On behalf of the McLean Center for Clinical Medical Ethics and the Department of Pediatrics, I'm delighted to welcome you to today's Festrift Honoring Bill Meadow, Professor of Pediatrics and the Director of the Neonatology Fellowship Program. Bill is one of the great clinician scholar educators in the field of neonatology. In recent years, his research has focused on ethical issues in neonatology and has examined questions about resource allocation and informed consent in the NICU. Bill has been the key contributor to our knowledge of prognostication in the NICU setting. I wonder if you'd all join me now to recognize Bill Meadow and his achievements. Bill and I go back a long way to the early 1980s when he was just finishing his fellowship training here at the university, but we really came to know each other when Bill trained in ethics at the McLean Center in 1993-94. We really came to know each other then. The Center hasn't quite been the same since. Bill's involvement made a dramatic difference in the Center's teaching programs and especially in its case conference model. For 10 years before Bill arrived in 1993, the Center's weekly case conference had been a good conference, not unlike many conferences held each week at our medical center and at other medical centers around the country. Bill came along in 93 and suddenly transformed the conference with a vigorous, no-holds-barred debating style in which every voice was heard and in which adversarial verbal exchanges, almost all of them, civil and respectful, became the norm. The air was filled with these intense exchanges, caustic words, seal-tipped irony, and always humor to lighten the burden of making tough decisions where there was no absolutely right or wrong answer. When fellow applicants from around the country visited us at the ethics conference, they would often say to me, gee, Dr. Siegler, I've never seen anything like that. That was wonderful. Bill had changed the conference from a staid, conventional academic meeting to something that was rich, vibrant, thrilling weekly event that no one wanted to miss. Bill and Sue McCrae were in the same fellowship group in 1993-94. That year, Sue, who couldn't join us today, took very careful notes of Bill's comments at the weekly conference. At the end of the year, Sue designed a T-shirt that included some of Bill's views on ethics on the back of the T-shirt. Recently I found one, maybe the only one, of the remaining T-shirts. I show you the back of the T-shirt. These were things that Sue had written down that Bill had said during the year, different ways in which ethics might work in the setting. You won't be able to read all of them, but we'll make this available afterwards. Some of you don't know, Bill and I would occasionally, very rarely, just occasionally disagree over an issue. One of our favorite arguments, an argument that went on for years, centered around the issue of slow codes. Our arguments were intense and always polite, but it was clear that we differed fundamentally about the issue of slow codes. And finally, Bill had had his full of just verbal exchanges with me, and in 2011, he and John Lantos published two powerful, and I must say I'm rereading them pretty persuasive papers. One in the American Journal of Bioethics, and another in Acta Pediatrica on the topic, should the slow code be resuscitated, papers that I call to your attention. And speaking of resuscitation, it was Bill's work with Dr. Lantos, Jesse Hall, and an outstanding team of medical students, residents, fellows and faculty that Bill had assembled who resuscitated the fields of prognosis and prognostication. By using empirical data to resolve questions that previously had been examined without clinical evidence. For thousands of years, the diagnosis and prognosis were really all that physicians had to work with. Medical and surgical therapies were largely ineffective or outright harmful. But the savvy physician, I go back now thousands of years, who had seen cases like the one this patient had, could prognosticate. That is, could predict what the outcome of the disease might be. Traditionally, prognosis was less data driven than experience driven. Alvin Feinstein, a graduate of our college and our medical school, wrote in the 1980s that the most important clinical paper of the past 150 years was one on prognosis, published in the New England Journal of Medicine by Jacob Bigelow in 1835. A paper entitled on self-limited diseases. For Bigelow, the concept of a self-limited disease then created a large fertile area where diseases were not self-limited. And that allowed physicians to intervene to improve patient outcome. Feinstein has said that Bigelow in 1835 had revived the central concept of prognosis and in doing that had established a research agenda for medicine for the next 200 years. And then along comes Bill Meadows' work on prognosis only 160 years after Bigelow's publication. And Bill's work on neonatal ethics and prognosis extended the research agenda that Feinstein had referred to. Bill gathered data from many different sources to help establish prognosis in newborn infants. In 2008, he and John Lantos co-authored a book entitled Neonatal Bioethics, The Moral Challenges of Medical Innovation, a book that already is considered a classic in the field. Let me conclude by thanking Bill for all of us, for his great contributions to pediatrics and to neonatology, for his unsurpassed work as an inspiring teacher and mentor, and for changing the McLean Center and its programs. I now would like to introduce Dr. John Cunningham, the chair of the Department of Pediatrics. John. I'm proud of the University of Chicago and the Department of Pediatrics. I want to welcome you all here to honor our colleague, Dr. Bill Meadows. I decided when I came here today that I wouldn't wear a tie. Most of you who are in the Department of Pediatrics know that every event when I decided not to wear a tie today, to honor Bill. Because I don't think we know them with a tie, actually. So I decided that it was important that I honored him that way. I also decided not to discuss soccer, which he and I have discussed on many occasions. And unlike Mark, I don't have a picture to show you today. My favorite picture of Bill is walking down one of the corridors in Comer with an Ireland soccer scarf on. Seriously, I came to university approximately nine years ago. And during my interviews, I didn't meet Bill. But shortly after I started as a section chief here, I got to know Bill very well. I got to know Bill because the Department was in a period of a significant challenge. And as a co-section chief of the section of the Anatology, Bill would come to Section Chief's meetings where he would actually debate extremely strenuously about not only the need for strengthening the Anatology program and defending it, but also defending the Department of Pediatrics. In my view, as I contemplated what I was going to say here today, I would absolutely indicate that Bill is a small compass for our department. He provides us with the backbone and the rigor when we actually are thinking about every child. And I want to honor him by saying on behalf of my pediatric colleagues that Bill is a really important part of our lives. And I'm really honored to be here today to speak to his honor. Thank you, Bill. Thank you, Martin, John. Our first of the official best-drift speakers will be Professor Lainey Ross. The Caroline Matthew Boxquam Professor of Clinical Mental Ethics and Associate Director of the McLean Center. Lainey has written a number of books. She's probably the best-known voice of pediatric ethics throughout the country when my students in Kansas City heard that she's coming to give a thought here. They were going to say, Martin, can we touch the animal first? Sure. That's one of the most powerful voices back with the poor children and someone who has been fondly known by Bill for many years. Lainey, we've learned a lot. Welcome. But you are wrong. What a privilege to be invited to talk about my friend and colleague Bill and what he has done for neonatology and ethics, both locally and globally. Bill did the ethics fellowship in July 93 to May 94, and I arrived in July 94, so I get no credit and I take no responsibility for what he knows or doesn't know in ethics. Rather, I speak as a colleague and friend for over 20 years. Today I'm going to talk about three of Bill's most important contributions, his contributions at case conference to medicine in general and other contributions. So on the day I arrived, Diana Wu came racing into my clinic.  She wanted to make sure all new faculty were welcomed immediately and offered any help I needed navigating the university system. I could still use her help. What a wonderful colleague and networker she was. When she heard I was interested in ethics, she said, well, then you must meet Bill Meadow. Only a few weeks later I did meet Bill when we participated in ethics case conference. Bill arrived in W732, a room we have long since outgrown, about 10 minutes into a case discussion, wearing his cowboy hat and glasses hanging by a rainbow crokey. Greg Sacks stood at the front of the room. The case involved an elderly gentleman in his late 80s who was intubated on pressers unconscious with minimal prospect of clinical improvement and no prospect of neurological improvement. The question for the ethics team was to determine the appropriate course of action. The case involved the conflict between the healthcare team and the family. Greg wanted to follow the patient's wishes, which weren't fully clearly articulated but could be gleaned from his interactions with his primary care doctor. And Bill wanted to follow the wishes of the family. Greg was getting angry and angry that the patient's autonomous wishes were being ignored. Bill responded, I love you, Greg, but you're wrong. This would be a phrase I would hear many times myself as Bill and I butted heads in case conference time and time again. Bill eloquently explained that there were times that medical decisions were more about the family than the patient. I listened in fascination as Greg kept reverting to bioethical principles of autonomy, substituted judgment, and that the patient, not the family, should determine a patient's quality of life. And Bill defended his position based on intuition and emotions. This was a classic debate using Colberg principles and Carroll Gilligan's relationships. It was a debate about the proper aims of medicine, the dyadic doctor-patient relationship, and the family. Now, to be honest, I found Greg's arguments persuasive. And I'm glad that we did respect the old man's wishes, but we only did so after the ethics consult team had convinced the family that they wanted to follow his wishes. So in his own way, Greg did advocate for a family approach. The family, that is what Bill is about in ethics consultation and case conference and in life more broadly. How many times have you heard Bill introduce himself as Xander, Shmug, or Beanie's dad, or as Susan's husband? The family, it is the crux of Bill's approach to both pediatrics and ethics. And in pediatrics, Bill and I mainly actually do agree because pediatrics is not a dyadic patient-doctor relationship as classical bioethics teaches. Rather, pediatrics is a triadic relationship involving children, patients, and physicians, children, parents, and physicians. Bill and I agree that the central figure is the child. Now Bill's area of pediatrics is very specific, the premature or critically ill infant who cannot speak for him or herself. And so we rely on the parents to speak for him or her and to define his or her interests. Now it may surprise some of you, but who counts as a parent is more controversial than it may seem. And I'm not talking about IVF and surrogate moms or donated gametes. Rather in Illinois, the woman who gives birth to the child is the mother, unless she relinquishes her right. A man is the father only if he's married to the mother at the time of birth or if he signs the birth certificate, which he can only do if he agrees and the woman agrees. Now signing the birth certificate gives him parental rights and paternal responsibilities like paying child support. Many of our neonatal patients have only one