Hi everyone, thanks for joining. We're going to talk about personalization with intent stuff today. Or you can just take a nap. That's fine, too, after lunch. I won't mind. So yeah, we're going to be talking about intent-based platforms, specifically Six Sense. So it'll be pretty specific. So if you're using that or interested in it, hopefully this is interesting. My name is Judd. I come from UX and strategy and that kind of thing. But the big three ABM platforms I've worked with. So demand-based terminus and Six Sense have experience with. So coming at this from a fair bit of at least some hands-on knowledge with these platforms that are sometimes opaque if you haven't spent the cost to onboard them, all that stuff. I'm with Elevated Third. We're a B2B agency. And we kind of integrate MarTech with Drupal. That's sort of our sweet spot. So a lot of this comes from dealing with enterprise and the tools that they use and how to bring that to Drupal and the best way to get that stuff to work together. So lots of big clients. We do end to end. So strategy all the way through Drupal. So a lot of this comes from the need around B2B to speak their language, use their tools, be able to hang in those conversations, which are a little bit higher level. Lots of zeros attached to that stuff. So knowing how to get these things to work together technically and then knowing how to best use them is sort of where we're seeing ourselves these days. Just a little stat from Bombora to sort of orient us. When you're doing ABM, account-based marketing, people are using at least one platform, like Six Sense. But sometimes more. Sometimes a lot more. And it's very expensive. And there's a lot of orchestration that happens between them. But there's a lot of insight that these tools can provide, which is why everyone's using them, and which is why they're very expensive. So just some context there. Maybe just hands people working for an organization who uses an ABM platform. A few. Six Sense specifically. A few. OK, cool. Everyone else is curious. OK, so we really focused on this Drupal-Martek ecosystem. So it's sort of what Dries was talking about on the keynote today, the wave going up. A lot of this is about just continuing that idea of being open with a lot of APIs. And these systems that have connection points, that lets us do other things, are going to survive. We think. And so the ones that play nice tend to get more traction. The ones that don't tend to fall off, at least for us. So that's really where we see ourselves. And so this is really just a focus on why we care about these things. So Acquia being sort of enterprise focus, and then Six Sense as well, like trying to get these two things to play together. Drupal specifically with Six Sense is how we're coming at this whole thing. So let's talk about intent in terms of account based and ABM and that type of thing. Because the words can mean a lot of different things. And if you have questions, no need to wait to the end. You can just interrupt. OK, so for today our context, it's really the culmination of signals that represent the needs of an account. So account would be company, if you're not familiar with ABM. So whatever your vertical is, you can just think of it that way. What are they trying to do? And where are they in their decision making process along the way to do it? So like I said, our focus is B2B. So if you're not B2B, who's in your B2B focus? OK, not quite. OK, so if you're more B2C maybe or academic, this might not be super relevant. But your customer experience might be just as complicated. In B2B, it's very, very noisy. It's long sales processes. There's no single decider. So it's usually a group of people deciding. It's very complicated. We think we need an X. Let's shortlist some X. Let's do some research on an X. I got to propose my boss about an X. And all these things are very, very expensive. And people's jobs are on the line if they pick the wrong thing. So it's high risk. And it's very long. Sometimes like years long, where you're trying to cultivate people along a cycle. So when we think about personalization, it's like we're really coming at it from how can you help this mess be a little bit cleaner, which is challenging. Yeah, so months, years even, 18, two years, something like that, you're nurturing people. And it's not just the technology process. There's a lot of human effort involved in this mess trying to move people along the funnel. And that's what we're talking. And this is the big thing with that chart. It's like no one wants to be talked to along the way. It's becoming a big problem, including me. So I'm guessing no one in this room likes any of these things, like cold sales marketing emails. I'm sure everyone gets at least five, 10 a day, maybe. Random sales calls, no one likes that. Apologies to salespeople in the room. And then forms that inevitably lead to the other two, which is why people, if you're in B2B, you get tons of Gmail form submissions, because no one wants you to call them. So everyone's trying to avoid and evade all of this stuff, which I get it. I use ad blockers and all that stuff just like everyone else. But it poses a challenge for businesses. And they're becoming less effective. So you might be reading things about MQL strategies in general are just starting to become less and less effective, just because there's so much noise out there. So 6 cents, I guess a little plug. They're an account-based marketing platform, but it's really about funnel intent. So what they're trying to do is they call this whole thing the dark funnel.  