Good morning, everyone. Here's the disclosures and the research. Wow, there's a lot of hype in regenerative medicine. Thousands of clinics are opening up, and I'm sure at least 10 in your community. But the difference is, many of them are not orthopedic surgery clinics. There are other subspecialties that are coming into this regenerative game. But the truth is, patients want it. There is a proposed market cap here of $45 billion by 2021. So the need is there, at least to discuss it. But this morning, I wanted you guys to experience firsthand the hype that's happening outside of Anna. This is an undercover investigation that was done in Chicago. Please listen to what's being said to the patients. All right, we didn't get the audio right in the back. This is critical. Can you start it again, please? Sorry, guys. Here we go. We'll go in and regenerate that tissue that you're missing. So you can get new cartilage. You can get new knees. You can get new shoulders, new nerve. Describing how stem cells repaired her injured right ankle. I can jump up and down. And on an x-ray, I have an ankle joint again on the right ankle. inside where before I didn't have one. If you have type 2 diabetes it can regenerate your pancreas. We just had a woman who has epilepsy and we injected the nose area with some stem cells and they went directly into her brain. I'm told that there's no proof that stem cells, as you are suggesting, actually work as you describe. So who said that? You got to consider the source. Perfectly said. Well what makes it worse is the stem cells aren't really stem cells at all and they're adult versions of the true stem cell and don't even meet the definition of a stem cell at all. What's worse is that there's new subspecialties that have been formed. These are non-operative orthopedics doctors who are positioning themselves between the patient and the surgeon. This has been a mess and Anna has been at the forefront of fighting this battle. The Biologic Alliance has been formed and again Anna is front and central. In fact, under the leadership of Lou McIntyre, there's been the Alliance State Advocacy Program that has been formed. These are surgeons from every state of the union that are going to be working with the medical and surgical boards to help combat these comments that are unwarranted and unsafe, unscrupulous clinics. So let's get to the update of the biologics. PRP, remember, comes in at least two different forms. A leukocyte poor, which is green, which is anti-inflammatory, and leukocyte rich, which is purple here, lying, which is inflammatory. Here is the level one evidence of the uses and current indications for PRP and let's examine these closer now in 2019. If we look at a recent review by Dave Flanagan, it shows that PRP therapy averages a response rate of 55 percent. Really? We're flipping the coin? And so what we have done is gone back to the laboratory to figure this out. We have harvested stem cells from normal tendon and tendinopathy tendon and we discovered something big and that is these stem cells supposedly are not able to make tendon tissue. So what we have done is we have gone back and we've looked at the biologics, we've looked at the PRPs and indeed they are not powerful enough to reverse the machinery problem in tendinopathy and only one thing was. BMAC. So please stay tuned for additional clinical studies using BMAC and tendinopathy. Does PRP lead to muscle regeneration? Level one evidence suggests the answer is no. We went back to the laboratory and it's the third column in. PRP doesn't do anything to the muscle stem cells. But if you take the platelets out of PRP, otherwise known as platelet-poor plasma, you can actually make muscle tissue in the culture flask. Here is the animal trial showing bridging regenerate muscle through created defects and muscle problems within the animal and that is in comparison to PRP where you see the standard fibrosis. Here is where we're using this in our athletes. Platelet-poor plasma two weeks after injury and although they're getting back to play in the standard time, we see that with a follow-up MRIs there is no more scar tissue plane. What about PRP and osteoarthritis symptoms? Does it work? Yes. Are there caveats? Yes. You must use a PRP that is non-white blood cell containing or anti-inflammatory based PRP. And it tends to work better on the patients with osteoarthritis who actually have a component of inflammation. That is effusions, reactivity with exercise, and morning stiffness. Everyone wants to know what is really behind stem cells. Is this hype or is it reality? Plenty of good data to suggest that these progenitor cells actually produce pain relief and they do so by activating opioid receptors. Other than that they are strongly anti-inflammatory and they do so by modulating the immune response. So we do say that there is strong favor that in the future stem cell therapy is real but as of this year it is unknown whether or not the stem cells can actually rebuild our cartilage or the pancreas as the one other doctor suggested. Types of stem cells are either the bone marrow stem cells or the adipose derived stem cells. With the rotator cuff use of stem cells from BMAC, one study by Hernegau suggests that it works. And the rotator cuff repair weight is double than that if you don't use the cells. The problem is this study may be biased and so Nikhil Verma and Brian Cole are doing a follow-up study with some interim results of 30 patients per group suggesting a slightly higher healing rate with the cellular group versus rotator cuff by itself. BMAC and the use of osteoarthritis has shown no improvement in comparison to saline. The problem with these studies are that the patients improve rather substantially with just a saline injection so it's hard to prove that the BMAC was better. That being said too when you look at the different machines that are available, this is the partial list, the point was that all these machines produce a different kind of BMAC so we really need to be careful to choose a product that we want for the indications that we're trying to use it. There is a good study to show that if you use the ACI technique, a mini open technique, that you can regenerate cartilage if you use a patch and the mini open arthrotomy. Adipose tissue can be harvested from the abdomen and from the knee and but if you do so always fat tissue needs to be fractionated. It needs to go through syringe emulsification on the left or a ball bearing system on the right so you can harvest 20 percent of the usable cells that you can use for your therapy. Reasonable results, three randomized control trials all showing adipose drive cells work to improve the symptoms of osteoarthritis and only this study shows that you can regenerate some cartilage as well. Here's the follow-up MRIs and I know it's small but you can see the increase in the regenerate of the cartilage. Amniotic fluid at this time is hard to recommend and the reason is because the delivery suite there's plenty of good cells and growth factors but by the time you sterilize it and place it on the shelf it is hard to really get any benefit out of those growth factors and there's no usable cells remaining. So there's lots of hype and recent emerging results. Stay tuned for improvements in biologics which are sure to come around the corner. Thank you.

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