legal parent, mom, although there may be many parental-like figures from dad to grandma at the bedside. And so mom is the only one who gets to make decisions for the baby. I hear Bill now, Laney, I love you, but. Bill does not approve of my focusing on legal parentage because what he really wants is to create a family consensus on what is in the child's interest. And I agree, that's ideal, but I do focus on legal parentage because it does and should impact on who has final authority. This is not to suggest that we should ignore the dad when available, nor should we ignore the grandparents, but it is to say when consensus cannot be reached and those are the cases that come to case conference, it is the legal parent or parents who have the responsibility to decide what is in the child's best interest. And it is the legal parent who gets to determine which other voices are heard. I think Bill and I agree that the legal parent shouldn't ignore all non-medical interests, nor should she ignore the interests and needs of other family members, but only to say that the child's medical interests are paramount even if other interests are legitimately considered. So I went and put Bill's name into Publisher Perish, an online scholarship assessment tool, and it gives you an H-index, which is an author-level metric that attempts to measure both the productivity and citation impact of a scholar's publications. It gives a G-index, which is an index for quantifying scientific productivity based on publication record and lots of other data that may or may not be useful. And here's what I learned. Bill's most cited article was entitled, Changes in Mortality for Extremely Low Birthweight Infants in the 1990s, Implications for Treatment Decisions and Resource Use. This article focuses on one of Bill's major contributions to neonatal ethics, and that is on the inaccuracy of prognostication, whereas we learned at CHOP, the Children's Hospital of Philadelphia, where we both trained about a decade apart, we learned never trust a creamy to follow any predictable pathway. Creamies will always surprise you. And Bill's data show that despite comments that neonatal intensive care or NICUs are expensive, they save a lot of lives and are a bargain when one looks at cost versus life year saved or quality of life year's gain. So we should acknowledge Bill as the premium advocate that he is fighting for their fair share of resources, which he did at Ethics Consult and as Dr. Cunningham suggested, he also did it often at pediatric faculty meetings. But Bill's advocacy doesn't stop when they leave the NICU and here Bill's contribution, while less well cited, is also very important.  Bill's work, like Diana Wu's work, engages the premium in the NICU follower clinic. Much less sexy work, less financial incentive than intensive care work and yet really important because graduates of neonatal intensive care units still have a lot of challenges to face. And so once again, a thanks to Bill the advocate who speaks for one of our most vulnerable populations, children who cannot speak for themselves, particularly for those whose parents have neither the resources nor the skills to fight for them in the public arena. Thank you, Bill. And then I wanna point out Bill's least cited article. Bill, we're glad you switched from piglet physiology to neonatal ethics. So let me ignore how an online impact factor metric evaluates Bill's work because there's a lot of controversy about their validity. Instead, let me share with you two other articles of Bill's, my favorite article and my least favorite article. So I'll start with my favorite article and it's entitled, ought standard care be the standard of care. In this article, Bill and colleagues examined when to start antibiotics in the emergency room for a child presumed to have a serious infection like meningitis. Bill and colleagues showed that at two premier pediatric institutions, unnamed in the city of Chicago, the median time until the initiation of antibiotics was two hours. And then he queried infectious disease physicians and emergency room docs and said, how long do you think it takes from the time a child presents until they get antibiotics? And the emergency room docs thought a median time of 46 minutes and the infectious disease docs thought a median time of 80 minutes. That is, both thought it took significantly shorter time than it actually did in the real world. So Bill and colleagues explain why this discrepancy is so important. When an outcome is bad and the family goes to court, the ethics, the experts will claim that the hospital failed to treat the patient according to quote standard of care because it took longer than what the experts would expect. Bill and colleagues argued that standard care should define standard of care. So why do I love this article? I assume that Bill researched this article after a thoughtful, careful colleague was sued for events beyond his or her control. And Bill is at heart a pragmatist. He's a practicing clinician in the real world where getting antibiotics can and usually does take longer than one might ideally hope. Bill concludes the article with this sentence, medical expert testimony that has no basis in reality ought not to be credited. So Bill advocates not only for premies but for his colleagues as well. We owe you another thank you, Bill. My least favorite article is Bill's work on the slow code. Now we all know what a code is from the myriad of TV programs in which patients almost die, they're resuscitated or coded, and at the end of the hour, they're back at home or at work resuming their normal life. Sad to say that's not how it works in real life. John Lantos was an author on a paper examining codes on TV versus codes in real life. In the study reported in the New England Journal of Medicine, researchers found that over three-quarters of patients receiving CPR on TV programs like Chicago Hope, ER and Rescue 9-11, they survived their immediate cardiac arrest and all but one survived with no long-term disability. In reality, fewer survive and even when they do, some die shortly thereafter or suffer permanent neurological damage caused by their disease or by the rescue effort itself. But the public knows that CPR is effective from their TV experience and so even when physicians explain that CPR will not be effective in your mother, flash sister, or cousin at this time, family members demand it. So what should we do? Bill and John offered three options. One, perform a full code that is messy, virtually always unsuccessful and leaves healthcare providers feeling moral distress. Two, override the family by getting an ethics and or a legal consult and ordering a unilateral do not attempt resuscitation order. Or three, provide a slow code, a symbolic gesture of a code without doing all the real heroics. That is, maybe do a few chest compressions, maybe give a round or two of meds, but do it slowly and stop it quickly. Bill and John support option three on the grounds that it gives the family what it wants but does not distress the healthcare providers. So they view it as a win-win. I disagree and I disagree strongly. I don't think the slow code respects anyone. The family has requested. No, they've demanded a full code because even if unlikely, it could work. They've demanded a full code, not a parody of a code. The physicians who are being asked to participate in a false code should be morally troubled by lying to the families and by causing any harm to the patient when the treatment is useless. I hear Bill saying once again, as just as if we are butting heads in case conference, Lainey, I love you, but you're wrong. Bill's other key contributions to the McLean program, the university at large and the wider hard park community is his role as a mentor. A large number of NICU fellows do the McLean Fellowship and do ethics research. Many co-authored with Bill. Pritzker Medical students work with Bill through the summer research program and again, many publish with Bill. Bill also mentors and collaborates with many peers at UFC around the country and as we will hear today from peers around the world. And it's not only pediatrics and neonatal ethics that Bill is a premier mentor, but it's also in his role as soccer coach, dad and friend. Bill is an effective mentor because he teaches by example. He always has a smile, a kind word, a supportive gesture. He's an effective mentor because he loves what he does. So I'm looking forward to hearing from the other speakers, many of whom who have worked closely with Bill clinically in the NICU and others who have collaborated with him in his research. For those who attended case conference, you have seen Lainey and Bill but heads a lot. On the note of butting heads, let me end with a final slide. I love you, Bill. I love you, Bill. No buts. I'm delved into these crucial studies with Dr. Meadow Moore as the afternoon goes on. So we're going to hold on a question for this one and introduce the next speaker, Tyler Grimes-Chisell, who was undergrad at University of Chicago, did some early research with Bill. And then I'm sure because of Bill's excellent mentorship, went on to complete residencies at Johns Hopkins University, after his child neurology and clinical and biochemical genetics. Now is at Vanderbilt University as vice chair of education in the Department of Peace. He's won numerous outstanding teacher awards but the most interesting thing that I found a book in New York online was your invited back to your high school to give the commencement address in 2002. It was surprising, right? Or good afternoon. Thank you, John, for organizing this. It's a pleasure to be here. And I'm gonna say, as John mentioned, I experienced working with Dr. Meadow as a college student. And so my comments are going to be based through the lens of a college student. And it was about 25 years ago. I started college when I was just finished third grade. And so it's really been fun for me to think back. It actually wasn't too difficult to come up with what I wanted to say because I actually have been repeating a lot of what you taught me since that time. So while working with him, and I'll tell you a little bit about the work that I did while I was a college student with him, I had the opportunity to go to the NICU and do rounds. And so I really think that at least this portion of the talk should be subtitled. This is a college student. Show him all the respect he deserves, which is none. And that's what he would say when there was a group of us actually, maybe three or four college students who were part of this early lab group. And we would go and NICU rounds and I literally knew absolutely nothing. And I remember saying, I feel so dumb.   I'm like, okay, thanks for clarifying. So I graduated in 89 and shortly thereafter when I came to USC, I began working with him. So the work that we did that John mentioned was predicting survivability of extremely little birth weight infants. And the publication that we had several years later, I think it was in 2006, was basically saying that the best predictor of survivability was whether or not they were alive. And... But it got published. What was interesting is it was on Day of Life 4. So if you were alive at Day of Life 4, you were going to continue to live and you may be in the NICU for a long period of time, but those who passed away did so early on. And it meant that we should continue to invest in them. And so I think that that was a pretty cool experience. What it led to for me was after I went into residency in Baltimore, I became part of the Hopkins Ethics Committee. And I really believe a part of the reason I was selected as a resident was based on my experience with this publication and also with my experience working with Bill. And then I had the opportunity as a junior faculty member to be on the Ethics Committee for the Academy of Neurology. And again, I could write about my experience, not just the knowledge part that I learned in a lot of excellent courses here at USC, because I was a history and philosophy of science major, but also what applied ethics looked like in somebody who was a clinician. And so it had a long lasting impact on my career. But there were some other things that I learned as well along the way. One of them was work-life balance. We didn't call it work-life balance back then, but that's what you were modeling for me. I remember I think it would have probably been the lab school going to pick up your daughter and talking along the way. And I always saw how important family was to you. And that was really important for somebody who was going to have to learn how to manage the demands of medical school and residency and being a faculty member. And that was pretty awesome to see. I also learned about personal health maintenance. So I remember walking into the hospital one day and Dr. Meadow was passing me. He's like, oh, walk with me. Right, walk with me. It was more like run with you, right? And so I don't remember what the building was. Hannah Gray was the president.  