So the trick is, well, can we maybe see what they're doing during that process so that we could engage when it is maybe most receptive to that? That's basically what they're trying to do with this stuff. And they're using intent signals to try to figure out and predict along that path where you might be. So if someone does reach out with an email, they're like, oh yeah, that makes sense. I'm in the decision phase. I'm already looking at vendors. I'd be happy to talk to you. So the timing is super important, and that's what they're trying to do with these systems. So they do account identification, which is important for personalization. If you're doing real time, which we'll talk about. So that would be on the fly, sorry, after lunch. On the fly, right, company identification, and then there's keyword intent. So what they're looking at, which is not the same as search keywords, and we'll talk about that. And then the targeted advertising, which is really like, it's not the same as its display, but it's more about feeling out what people are interested in in terms of everything that you do and where they might fall, and using ads as sort of a litmus test of where they're at. So you can plug all these things into personalization on the site, and so hopefully you're already connecting the dots there, how that might be useful. So what prospects are interested in before they ever hit the site is basically there and all the other platforms model, right? That's why they charge and have so many zeros on their price tags is because this is super valuable if it works. Some of you are probably wanting to do this after realizing how many platforms are tracking you and trying to predict all of the stuff that you're doing, just kind of the way it goes with B2B. So that's more like the context on the six sense platform. So let's talk about keywords, which should be familiar to most of you. So they're like explicit keywords, not that kind of explicit, but very targeted to an intent, right? So something like account-based marketing, they tie very specifically and all of paid search is tailored to trying to match up to those specific keywords with wild cards and edge cases and all this stuff. And then you serve an ad and you get a thing, right? So that's sort of the paid search game. So you kind of have two ways you can play it, right? We're all familiar with this, organic. You're trying to guess who, where they are in the funnel when someone reads a blog post about whatever, answer the question and then subject, it's changing, right, based on algorithms. Ignore my spelling error on the plane last night, this is late. And then there's paid search, right? So it's very narrow and expensive and competitive, right? So the intent is like you have to catch someone the exact moment they are trying to buy a thing, which rarely happens with a $100,000 SaaS product. So like using these techniques that you would sell shoes with is not always the best approach. So implicit intent is kind of the different way of tackling things. So if you're not familiar with how this works, so like Bombora and Demanbase and Sixth Sense as well, like they are observing a huge content network. It's like 14 million sites or something crazy, right? And what they're doing is they're adding metadata keywords to content and trying to build bigger layers of context around what this means when you're searching for it. So Forbes writes an article about content management systems and why they're boring and whatever. They're tagging this with other types of keywords and then sort of rolling it up into concepts, like Bombora has categories. And what they're doing is saying, okay, I'm reading signals that they might be interested in this thing that's not on your site, it's everywhere. So CNN and Forbes and all these like TechCrunch or whatever, these are all signals that people are using. Question? Yeah. Yeah. Yeah. They're not worried about it because they're kind of validating with first party data. That's how they explained it, but everyone, all these platforms are keeping it pretty close to the chest of what they're going to do when that happens. So we'll see. I don't have a good answer for that. We're with personalization, we're also investing in first party. And then UTMs are always your safe fallback. And so we leverage a lot of that, which we'll talk about. Yeah, the apocalypse is definitely going to be a concern. That apocalypse, not the other one. So the coverage, so if you're curious about like how extensive this is, so they've got a, you know, millions of websites in the network and then Bombora, which is like a six sense piggybacks on Bombora data that kind of incorporate it so you get the benefit of a little of both. Or you can subscribe to something like Bombora itself. But there's a ton of data there. And that's really what you're paying for, is like they're monitoring all of this, categorizing it, making it portable, making it easy to decide things against. And then you're able to drop people in a bucket, essentially, that's what you're paying for, right? So not something you can really do with paid search, right, because that's not going to tell you, you can sort of get an audience, but you can't do like company filters and all that stuff, it just gets really hard. So another thing these tools are trying to do is like there's a ton of noise in this, right?   Like that's not necessarily, we're looking to change email platforms. And so it's trying to like balance all this stuff and calculate all these intense signals to try to say, ah, this is a clear differentiation from the background noise, then that truly represents a change versus just the every day to day stuff, which is a challenge. Like they're not always good and they're not always comparable based on the industries, right? Sometimes there's variance. And so if you ever go down this route, like trying these out, always ask them for samples of their data so they can prove the use case there, right? And so you can kind of get into this loop of content where you're using six cents or something to say what are prospects searching for? That would be like your, of the Bombora network or six cents network, what are our clients, potential clients really interested in? Then you could feed it back into like we need to write content for these kinds of themes because this is like the cutting edge stuff and then it rolls back and then you're starting to own turns from that and it's a loop. So it kind of adds on to your content strategy versus just like Google Trends, right? Something like that, which is like really general and not very specific. So there's all kinds of little ways you can use some of this data to feed back into something like personalization, which is what we're getting to. Any questions on that in 10 or how it works? Okay. Okay, so segments. This would be so intent is more of like activity, things are doing, and then segments help us group that into something manageable that we can use. So with six cents, you get this thing. And if there's any more technically minded people in the audience, like this is really, really valuable. The ands and ors and logic, it's really solid gold. So here's an example from our own use case. We use it. Is this a laser? No, okay. So, you know, for us, right? Like we monitor Drupal keywords and then agency, right?  