptions, they are part of a big series. They are usually big family, you know, whether it's Marvel films or Star Wars. And I understand that I'm as responsible for this as anyone. But the film business has become such an IP content, sort of series-minded thing, whereas television has really gone to places where there are some amazing limited series. And even though they are series, there are great characters. There's daring storytelling being done. There's just wonderful, as cinematic as anything, filmmaking being done. And especially given the freedom to sort of not worry about either commercial breaks or language, there's been, like, it almost rivals what was happening in the 70s in cinema on television. The kind of storytelling that you're seeing if you curate what your selections are in TV. So that is a great thing, that people are being given more of a chance. I do think, though, that there was a moment where everyone was on their best behavior about this and starting to realize we've got to change the way we do this. And that was kind of great. I'm feeling that that's not quite as front of mind anymore, and that people are, it's sliding back a bit. I'm not saying that there isn't and aren't great efforts being made and don't need to be. At Bad Robot, we are, it is a value of ours. My wife, Katie McGrath, who's a co-CEO with me, this is something that she had this idea, which was a great, imperfect, but like a beginning of a solution, for us at least, is a step, which is that whenever we're going to hire anyone in any capacity for production or at the company, that the people we are interviewing look like the population of the country. Which is to say, make sure we are seeing people. And by the way, you don't always, and there's no mandate and there's no requirement that certain people get hired, but it's literally about making sure that you are actually opening the, you know, widening the playing field so that you get more options. Because there is this sense of just going to the usual suspects and looking to the people that you know. And that can be, that can work. I get that, and I understand it. But there's often a more narrow sense of ideas or life experience or attitude or personality. And I just think that it's opened us up to storytellers that we otherwise wouldn't have worked with, executives we wouldn't have worked with. And it's something that we find has helped at least mitigate some of the things that we were absolutely guilty of and responsible for years earlier, where we wouldn't look as widely as we could have. And we found ourselves actually limiting ourselves. It's better for business when you have people that have a diverse life experience and point of view working together with you. Well, that's a joy to hear, because sometimes people don't understand that. But I think we agree with you here as neurosurgeons. We like that enrichment, and it broadens our scope. And of course, we're serving people. So we like to have our neurosurgeons look like the people we serve. All right, well, thank you very much for being with us. This was great. Thank you so much. All right, thank you. Thank you. Thank you all so much for joining us. We ask that you continue our spirit of inquiry and innovation in the exhibit hall. We have Lunch and Learns that span everything from mastering complexity of spinal surgery to techniques in dural repair and robotic navigation and surgery. And then join us for our scientific sessions this afternoon. Thanks so much. Thank you.

Dr. Odette Harris

neurosurgeon

diversity in medicine

neurosurgery

neurosurgical trauma program

Stanford University

Fred Meyer

leadership

advocacy

Dr. Russell Andrews

underserved areas

global neurosurgery initiatives

J.J. Abrams

technology in film production

diversity and inclusion