And it seemed like she was on the 13th floor somewhere. I don't know what floor it was. And so we go into the building and I'm looking for the elevator, but we took the stairs all the way up. Well, I'm covering all my textbooks. And we got to the top. I was still had a pulse and was breathing. And you went into the meeting and he's like, great. And I was completely out of breath. And I thought, this is really important.  So I knew it, walk with me. While I was fourth year in college, I got engaged, which was surprising to me, actually. That happened. And I remember you saying, you got married pretty young too. I was 22 at the time. My wife was, wife to be, was not quite 20. And so, whoa, right? And so you said to me, you're too young to get married. And I was like, how old were you? He's like, it was a different era. So the next time I saw you, I was working at a computer doing our, it was a retrospective chart review that we were working on. And you saw me and you said, yes, dear, yes, dear. I don't understand that. And then the next day, same thing. Instead of hello, it became yes, dear, yes, dear. It's like, you need to practice saying that. It's been the best marriage advice I've ever had. And it's worked. This is my family. So I have five children. My oldest is 17. That's Elise. Elise, Caleb, Moira, Justin, and Leah. And this is my wife. She looks like one of my kids here, but this is Teresa. Teresa says hi too. She remembers hearing about you when we were courting. And so she knows how much you meant as I was going through med school. And so she says hello too. All right, career advice. So I went to med school here at Rush and then I got into residency in Baltimore and I started getting really interested. I knew I was gonna be a child neurologist, but I started getting interested in metabolism and biochemistry. And I remember coming back, my wife's family is from Evanston and so we must've been visiting family and I stopped off in your office. And I said, you know, I think I wanna do genetics after I do neurology. And you said, what the? And then, why would anyone wanna do that? And so I was lamenting how much time that was gonna take me and what I remember you saying is Tyler, if it's what you love doing, who cares how much time it takes you to do it? And that's how you lived your life and how you did your work was, if you love what you're doing, and I could see that. And so I went into genetics and I work as a biochemical geneticist and child neurologist now and do a neurogenetic clinic. And I love what I do and I'm so glad that I didn't listen to a lot of people saying it's a lot of years and you're really gonna do that and you're gonna make less money than if you wouldn't do it, and which is all true. But it was really good. I also, again, I didn't know this at the time because I was just a college student, I really didn't know what rounds looked like. But when I started working in the NICU as an intern in pediatrics, I could reflect back on how you did rounds in the NICU and how the rest of the planet did rounds in the NICU. And it turns out you don't do rounds in the NICU by constantly walking from one bed to the other and never stopping. And I could remember the interns running after you, trying to get all the data points out before you had gotten to the next child. But when you did stop, it was, and I remember this case where you were there as well, we were in a circle talking about a baby in the NICU and doing ethics rounds in the NICU. And that was pretty awesome experience. So the data was not always as important. I think what you would say is I only want to know the data that's important as a resident that makes you very nervous because you don't really know what that is important. But the ethics part was pretty interesting to see modeled. You also had some interesting teaching strategies. So, John mentioned I'm now vice chair for education. I do a lot of teaching in the med school. I teach metabolism and genetics at the beginning of first year medical school and I teach from neurology and neuroanatomy. I'm involved in residency. And we're all about flipped classroom now and just in time learning and team-based learning. How do you engage the learner? And so there's one technique that's not really been utilized as broadly as you use that. But I remember one time you were asking, we were in our lab meeting and you were asking us questions and we didn't know the answers. And you were like, don't they teach you anything in university here anymore? I don't think they teach you anything. You don't learn anything. I guess I probably felt a little defensive because you had written on a chalkboard an equation. I remember what the equation was, but it wasn't balanced. And I felt a need to clarify that for you.  And I'm like, Dr. Meadow, your equation is not balanced. To which you flipped me off actually during the lecture. I was fully engaged at the time. And so at the moment I was completely shocked. I mean, I'm a college student. I had never been treated like that. But in retrospect, I realized you saw me as a colleague. What I loved about being at USC was the passion and joy people have for critical thinking and really the creativity. And you modeled that amazingly well. Even as I look back, more so than a lot of physicians I've worked with, you know, a lot of medicine is now just doing, doing, doing. And I remember at one point, I think you broke your leg or something, you couldn't take a shower and you actually had to take a bath. You remember this? And you actually would say, you know, I was in the bathtub thinking. I was in the bathtub thinking. And it was neat to see that. And I now try to emulate that when I'm thinking of, taking a bath, right? Yeah, yeah, or shower, right? But I prefer walking. And it's been cool to think creatively about the work that I'm doing because I don't think that most physicians took the time or take the time to really sit and think and ponder. And you actually were very explicit about that and really emulated what this university stood for in a way that I could try to emulate myself. And so the last thing I wanna point out is you really relish your work. It's the best, it's the best word I could think of. You relish and just reveled in it. And it was all a part of what you did. And I was hoping whenever I was in college I could find a profession that I could have just embrace and revel in as much as you did. And I love my work. And I think what's particularly important to me is that it was never about you. It was about your work and about the preemies and their families. You were doing patient and family center care long before medicine actually called it that. But it was never about you. And I've worked with a lot of really successful physicians who ultimately try to make it about themselves. And I really respect you for that. And I think it's incredibly inspiring to be able to work with somebody like that. And I hope that when future physicians work with me they also recognize it's about the privilege of being a physician and taking care of other people's kids. It's not about us. And so thank you for modeling that for me. Thank you. Thank you. For over two for two speakers who did not go to their 10 minute panel. I'm sorry. Someday somebody might leave time for questions or comments from the audience but I'm not optimistic. I've been speakers of re-enters. Here you are, Brie. Brie is assistant professor of pediatrics right here at the University of Toronto and specializes in the care of all the complex infants both in the NICU and in the NICU. Follow-up of NICU studies and factors that have to do with long-term neuro-development, developmental outcome and has been a long-time student in front of that bill. Hi everyone. I really wanna talk about how Bill really thinks about opportunities for small babies. Small babies scare a lot of people. Not him. So this is the playbook for Bill Bentham. So my son. Barks, no. So my son's at the lab school and they have a new process. So they have a new process. You see thinking wonder about things that live in this PVC cube. And things start out a little bit esoteric and then your son wishes that Spider-Man was in this PVC cube. And he can think and see, think and wonder about it. And I don't know how effective it is for the four-year-olds but I really think it's something that I see in only a few important academics like Bill Meadow. So he sees things and wonders every day in the nursery. He does this every night with many emails. He does this every week in lab meetings. He does it at every conference with many others. He does it in every city at lunch or dinner but he prefers dim sum. So he really wants to ask the question and answer it, are premies worth it? I'll talk just quickly because he would want me to talk about this, about the money. Can't you just make a cutoff that decides? What do you know and when do you know it? What does time do for us? Why can't you just give parents the most that you can and about teaching your team the most that you can? So why are NICU resources considered scarce? To have NICU resources for all babies, you have to provide better care for all mothers. Most mothers are young and many are poor. Dedicating resources to an unknown person appears to be hard. In terms of numbers from perspective, which he's shown us many times, in the United States about four million babies are born each year, about three million people die. About 500,000 of these die in adult intensive care units. Amongst the babies that die, they're just about 24,000. So just in raw numbers, NICU resources are a small portion of health care resources. He's shown you this before. Our smallest babies, the ones that are the most vulnerable, the ones that are most in question are these 500 to 750 grand babies. They are comparable to our highest risk adult NICU patients. When you look at the columns, these are all the resources given to this group of babies. We only have about 20% of our health care resources spent on 80% of those that don't survive. You can see in the medical ICU, it's quite different. So the smallest babies are thought to cost so much, except for maybe they don't. Next, I'm gonna talk about this myth that they're so disabled. So a lot of people are nervous that we're resuscitating the smallest babies. When we look at the children with the most impairments, they come from the bigger gestational age groups. 