Now it's like someone who needs our help, right? But one of those two things on their own might not be relevant. Digital agency is too broad. Drupal's too broad as well. Like we're looking for the Venn diagram between those two things and that's what this stuff lets you do. So if you can think about it like, oh, if we could personalize our site with these two audiences where they converge, that's what we're after here. And then something like B2B marketing or ABM, but not media buying, right? So now you can exclude the exclusions are almost more important than the inclusions. So that you can really tighten up your audience and say only someone like this should and will see our ads and our variations on the website. So all this is like precursor just getting somebody to show up on the website but thinking about how the segments work and who you're trying to target is important because that tells you what you're gonna say to that specific audience and when you're gonna say it. So extending on keywords, keywords can also imply your stage. So this is a sample set. Hopefully you can read that but something like employee HR tool is asked whatever product. Imagine some, maybe a company feedback tool, the name's probably missing a vowel or something like that. But when you're researching the concept that's more of your awareness stage. So you can sort of infer that if they're at this stage and they fall within our target, they're pretty early, they're researching concepts, I might have a problem, I don't know I have a problem. This is normal keyword stuff. Your consideration is like now I know I need a thing, I might not know what that thing is but I know I need a thing and then it's like, well is thing A versus thing B, which one's better? So if you can break up your keywords like that, you can actually use products like 6Ns to start to build your segments that way or it's like I can help you algorithm tell me where people are at in this funnel because I know that if they look at competitor name that they're pretty far along the process and I should talk to them now versus I just wanna watch and be aware of people thinking about employee satisfaction, right? And the nice thing is when like segments are dynamic, so when people start doing the next thing, they can move between the two, which is really huge. You can actually see their progress through segments and now when you think about adding personalization on top, hopefully it's clear like what messaging you might put forward for each group, like one might be orientation, messaging might be your annual reports around a problem. We work with a company that does like sort of mental health ERP stuff and so when they're researching teams like employee wellness, things like that, that's a long way from I need to replace my ERP with an alternative I've never heard of but they can say state of mental health is in this bucket, serve them that versus down here, right? So it just makes your library a little bit more relevant. So spheres of intent here, this would be like thinking of them not quite as separate buckets but like as big as you wanna go. We only wanna target engineering companies and only engineering companies in the US and only engineering companies do aerospace and only ones that are 100 million and above and then only ones that are researching whatever, you can get the point like tighter and tighter and tighter and tighter and then you can do things within those groups and have little splinter groups and sometimes we're just making little pockets of just trying to understand what's the activity within this subset of a market, right? So like very specific products, very specific keywords, competitors, all those kinds of things you can build these little pockets and personalize against them or not, right? And then the intent what we would call intent accounts are like the highest buying signals with the most activity and you're sort of setting those thresholds and then you can tune the website to talk directly to that group. So this is a thing that like if you again if you've never like gone down the procurement route with one of these tools, it's always hard to just get at that just show me the thing that I can play with. So hopefully this gives you a sense of some of the things you can do. So like, so imagine your big bucket is every company that I care about, let's say you have 5,000 companies that might buy whatever it is you do, then within that like you could say anyone who's been to the website more than five times show me those people or that plus they've also clicked on these ads plus they've had keyword activity around these five things in the last five days or a week or whatever. So you can keep compounding all those filters together with ands and ors to build all of these subgroups, right? And then there's AI pieces now that will then predict scoring on top of all of that. Like the likelihood of fit based on your Salesforce past history like it's observing your close rate and your open ops and all that stuff and it's trying to predict, oh, this matches a lot of other things that you've closed. You probably wanna talk to these people, right? So very powerful on the filter side and like I said, a lot of them we use just to watch.  