45% of children with impairments coming out of our NICUs are 25 to 26 weeks at birth or 27 to 28 weeks. Even the 27 to 28 weeks, infants who are disabled or have impairments double the rate of the smallest ones. Then people say, well, aren't the smallest ones more disabled? Don't they have more problems? Well, actually no. The spectrum of outcomes is similar and you can see at the raw numbers there are still more babies that have the greatest impairments and the larger age groups because there are more of them, more of them survive. So maybe it shouldn't be about the resources. Let's assume you can decide based on prognosis. Dr. Singh really helped us. She looked back and asked neonatologists, what helps you decide about a baby? Whether we should press on. She surveyed thousands of neonatologists and a lot of people said, I wanna see how that baby looks in the delivery room. And we went a little further with that and we asked about apcar scores. Well, one minute apcar scores are lower than five minute apcar scores but no low apcar score precluded a good outcome and no high apcar score ensured a good one. And so this, seeing how the baby looks wasn't as such a good idea compared to some other things. We looked at physiology scores. They didn't help so much either. So then our field moved towards an epidemiology approach and we still wanna know more about the individual patient's trajectory but our field went differently. There are large cohorts of infants that have been studied through the NICHD and the pediatrics with the next group, we surveyed the neonatologists again about 65% of folks use these tools and many use them after birth, which they weren't designed for. And I'm gonna talk to you a little bit more about this. I think this data is coming a little too early. So this is what you can do. You can punch in the numbers for each infant. Were they 23 weeks? Were they 600 grams? Were they male or female? Were they singleton or multiple? And did they have steroids or not? And you can get an output. We compared outputs across different weight categories for the best case scenario and the worst case scenario and you can see the numbers are pretty varied. Imagine trying to explain these to each successive parent and you have to be right about the gestational age and the estimated birth weight. We think that's pretty hard. So Goldilocks is with her porridge. That's a little too hot, right? I don't know if I can make those decisions that early before the baby's born. What other data is available much later? This is where I live most of my life in NICU follow-up. We can accept at the time of discharge if you need oxygen, if you have ROP, if you have an adverse head ultrasound, that that child will have additional needs and the parents are ready to take them home. That may be too late. That may be too cold. So we wanna get in the shoes of each parent who will ask what will happen to my baby not 100 more or less similar babies but my baby. And so we built a framework. Build, build the framework that you should ask each clinician every day for each ventilated patient.  And if you pair the intuition of death before NICU discharge with adverse head ultrasound findings, you can predict both good and poor outcomes. This is when more data is available. So we took a cohort of infants born 22 to 25 weeks and we use this framework. This is a recent cohort. And when you have the best predictors, no adverse head ultrasound and no predictions of death before NICU discharge, at two weeks of life we can tell your parents about 70% of them will do well. And that if you have these adverse predictors, we're almost certain the child may die or may have neurologic impairments. And so this framework gives us more information. It's available later when you've met the baby, when you can give parents an assessment of their infant. Skip this. In terms of our prognosis perspectives, there are few areas of medicine where you cannot continuously adjust to prognosis. For the smallest babies, you may have to decide or you may be asked to decide as a parent before they're born what you wanna do. It's hard to go back. And we're saying that's really tricky. And that first decision begets other decisions. We offer a different approach for prognosis. And then you have to say to yourself, if I offer these parents this chance, can they adjust to the hardships of NICU care? Jessica, Lydia and Marin have really asked parents, what does the NICU experience do to you or for you? And they say that getting to know the baby can be positive, the infant can be seen as a fighter or a miracle. And that they have feelings of being grateful to have parented. So this time isn't necessarily miserable for them and the parents can get through it. So I wanna talk briefly about expanding the playbook. I'd like to start integrating multi-time point counseling for families with one dedicated team. Seeing how to get parents this important information different times and doing it effectively, we wanna ask parents and clinicians what's helpful when prognosis isn't certain or when prognosis might be poor. And I wanna talk a little bit about parent engagement. The picture on the right is of kind of an old-style NICU where they're incubators and they're caregivers but not many parents. If you see on the left, these are frames of a small baby with their parents continuously there. And that makes a difference for prematures. Their parents being comfortable at the bedside. So we wanna talk in my future work about engaging families. I've brought Yaya Ren back to the University of Chicago. She was here as an undergraduate and we're gonna try to electronically create rituals for parents and premies. We're calling it kind of intuitions 2.0. Cultivating meaningful infant-parent relationships pre- and post-discharge, facilitating parent-medical team partnerships and embedding developmental and play activities such that babies get from the, these twins get from the incubator to holding their own photo later. Pre-me and you will be founded shortly. It's been supported by the Bucks Bomb Institute. We are a soon-to-latch social benefit enterprise working to improve health and developmental outcomes for premature infants. We're using mobile technologies to help parents at the bedside adjust to what's happening to each, to their babies. Building easy, accessible online communication and interaction protocols. We wanna do this in NICUs around the world. Yaya Ren has experience in other countries as an anthropologist and we're gonna do our phase one assessments of the mobile technology in Comer and we have a collaboration in Chile. And our mission is to give every premie their best quality of life. So how does Bill make it just right? How does he make the porridge not too hot, not too cold? There's always a list. Everybody on the team contributes to the list of important work that needs to be done. New ideas can come at any moment and new ideas can be tested quickly but then they should be dealt with methodically. You find ways to support every member of your team and you don't give up on your team or your patients and parents. Thanks, boss. That was awesome. We're gonna take a quick 10 minute break or let's see.


Yes, thank you for coming. I know it's late and he all tired So my name is Martin. I work for Amazon for a prime video and I want to talk a little about the profiler that we've done at Amazon so Before I start talking about my profiler. I'll just do a quick introduction to profilers in general and Probably some of you never used one. So I just do a quick introduction Then I explain why did we decide to do another profiler even though there is a bunch of Profilers already that I've talked a little about the Hawk Tracer features Do a demo and hopefully we'll have time for questions at the end So a profiler basically is a tool that allow you to to measure performance of the application and You can basically Split existing profilers into two groups The sample based profiler that runs periodically and checks some some information from your application So the simple profiler simple sample based profiler can be like that that you have a while loop and you check for example, the call stack of a specific process based on process ID and and later on you can gather those that you can gather the data and Generate some statistics of for example, which function was called? Most frequently This is not very accurate because that depends the accuracy actually depends on the on the sampling frequency so for example here we have one second a frequency and It's a good method to To find why your your application is in general slow But if you want to have like a very detailed data, for example, you had the spike performance by spike and you want to understand what's going on. It's good to Do an instrumentation based profiling So you basically modify your source code by putting some trace points and you exactly know How long or how much resources did we use at that point of time? So for example here We have very simple profiling Instrumentation based profiling we measure the time we spent in the full function by Saving the timer before calling the function and after calling the function and then we print the results doesn't apparently another Profiling a methodology is a guessing based profiler. I've learned from Alex today Which is basically a developer looks at the code and tries to guess why the code is slow but yeah Yeah, guess but it's profiling well I'm not gonna talk about this and the whole tracer is instrumentation based profiling that means that you I need to modify your Code you need to put some trace points in the code to know to find why to measure Some of the metrics so why did they now? Why did we create the profiler? There's a bunch of profilers already the spare of F trace LTT and G Etw for windows and many others So we have very very specific environment at Amazon my team is responsible for delivering Prime video up on on living room devices like streaming sticks smart TVs game consoles and stuff like that and Some of the devices are very have a very limited capabilities In terms of development. So basically all we can do we can just generate a package Which is executable with some assets and upload it to the device. So there's no way to SSH to that device There's no way to run another process and stuff like that. So we kind of cannot do much We well all we can do is just to run our application that we build also From the language point of view. So we have a native stack and the scripted stack And we wanted to be able to profile both stacks at the same time And we couldn't really find a good profiler for For this kind of use case So we decided to build our own and before we did that we gather requirements what we actually want to achieve by building the new profiler and So those are the requirements. First of all, we only targeting user space profiling Obviously for those limited platforms. We couldn't even load anything to kernel. So user space only We needed to build it as library because as I said, we can't run another process So it needs to be embedded to to the application itself Since those devices are sometimes very low and devices like I don't know a single core CPU 600 900 megahertz well for some people is not really low and but for us it is So we try to make the profiler so the overhead is Not that significant For some devices, we also don't have access to persistent storage. So we can't save results on the disk Oh, sometimes we can but we cannot access those data after that Because this persistent storage is only available from the application point of view So you can't log into the device and gather the data So we decided, okay, let's assume that we don't have the persistent storage at all And since we're running on different platforms different manufacturers, we wanted to have the Profiler as portable as possible so we can build it once Our developers learn the two ones and they can use it for for all the possible platforms that we support And it should be easy to use of course. So Everybody can instrument the code easily and gather data quite easily So we come up with a very very basic design As you can see there's a user application layer is basically the application That is running on the device and this application links to the Hawk tracer library Hawk tracer library might have a bunch of timelines. The timelines are basically like a buffers our user Sends events. So whenever you want to trace something. I don't know for example We want us we want to know how much memory we use at this point of time It generate we generate an event that contains the information about the memory usage It goes to the timeline and the timeline Accumulate those buff those events and once the timeline is full It calls the flush method and the flush method sends all the events that we gather to To a listener and the listener can be either you can use either the The one that is already existing in the library or you can define your own listener and what listener can do Well, basically listeners should save the data somehow So there is a file listener that saves it to the file or there's a TCP listener that streams the data Over the network and then the data is basically the binary stream and You can't really You can't really analyze the binary stream you need to convert this binary stream to some human readable format and in order To do that we created a Library, it's called hope tracer parcel library that allow us to convert this by stream to some structures that then can be converted to another To another format and so there are two options you can either use hope tracer converter Which is an application that converts this by stream to one of the well known formats like we currently support trace event format that is Supported by Google trace viewer and we also generate flame graphs If that's not enough for you the tab parcel library can be used You can use that for writing your own client your own converter and is available either for C++ Python or or us I'll show later how to do it in Python. It's quite easy So yeah, I mentioned those three components already So the event is as a thing that's basically carries the information that we want to That we want to kind of have in the in the results like for example I don't know time spent in the function or memory usage CPU usage at the that point of time It's a person for inheritance so you can have an event and then you can inherit from that event To add more fields for example The timeline is basically a buffer where you push events The timeline also timestamps the event So every time you you push the event event to the timeline it gets time stumped So we you know exactly when the event happened It can be it can be either Threat safe or not threat safe lock free that means that if you if you know that the timeline is used only in the single Thread there's no point of introducing new text and stuff like that But if you want to use the same timeline across different threads and push events from different threads Then you need to enable the threat safety feature, but obviously that Introduces us some extra overhead because you need to lock the mutex Every time you push an event and the timeline listeners basically a C function that user defines That gets all the events and does something with them and so I show you how to define Your your custom class, so let's say You want to create a you want to trace memory usage and the CPU usage? So how you do that you basically use the HD declare event class macro and the first argument of that macro is is The name of of your event the second one is the base event class because as I said it supports inheritance And all the events must at least inherit from HD event is a base class And then you define fields and the each field is defined by three properties Is a type is either integers string struct flow double and pointer and then the second argument is a C type So it's either in you in 6040 as here or a car or other and the last last one is is the name of the of that field and that That macro generates basically loads of code the most important was one is that it actually generates a C structure So you can see here that it generated the resource usage event C structure with those fields and with the With the base fields of type HD event and the HD event type has basically an ID each event has unique Identifier so we can distinguish them. It has a timestamp as I mentioned That's a pointer to a class that describes that data structure and It also generates few helper functions Is the one the function is for the first one is for serialized serializing the event So it serializes that event to to the byte stream The other one is for Getting even class instance So if you at runtime need to know what's the what's the structure of that event you can use that function and The last one is the most important I think because it's it's used for registering this event class in the in the hope tracer system So before you use the event class you need to call that function. Otherwise, hope tracer doesn't know What's the class and probably will crash if you forget about this and Basically, so the bad the the the byte stream that is sent to a client The client doesn't know about events event classes that you defined in in your application, right? You can define your applications and then have the client that receives the stream But it doesn't know what what events did you define? So first before we send any events we send the metadata stream and it basically contains Information about all the all the event classes that you registered So it contains information about the class name about the class identifier and all the fields That are defined in the class. So then and the next when we actually send the stream So it's below First we send the class ID And then we send all the other fields. So then the parser knows, okay, I got this class ID I know how to parse this because I already got the metadata stream So I know that the next field is for example a timestamp field and it has eight bytes Then now next field is a CPU usage. It also has eight bytes in is integer So I know how to parse it. So there's no need to recompile a client if you add a new class to your library Timeline basically most of the time we are using the global timeline And the global timeline is not actually the single timeline is timeline per thread. So we don't have to lock everything Every time we we push something to that timeline But it shares the listeners. So if you register a listener to one of the timelines in one of the threads you will Kind of automatically register it for all the other threads for global timeline if you really need to create your own timeline You can do that But as I said, it's very very uncommon use case So I just recommend you to use a global timeline and to access the global timeline Just call HD global timeline get it will return a pointer to that timeline So Our most common use case is to measure the time spent in a function or time spending the scope So we've also introduced some of the helper macros That allow you to measure the time we spend in a scope So there is HTTP function that takes the timeline pointer as an argument and it basically measures The time spent in the full function And the output if you look at the end of the slide is basically it generates a new event With the duration, which is how much we spent in that in that scope It also adds information about the thread identifier. So, you know that this function was called in In this particular thread and it also adds the label. So in that case The HTTP function macros sets the function name as a label If you want to trace custom scope, you can do that. It's just another macro and plus You also need to add the custom label for that and this those macros are only available in C++ and in the new C compiler because C basically does not have such thing like like a distractor So we don't kind of we don't have a way to call a call back at the end of the scope If you want to measure arbitrary code, not necessarily Not necessarily a scope. There's also a set of functions start Call stack start string and the stop and that measures the time between Calling those two functions and again it generates the same event with the label that you specified here Yeah, so this code is basically like a scope of the C C++ variable So in this example The scope of this trace point HTTP function is the whole function But here it only is instead of inside this curly braces So yeah does the scope And So that was more or less about the whole tracer internals And now how can you integrate it with your project if you just download the source code do make make install It will install the PKG config file So you can just use a PKG config and compile it with your with your project This whole tracer itself uses a C make as a build system So you can either use it as an external project very easily There is a an example how to actually do that So I recommend you to copy just the whole tracer that C make file to your repository and and include it in your project or If you installed it as a system library You can just use a find package hook tracer with a specific version and then link it to your project and the third option is The one that I actually recommend is That we basically is like SQLite. It has many files But at the end all those files get merged to a single file So the same hook tracer and we have three files. Eventually. We have HT config where you can modify a configuration We have a header file and the cpp file where the whole implementation is and the cpp file It can actually be compiled using a C compiler. You might just Not have all the features But yeah, it's it's possible to compile it just using the C compiler MIT sorry I should mention that before yeah, the license is MIT So you should be able to use it as you want Okay, so demo the first demo So I've implemented a Sorting algorithm it sorts 400 numbers and Turns out that the algorithm is very slow. So if you see I press enter now and Yeah, it took a while to to sort those numbers. It was only 400 numbers. They should be like very quickly So let's look at the source code We call the quick sort here. So now we want to know why is it slow and in order to know why is it slow? We need to instrument our code So I'll show you how to set up The code to to to basically work with hope tracer at the beginning you need to call ht init function This is very important. It initializes some internal buffers and registers some base classes So don't forget about this Then we need to create the listener as I said the timeline needs to have a listener Otherwise, no one will be able to access those events that we generate So for this purpose we we decided to use a file listener a file listener basically saves all the events To a file. So we decided to save save it to a sort dot htdump file as it so it will generate the binder file There is some check if the listener was created correctly Then we registered the listener to the timeline because we only created an instance here but now we need to actually register it to the timeline and We use the global timeline as this is the most convenient thing to do This is the callback of the function and this is like a user data. So the callback knows the context and Then we initialize our input. So we generate 400 random numbers and Then we quick sort this array So if you see if you look at the functions, we basically I added to all the functions I've added this trace point. So whenever function gets called we generate the event. How long did it take to? To execute that particular function and we have a few other functions We have a partition function. We have a quick sort function and we also have a swap function So now I run this it was already instrumented. So if you look here, it already generated this sort dot htdump file and now This is a binary file. So if you try to open this Yeah, you will see this is basically the binary file So what we can do we can convert that binary stream to something that we can actually read and I mentioned about the how tracer converter Program, so if you look at this, you see that This program takes basically three mandatory parameters. The first is format, which is an output format Which we convert our data to and it can be either a flame graph or a chrome trace Or it can be a debug which basically prints everything as it is So we decide to use Chrome trace another parameter is output file let's say sort slow JSON and And the source source is very important as the program needs to know where to get the data from and the source this Chrome tracing How tracer converter tool only supports two sources. It's either a file name or a TCP IP address In case we for example stream the data over the network. It can listen to to a specific port and receive the data So the source is sort htdump We run it. It's processing the data. It's completed successfully. Let's see. We have this. Yes So we have sort slow and now We can use the chrome tracing viewer to actually see Why our application is slow? So I love the JSON file that we generated and we see basically this shows the cost tax of In of our application the X X axis is a time and And we see that basically since the quicksort is a recursive algorithm We see that quicksort cause quicksort and so on and so on But if we look closer, we basically see that apart from calling quicksort It actually it also calls something different and if we zoom in More we see that actually most of the time we spend in the swap function I don't know if you