Look at this group and then what keyword activity is popular in that group plus the pages they're visiting. It's a lot better than GA which is just showing you page views and then maybe where you're from, maybe a UTM code like served from a very specific campaign but this can tell you what content are prospects really after and then you can really lean into that from a personalization standpoint. So just a little bit of a closer view here. You can see on some of these like Bumble or a company search topics in the medium like when someone's looking at a G2 like they're in pretty deep consideration mode so they can flag like anyone who starts looking at G2 for our SaaS product versus other peoples, you can start to personalize against stress radius, all this kind of stuff. Direct integration with LinkedIn campaigns. So this is all I think a good sort of framework to think about everything that's happening outside the site. It's like one dimension outside with all of your campaigns and everything. It doesn't really get talked about too much here like at DrupalCon but there's this whole ecosystem happening that's feeding all of these data points into a Drupal site.  It's like, hey, welcome. You're like, well, I've been here six times. Like can you show me something new based on what I've been doing? So that's really what we're after with this but you can see on this company profile stuff like estimated employees. If you're not familiar with industry codes those are like the government codes that specify like certain industries like agriculture or education or whatever. So you can do that on the fly and pick people out based on their IP address and all kinds of other things that they're doing from a identification standpoint. So we divide segments into a couple of types. So like outreach, that would be like if you have salespeople, right? Like highest intent, you need to talk to them right now, like right now. You wanna know who those are. Watch lists and then sort of niche nuance. Like maybe we're trying to get into a new vertical or a new market. You might actually set that up, warm them up, like kind of watch what things are doing and then develop an ad campaign and then sort of roll that out, test the audience, get some traffic and then develop that feedback loop. So it's really a lot of this concept. I don't wanna watch 5,000 people. I want this thing to like light up when there's a couple of people that I should look at and then see. So it's a big priority game because we all only have so much time. If you have limited salespeople, then limited marketing people, you have limited writers. It's like, what do we write about this quarter? You're doing quarterly planning for content strategy. It's like, what are our content pillars? It's like, well, go here. What are the top five things people are looking at? And then you could dig in and say, that's a pretty good bet versus watching our competitors and they're talking about X. Might be not the best strategy. So we've got our intent signals. We've got our key words that helps us sort of prioritize and box people in. Then we get insights to help see if we're on the right track with a very specific company. So this is more ABM specific stuff, but TAL means target account list. If you're not familiar, that's like who you want. You don't care about anyone else. You're focused on this list. A static list would be like a group of a leadership team says, we like all these logos. We want these hundred people. You're like, okay, we'll try to get on Google's list. Agile would say, we're gonna take all these signals and then sort them in highest intent to lowest intent and then take those top 100 and go after them because the odds of us closing them are better than your vanity list of the logos you recognize, for example. So you can use this as a way to prioritize how you would go to market with a personalization campaign. So you might even take the top 10. Let's say they're in a specific vertical, then go with that as your first personalization campaign out of the gate. And then it's constantly updating. You're sort of let go of the if only this list was perfect. Everything would work out. You just let it go because it doesn't matter. So another thing that you probably have not seen if you've not been through the sales process before or have seen these platforms. So this is a very specific account. And within an account, you get all kinds of nifty secrets website visitors, branded keywords within the sixth sense network. Again, that's not search traffic. That's on their network. All the cumulative traffic that they're saying, this company is interested in website migration and they've done it 10 times within the last 30 days. Oh, okay. So you can imagine how you would craft an email followup based on that. Top pages visited by the account, pretty easy, but still more valuable than Google because now it's like only people at this account, this company are viewing these pages and we even see which cities they're from. So you can really start to narrow, okay, it's probably this digital marketing person that's based in Raleigh, like looking at these pages, that kind of thing, right? How might we engage with them in an appropriate way without being creepy? And then you can see like on the keywords here, this bigger exposed list, yeah, the numbers are just the frequency. So you can really start to wait like how much of that is happening. And it's really insightful. You can just like click down company lists and I'll do this like every Monday. Just be like, hmm, that's weird. Like it's starting to shift and you'll start to see trends over different companies and all that kind of stuff. It also organizes everything in a timeline. So if you're thinking about when to do something or let's say you've got a personalization campaign running, you can kind of see how it's working based on someone visited this thing, then they got an email and it stacks all in order and you can sort of see that cumulative effort compiling over time. Yeah. Yeah. Yeah. Yeah. So Six Sense has a, it's like a, what's the KFC, the magic herbs and spices. It's like 14 magic ingredients. So it's doing some kind of like done in Bradstreet comparison plus IP plus its own proprietary plus Bombora. I have no idea. But it's pretty accurate. So we were on demand base right when COVID happened and we saw a 40% hit on their accuracy because everyone was working from home. So they didn't know how to handle it. It was pretty brutal, but Six Sense has more and we didn't see that jump, but it's all secret. We'd have no idea, but it seems pretty accurate from experience. Yeah. So campaigns, pages, keywords, all that kind of stuff. So you can really start to see sort of the development of an idea too. Like they started researching thing, they come to the site, they click some ads, they come back to the site. So that B2B journey, you can really see it start to manifest in this kind of thing. Location, this is, if you didn't know this technology exists, it does.  