can see but this is basically it's it's quicksort the blue one is a quicksort function then the Green one is partition and the green the light green is is a swap method So we spent quite a lot of time in the swap method. So that's probably a function that we should look into and If we see how the swap method is implanted it takes a and b as an argument and we want to swap values So how did we do that? Well, yeah It's someone implemented it as the saving is to a temporary file and then It's actually serialized to a string and then we read it That's probably why it's slow. So if we just change the implementation to something like This Yeah, there is a trick with xor. Yeah, I I'd have to think about it, but yeah, I'm definitely that's possible Yeah, so if we fix that then probably our trace is gonna look completely differently believe me Saving temporary data to a file and read it after that. It's is ways of time So I'm not gonna recompile it and rerun it I guess you all believe me that this is gonna fix our performance problem and it's gonna be much much faster Sorry, oh Absolutely, thanks Yeah, live demo never works So that was the first demo and the second demo So as I mentioned so imagine that we previously we I I showed you how to how to create your own class which was for memory usage and CPU usage tracking and Actually using the Chrome tracing viewer we couldn't visualize this so How can we how can we see like a custom data? So for that I as I mentioned We can build our own Our own client to to process events So there's a module hope tracer for Python. It's very simple to use you create a client You start the connection. So I said, okay one two seven zero zero one on port eight seven six five And then whenever we receive an event Here we check if the event name is the resource usage event If it is then we take the CPU usage we take a memory usage We print CPU usage and we draw memory usage on the graph I'm not a Python developer. So maybe that's not the best way to to graph something but It works and the our code is very very similar to the previous one Instead of doing the file listener. We created the TCP listener that basically creates a server that streams the data We also have this The class that I showed before so this is the definition of our class and then every Every second here in the while loop we allocate some amount of memory half of the kilobyte Then we make our CPU busy and we sleep for for one second and we report resource usage So let's see how do we report your resource usage? There is a macro ht timeline push event It takes a timeline as a first argument then the event type Then values of that event that we want to attach to this event and then we and then we pop push The and that pushes it we also flush the timeline manually instead of waiting For the buffer to gets full because we want to have the data immediately in the client So it's kind of smooth drawing So we can run the demo I Run the resource usage and I run my Python client and Yeah, you can see that it draws the memory usage here So basically what we've done we made our custom kind of event converter And we decided how we visualize the data in Python just in I don't know 20 lines of code And also the CPU usage is printed here. So it's around yeah one two three percent Yeah, so that was the second demo There's bunch of things that we want to do for the future. There are some missing features like we don't support floating point numbers at the moment Optional fields is also something we want to have so for example You have a class with some event with some fields But sometimes some of the fields should not be included. So that would be nice to have We also want to have more converters in the whole tracer converter like a CTF is a common trace format supported by trace Compass or LTD and G scope viewer So we nice to have we use that profiler also for profiling C++ and Lua or JavaScript stack at the same time But Lua bindings and JavaScript bindings are not open sourced So we also want to do that and lots of documentation improvements even though the documentation is quite okay I see we can we can improve that more. So yeah, if you want to help just go to hocktracer.org slash community And you will find how to how to contact us and We we can work together. Yeah, there's a bunch of links There was also a rust bindings Alex had a talk today Afternoon, so you search for FOSDM 2019 profiling rust you should find that presentation. It was pretty cool Okay, thank you. I think we have Yes To create So that depends Creating new event of Having ability to create a new event class in the other language might be quite tricky But assuming that you already have all the event classes defined in your C or C++ code base And you run it your other language on top of that It should be fairly easy because you just need to expose So for measuring time you need to expose two functions start and stop Plus maybe start hocktracer or star registered listener. So you should be fairly easy for us I don't know how much work that was for Alex Yeah Yeah That depends what you want to do, but if you just want to measure time it should be should be fairly easy. Yeah. Thank you


Hi everyone, my name is Evelyn and I'm going to be teaching you how to start with your decorations for your altar. Okay, in your box you should have found some candles, some right here, and tissue paper with some pipe cleaners. We'll need that for making our merry golds and some instruction. So some sheets of instruction, a sheet you can fill out and talk about with your family, some questions about the members, family members you want to remember, and this coloring sheet of skull. So you have some you can draw in and create your own style of skull. That's pretty cool. I actually made some, painted those, and I made this little like folding paper thing in the back so it could stand and it'll be a great addition to my altar. So I'll put these aside. I'm going to show you how we can do our paper flowers. So our merry golds, they represent, you know, it's la flor de los muertos, so the flower of the dead. So when we see it in the day of the dead, we have a lot of these, people get real ones or they make some. We are going to make some with our tissue paper. So we did get this big old sheet. Let's see, huge tissue paper. But what we're going to want is probably a size like this. So what I'm going to do is cut it, you know, this way and then cut it that way so that we can get about the size we want, right? Let me see, where are my scissors? Okay. So I'm going to cut down this way, just follow the line, kind of stack those on top of each other and then we're going to go the other way. I'm going to put this one aside. You can save it for later if you want to do some papel picado, like hanging. I made these really cool school ones, but we do have another video where we show you more in depth about papel picado and the history about it. So feel free to watch that later as well. But we have this half and I'm going to do one more cut and it'll be about this size. This size will get you something like this. So anything smaller will get you a little smaller one. So you can do that as well. I like this medium size. I'm just going to cut that and now they're stacked. Perfect. Next up, we're going to fold this accordion style. Just do this. You notice right here, I have orange, yellow, orange, yellow. So it's a pattern. It'll look really nice on our flower once we open it up. We'll keep folding accordion style. And you're going to start looking for your pipe cleaner. Note, you did get three pipe cleaners. You can make multiple flowers if you'd like. So maybe this layer that I have here might be a very, very fluffy flower. So you could use probably about five sheets. I can tell already it's going to really be a fluffy flower. But I grabbed my pipe cleaner. I'm going to grab, make sure it's centered, twist nice and tight. And we can cut this off and use it, right, again for more flowers. But next up, I'm going to shape the flower.  And again, you can cut this off, but I'll leave it for now because it helped me hold it right. And you'll open this up. And the hardest part, patience. We need to pull each layer slowly, careful not to rip that, so that we can have our merry-go-old. I'll show you right here. I did one side. That's looking so nice, right? Let me open this up and we'll... I did here about five layers of tissue paper. You might want to try to stick to that. It's just much more easier, I think. I'm pulling those apart. Okay, last two. You can kind of see the flower forming and it's really looking nice. Oh, I think they're missing a layer. Yup. It looks really nice. I'm going to cut this off, save that for another flower, I might do like that. We have our merry-go-olds. They're also known as Sempan Tsuchiles. And you know, like I said, we use them for the Day of the Dead and they're really great additions to your alter, your flenda. I'm going to talk a little bit more about what we have on our alter. So for the Day of the Dead, your alter needs to have four elements, which consist of fire, which these candles will be very helpful. You'll just turn them on and I have another one here, another candle. You can get creative. Make sure to check with an adult. Ideally, we want to have some not real ones without any supervision. Keep those... These are great. They'll do the job. As well, we want water, that's another element that we'll have. So we have here a jar of water that will be great for our alter to represent that. The papel picado, it does represent wind, right? So we have this paper or we can create one hanging. These merry-golds, they are great for the flowers and then also representing the wind. So it's great to just do these. And then we have earth, which is food. And so we have some tamales here. I do have a picture of, it's very popular, the Day of the Dead bread. You can see it's kind of shaped like skulls in a way. And so this is used to represent the Day of the Dead. We eat it together. It's very tasty and very delicious. So it's also another option to have on our alter decorations. You put food of your member, your family member, their favorite food that they used to love. So you add some of that on there. Let me put this here. We also have salt. So the salt is used to purify the soul of the dead. And so we have some here to also add to our alter.  You want to add things they like to eat, maybe their favorite TV show, a picture of that. It's their favorite things. This is focused on them, celebrating them. And we also use, you know, food and activities, family activities. We talk about our favorite memories with our family members. And you need a photo, which will be, oh, I have here Selena. And we'll be doing that next with our staff, where we'll be adding, you know, to our alter stuff that we want to represent, maybe loved ones, dear ones, and we'll be watching that next. Hi, everyone. My name is Brian Rivera, and I wanted to add who would represent. This is my dog, Chiquita. She's no longer with us, but at least by putting her here, I'll always be able to continue to remember. Hi, everyone. My name is Cynthia Baltista, and I am adding a photo of my grandparents to the alter. This is my mama-cooka and my abuelito Emilio, and I am going to add them right here. Hi, everyone. My name is Ana Garcia Villalpando, and I'm adding this little statue of El Chavo, Roberto Gómez-Bonaños, because he had a great part in every Mexican household. Hey, everybody. I'm Sheridan. I'm adding this school that I bought in Tijuana with my tía a few years ago. We don't really celebrate the Alas Muertos in my family, so we just started, and this is kind of one of the first things that we bought, so I just want to add it to you here. Hi, everyone. My name is Evelyn, and I'll be adding Selena Quintanilla, the queen of Tijuana music, to our alter. Hey, everybody. Thank you so much for joining us. I just wanted to say one last thing. Since the Alas Muertos first began to be celebrated over 3,000 years ago, when we practice these traditions and we keep them alive and we maintain them, we connect ourselves across space, across time, to those very first roots of our culture. And so with that, goodbye, Guidance, and we'll see you next time.


I'm going to show you how to access the JSTOR database from the IRSC Libraries homepage. You'll start at irsc.libguides.com and then you'll click on Databases by Subject on the right hand side. Since we know we're looking for JSTOR, you can choose it from the alphabetical list. So we'll click on J for JSTOR and scroll down. Once we click on JSTOR, it will open in a new tab. You should be prompted to sign in with your MyPioneer portal credentials. So that will be your full Rivermail email address with the at mail.irsc.edu at the end and then your same password that you use for MyPioneer portal and for Rivermail. Once you enter your password, it will prompt you to send the code to your phone. Here you'll enter the code that you received via text message. Now I'm inside JSTOR at the Advanced Search screen. If you have any trouble logging in, please contact a librarian at library at irsc.edu. There's some login issues that only the MyPioneer portal department at irsc can address but if that's the case, we can still help you troubleshoot and get you in touch with that department.


Meat boy is back and today I'm going to show you guys how to cook a thin or small steak.  So sometimes something on the thinner side there's definitely a few tricks you can use to get that perfect steak temperature. So here we have two steaks from Frankie's free-range meat the bevet steaks which come two to a package four ounces each and we also have the 8 ounce ribeye. This isn't actually something that I would consider on the thinner side although some of you might this is kind of like average so you shouldn't really have a hard time cooking something like this even if it's at room temperature but these bevet steaks are definitely on the thinner side so when we open this up we have two steaks here that are pretty small pretty thin you know it doesn't really get much thinner than this so the main thing to keep in mind here is we've had this sitting in the fridge they are pretty cold you cannot cook a thin steak from room temperature you're gonna overcook it so what we're gonna do here is a little bit of salt season it on each side and we have a clean kitchen towel just a non-toxic surface that you can dry this with you don't really want to use paper towels and we're gonna let these steaks sit in the towel with the salt while we heat up our pan. So I like using these green pans for the quick sear on these steaks because if you have a cast iron or a steel pan carbon steel if it gets stuck just a little bit you don't have a long cook time to let that crust naturally detach so go with something like this so after you know a minute or two of sitting in this towel the steaks have a nice dry surface then we can put it in the pan so we want to move this around and flip it pretty frequently what the pan being basically as hot as possible if the surface of the steak is dry and the pan is really hot and there's oil in it you're gonna get a really nice crust really really quick and since we had the steak cold in the fridge the inside temperature is not going to get cooked that much so we got a pretty nice crust within you know just a few seconds here so if you're not getting a nice crust always just add a little bit more oil and you'll basically fry the surface and get that really nice browning now as you can see there's like an insane amount of smoke coming off this pan so normally I would put like parchment paper or something to cover this just so I don't completely smoke out my kitchen so it's simple guys really hot surface a little bit of oil have the right pan dry off the steak and you know you have a really really delicious piece of meat with a perfect crust in just a few minutes oh god I need a gas mask in here so we're just gonna take this steak out of the pan let it rest on the cutting board and this other steak I actually usually just you know take it like this put it on a plate and let it sit in the fridge until I'm ready to cook with it and that surface will dry out even more and it'll be even easier to get that crust we're basically in a cloud of smoke over here but we're gonna slice this for you guys just to show you that it's really really rare on the metal you know we were able to get a nice crust without cooking the inside so you can really take this to whatever temperature you want of course we want to slice against the grain there you go blue rare on the inside nice crust on the outside you know despite how thin this steak is you know even like even on the edges you know where it's thin it's still really really nice and rare on the inside so that's really it guys cooking steak doesn't have to be this huge big thing you know you could have a really really delicious perfectly cooked piece of meat within just a few minutes for lunch dinner whatever time of the day you'd like to have it so on Frankie's Fringe meat we do have these bevet steaks we have flat iron steaks those are both kind of pretty small and convenient and we also have new steak sale going on with like eight ounce ribeye eight ounce strip steak as well as some sirloin steaks which are on the smaller side and perfect portions if you're looking to have you know four ounces to eight ounces of meat per meal so definitely check out frankiesfewrangemeat.com if you want to do something special you know you could do butter, thyme, garlic in there and even take some of our collage and broth and reduce it in the pan to make a really really nice delicious sauce gravy for your steak you can also go to franktestefa.com to check out all of my other businesses guys I'm always wearing me you know Wi-Fi shielding clothing we got our Wi-Fi shielding hat on right now but there's a lot of creative products and ideas that you can explore on franktestefa.com as always guys please drop a like on the video leave a comment down below subscribe so that YouTube can unsubscribe you next week and be sure to check that notification bell so they don't notify you of my videos thanks again for joining guys and I'll see you soon


Hello, my amazing math minds, and welcome to this week's Math Tip Monday. My name is Heidi Rathmeyer at ESU 8, and today we are going to have another installment of 13 rules that expire. This is an article by Dr. Karen Karp, which addresses how teachers can perhaps lead students to some misunderstanding of math concepts by using imprecise vocabulary or relying just on shortcuts and tips or tricks and not really promoting the conceptual understanding of math. So today, the phrase or the phrases that we're going to talk about have to do with the equal sign, which students sometimes are led to believe is an operation, like find the answer or write the answer or it makes something. The problem with this is, well, it expires pretty early, and I think a lot of teachers use it even past first grade. So let's see where some of this confusion may come from. So on my iPad, we can see we have some simple problems. The first one we would encounter certainly early on in the primary grades, where we would have seven plus two, and the mistake comes in when teachers might say makes something, which gives the impression that the equal sign is the operation as opposed to the plus sign. So obviously what we want here is nine. Now, really, the equal sign is a relational symbol. We are just showing that what's on this side of the equal sign as the same amount as what's on this side of the equal sign. And here's when you know your kids are using the equal sign as an operation as opposed to a relation when you come to this bottom problem, where we have seven plus two equals a blank plus five. Now if you have a kiddo that is treating the equal sign like an operation, they're going to put a nine in there. So if you see that, you know that's the problem. They're treating it as an operation as opposed to a relational symbol. So obviously the answer we want here is four so that the amount on this side is the same as the amount on this side. So this is a very good example where you can understand a student's misconception based on the way the problem is set up and their understanding of how this equal sign is used. So I think that's really important because I know when I get into the algebra that I might teach with eighth graders is often we see equations set up like this where kids think everything needs to be done on the left hand side and they forget that this is a relational symbol because then when they are given this set up they get really confused and they don't know what to do because they think all the doing needs to happen on this left hand side. So I encourage you with the younger kids to not only write problems like seven plus two equals something, but to write it as seven plus two equals something over here so that they understand that the equal sign is not about an operation. It's about a relationship between what's on one side and what's on the other. So when we get to algebra they don't run into this issue here with this scenario where they just don't even understand what to do when it's exactly the same thing as they would have done on this top one. So those are just some examples of some misconceptions that students can obtain based on some of the vocabulary we might use in the classroom or even just how some problems are set up and how we solve some problems. So as you're working with equations in your classroom just be very careful with the vocabulary that you're using be precise with the vocabulary and make sure we're emphasizing the conceptual understanding of just what an equal sign really represents. So until next time, stay well, be kind.


and welcome to module 20 of chemical kinetics and transition state theory. Now we have developed some of the language of statistical mechanics specifically partition functions. Now we want to direct our attention towards calculating rates for using these partition functions. So before doing that let me tell you our general prescription on how we are going to calculate the rate. So this is going to be a small module but it is an important module. So we are actually going to not think about molecules today. Let us think about something better. Let us think about cars and I have a puzzle for you today and we are going to solve this puzzle. Imagine I have a road and on this road you have a lot of vehicles that are moving. Now you have a distribution of speeds. Yes, so you are really thinking about some highways, many cars are moving, you have different lanes and just for simplicity let us assume you have cars moving at 30 meter per second, 20 meter per second and 15 meter per second, only 3 speeds. Just as an example and let us say 50% of the cars are moving with 30, 30% are moving with 20 and 20% are moving with 15 meter per second. Now imagine I have some signpost somewhere, just a spot on the road and I ask you the question what is the rate at which cars will be crossing this line, this blue line here. And we have to assume some density of the cars and let us say that density is some 2 cars per meter. That is actually a lot of cars but fine every kilometer you have a 2000 cars. So a very, very busy highway I guess but let us assume it whatever it is a number. So this is a puzzle for you. What I want you to do is this is one of the most important things actually. If you can solve this puzzle you understand the essence of all rate theories then. Everything that will forward here from this point on you then understand. So I really want you to take your time, pause this video and get this answer. Most important I want you to understand is the logic behind how to solve this problem. So pause the video and solve this problem and do not rest until you have solved this problem. Please pause the video now. Okay, hopefully you are back and hopefully you have tried to solve this. If you have not please pause the video and do attempt to solve this one. This one is critically important. Okay, we are going to solve it together now. So we are going to divide this problem. The total rate will be the rate at which cars moving with speed equal to 30 meter per second plus rate of cars traveling with 20 meters per second plus rate of cars traveling with 15 meters per second. So what I will do is then to find these three individual rates. So let us focus on rate at 30 meters per second. How do I solve this problem? What is rate? So we have to get back to our fundamentals. Rate is the number of cars crossing the signpost per second. So if I wait for one second, I have to observe how many cars passed which were traveling at 30 meters per second. Okay, so imagine you are sitting there at that toll booth at the signpost and every time a car traveling at 30 meter per second crosses by you have a counter and increase the counter by 1. And you find the number of cars that passed in 1 second. That is the rate. Okay, by definition. Okay, okay. So how do I calculate this number? Well, the idea is in one second cars traveling with 30 meter per second will travel well of course 30 meters. Okay, the speed is 30 meter per second in one second you have 30 meters of distance. What it means then is if I take a length of 30 meters here, cars that were in this 30 meter would have crossed this blue line. And any car that is outside this 30 meter line will not have crossed this blue line in one second. So in one second time only the cars that fall within this 30 meter range will be able to cross. So this number, so this rate of 30 meter per second will be number of cars in 30 meter length. Okay, so this will be equal to density of cars with speed equal to 30 meter per second into 30 meter. So I find the density in per unit length which have this for following speed and I multiply it by 30 meters per second. That will give me the rate. So this density is the density of cars into fraction of cars with speed equal to 30 meters per second into 30 meters per second. The density of cars with a particular speed equal to total density of cars per unit length multiplied by the fraction of cars that were traveling with 30 meters per second. Yeah, so that is how I will find the density which are with a particular speed. Because think about it very carefully what have we are doing? The total rate at 30 meters per second will be the number of cars in the 30 meter length because those are the cars that will be able to cross this signpost in one second time. Fine, but the number of cars in this distance is nothing but the density of the cars into this distance. The density of the cars will be the total density of all kind of cars multiplied by the fraction of this particular kind of car. So this rate at 30 meters per second is then density, the total density into fraction of 30 meters per second into 30 meters per second, the speed. The density is 2 cars per meter, that is the total density. A fraction for 30 meters per second is given to be half, 50 percent. 50 percent is nothing but half into 30 meters per second. So if I multiply this, I am going to get 30. So I can do the same for 20 meters per second too. This will be the same as a density of total cars into the fraction of cars travelling with 20 meters per second into 20 meters per second. The same logic in one second, the total number of cars travelling with speed 20 meters per second, well those cars better be in this length of 20 meters. Same logic. So this becomes 2 cars per meter into the fraction here is 0.30 into 20 and I can calculate this, this is equal to 12 and the corresponding rate for 15 meter per second will again be the total density into the fraction of 15 meter per second which is 0.20 into 15 meters per second. So this is equal to 6 cars. So the total rate is then equal to the sum of these 3 which is nothing but 48 cars per second. So if you sit at that sign post, you will observe 48 total cars passing. So we want to generalize this a little bit. The total rate, if I have in general some number of cars with some number of speeds will then be equal to sum over all speeds at which the cars are moving. The total density of cars per unit length into fraction id u.  So I have to find the number of cars in this u meter length but the number of cars in this u meter length is nothing but the density of cars, total density of cars into the fraction of density which are moving with speed u multiplied by u meters. So that will give me the rate in per second. I can generalize this a little bit. If I have a distribution of speeds rather than summation, this summation will become an integral. So imagine you have a cars at all possible speeds travelling not only at 30 but you also have at 30.001, 30.002. At every speed there is a distribution that is how molecules behave right. So I am trying to get to the molecules now from cars. So the fraction basically gets replaced by some density into density into u where d is total density per unit length, rho of u du is fraction of cars speed u. So this is the expression I get. Rate is equal to integral and I had forgotten to do one very important thing which is the limits. So we are only looking at positive speeds. For integral goes from 0 to infinity, all cars that are moving with positive speeds. So these limits are very important. So in writing this expression, we have made two important assumptions. One is only forward speeds. That is that is that is cars are later on not turning around and coming back. Then your rate decreases, the forward rate decreases. So we are assuming all the cars once they go through this goalpost, keep on going forward. And the second is importantly we are treating cars classically obviously. This becomes a bit more tricky when you think of atoms and molecules. Cars are of course described by Newton's laws very well. Atoms molecules most likely they are but you can have exceptions. So today I just want to give you this important expression for the rate. Any time you calculate rate actually this fundamental expression is used. Rate is an integral over speeds, the density multiplied by the probability that I am at given speed u and multiplied by u. So this u is called the flux. So I am at a given goalpost. What is the flux multiplied by its density? That is how you calculate rate and in doing that we have written two assumptions here. We are really thinking of a speed and when you even use the word speed it is somewhat classical. In quantum mechanics you have to be very careful when using the word speed. So we will just end here and in the next module we will actually derive transition state theory. Thank you very much.


What's up everybody JC over to ask these case breaks calm We just sold out 2021 panini flawless baseball. This is a one box briefcase break random teams number five and again guys Fresh case five and six are from the same case 30 total spots every gets a random team in the MLB Again here the cousin names Carl All the way down to Brandon member two fillers a quick pitch Pack filler number 24 and 25 helps sell it out the rest were bought straight up. Appreciate it guys Dusty you got last one mojo put that right there and then of course there's the teams Let's click the dice roller roll it and we got ourselves a four and a five nine times Good luck one two three four five six seven eight and nine Four and a five Dusty at the top Down to here one two three four five six seven eight nine Nine times Brewers down to the Braves So does it with the brewers car with the Cardinals as well as the Phillies Nicholas with the Pirates car with the Cubs Giants been with the Nationals car with the Red Sox as well as the Royals That's where the Yankees car with the Marlins as well as the White Sox Angels Orioles twins might go with the Dodgers car with the Tigers might go with the Reds car with the Guardians as well as a It's been with the Mariners Brandon with the Padres dusty with the D-backs Carl with the Mets and Blue Jays Michael the Rangers car with Astros Does it with the Rockies car with the rays and mark with the Atlanta Braves? Now if there is anybody that wants to trade I'll give you guys a quick trade window All right guys All right, so I'll pause the video guys All right, thanks for what you got guys. No trades no true chatter or nothing. So Lego so there's flawless baseball 2021 The gold All right, so back to the way it was guys top bottom Let's see which box we can do here. So if I roll a one two or three, we're gonna go with the top box four five six is the bottom Four so one two three four five six we're gonna go with this box. So the top box will be for number six So our six Well, the good thing about flawless mark is that flawless is more emphasis on obviously nice card But like there's a lot of good veterans basically the checklist is pretty big for a lot of the team So a lot of the more historic teams Yankees, you know Dodgers Mariners for like each real kangaroo junior, etc. Rookie wise You know, there was obviously a couple of them. So 2021 I believe had, you know, John I think I would soon John India's in this, right? Kalanek maybe pretty much all the rookies in 2021. So Kalanek Mariners India ain't India would be Cincinnati Reds, I know Joe Adele would be angels bus angels would have Shoahio Tani But flawless just has a lot of good Veteran like presence rather than like Immaculate being a lot of rookie stuff and prospects But a lot of the bigger teams like the Yankees and stuff are pretty Good to get I think what did you get mark the Atlanta Braves? I want to say Atlanta Braves are great You got Ronald Acuna jr. Christian Pache will still be there for the Braves Then you got all the other legendary Braves that were before Acuna and stuff So I'm not bad teams you not a bad team you got there man I think Braves would have been either a couple hundred dollars or well over a hundred for sure This is a bigger team. Oh There's actually a middle card. No. Oh, no, maybe not It's like me out. It was just a little Little that so occasionally they do put the middle cards in some brief cases depending if there is a Pleat or something like that Ten to ten Trevor Rogers That'll be for Miami going to Carl Eddie Murray for Cleveland nice triple relic there six of 15 Cleveland Carl as well There's for Atlanta there you go mark. That's Ian Anderson nice little patch autograph six out of 20 We have for the California angels Fred Lynn 10 or eight out of 10. That's great patch autographs So California angels would be Carl with the Los Angeles angels We have a Mickey Moniek Patch autograph nine out of 20 for the Philadelphia Phillies going to Carl We got a dual autograph Both for Texas. That's Adrian Beltry and Raphael Primero That is 10 out of 15 Texas that would be Michael with the Texas Rangers very nice Ooh great picture here Tristan McKenzie. That's a rookie autograph green emerald one out of five That's for Cleveland Going to Carl and last hit before the encased cards guys. Good luck We got ourselves a Casey Mye's RPA very nice That is 11 out of 25 two-color patch an autograph for Detroit going to Carl very nice RPA So my stuff right here guys Flawless is just flawless, right? I mean, so they call the flaws. Oh, this is I might be the hit Where's this the hit? Sammy Sosa for the Cubs little diamond Sierra number 420 nice Chicago Cubs going to Carl very nice And here we go guys. Good luck The next one's in the store 6 out of 10 Ricky Henderson That is a Ruby 6 out of 10 For the Oakland athletics Oakland a is going to Carl. What a break for you Carl. Oh Very nice. So since there was a veteran on this side the second half of the case might have a Ricky Something big knows Nice little case right here though guys remember we do have another one It's in the store got to do two fillers in 10 spots, but again if we sell the spot straight up We can always cancel filler There you go guys little flawless brief case break in the books Jaspies case breaks calm appreciate it guys