So you have visit locations and then there are cross references to your company, what your job title is, and that's how people get your info. So yeah, that's kind of how the game is played right now. But that's more on the sales side and outreach. But again, like Six Sense specifically knows that this is all irritating. And so the trick is the timing. Like if it's helpful and you are like, hey, I know you're interested in these things, you see a lot of cumulative activity. You increase your odds of not getting the door slammed in your face or your email getting read when it hits at the right time. So we talked about this, density searches, all that stuff. Okay, so what does all this have to do with personalization? So we know who we're targeting, we know what stage they're at. Now this is the thing that people just never think about is we have to say something interesting. Because a lot of people are like, if only I could put this in front of people and then it's like, well, we just changed the image. And you're like, well, okay, it's a start, but it's sort of like message first a little bit. So when we do display ads, something like this, we're really thinking about how the keywords are bubbling things up so that we can actually use those specific terms in ads or whatever or to inform the pieces of content that we're producing next. So back to our stage example, using these same keywords for our hypothetical HR platform, you can see like, oh, I'm seeing a lot more traffic against recognition than engagement. Ski the ads towards recognition, right? It's like you're actually tilting the message with some of this insight that the platforms are giving you. Hopefully that makes sense. But yeah, more aligned with the buying process, but using those keywords to inform what you're actually saying. So we've all heard this to death at this point, I think. It's still valid, but I sort of think about, so in B2B, if we could just have one-on-one conversations with people and be like, hey, where are you at? I'm not really interested in things, but I'm kind of wondering about this problem and you're like, oh, interesting, I have this thing. Here, read this thing and maybe come back in six months. We would just do that if we could do that, but we can't. So we have to have these artificial things, like sites and site maps and searches and all this junk to sort of simulate this and answer these questions. But I think it's useful to think about personalization in terms of a conversation. When you think about it, it's like, oh, I'm responding to what you're saying. I'm listening to you, I'm reading some cues and saying, yes, I have this thing. Is that me? Oh, okay. I was like, am I done? I was like, okay. Right, so just it's feeling more natural, right? And who knows how GBT is gonna change this? Maybe one day, we won't need B2B websites at all. We'll just have content streams that just answers all your questions for you. But for now, this bore give and take is sort of what we're after. And so that you can read some of these signals and respond, right? So think of it like right intent, right content in the right context. It's maybe a little bit of a better evolution to that idea of right person, right time, because you should know all these things already. So now it's just about recognizing their intent when they land and say, I know someone got here and I know exactly how they got here and where they're at. So that I can respond and it just smooths out the process and you don't have to like dump welcome messages and they don't have to wade through like six different UIs and all this stuff because a lot of historical UX like couldn't count on any of this. So you had to like walk people through or have a choose your own adventure that applies to literally everyone which makes it a mess for everyone, right? So if you can narrow things down it's gonna make things simpler. So get to the modules, right? So smart content is our tool set. So you can do a bunch of things, right? And what it does is it takes essentially block layout, right? So layout builder or anything component based and says, well, I can show A or I can show B based on very specific rules. So, you know, first time visitor or segments or whatever, right? So if you've got blocks, if you've got a site you can use smart content to show it in different use cases. So I've used this metaphor for a long time.  But it's not changing like every single thing on the site but maybe 20% something like that but I think this metaphor is good because you're also having to maintain all the other sides of the cube, like all that other content. And so it gets complicated.  So all this intense stuff also just concentrates your effort onto, well, we only have so much time. Let's personalize for this group that we know is throwing up a bunch of signals that hopefully we can capitalize on. So stuff you can personalize on. So anything in the browser, you can do. So, you know, GEO, all that kind of stuff. Clicks, views, set events, right? Capture it if they clicked on this, that kind of thing. So self ID, that'd be like UTM strings from any ad platform. Email activity, it's like partot, MailChimp, whatever, Marketo. Lead scoring, depending on the system. Segments, first party, and then cookies, like we've done that ourselves, like just write your own cookies to the question about third party, right? So then you'll know, like when they come back, they clicked on this service line, so it's a good guess, they were looking at that, whatever. And then all your third party platforms would be the next effort, right? So even something like IP info, which is sort of the lean version of this, might be a place you could start. It's usually for localization, something like that, but it's definitely doable. So, segments. So, the language is somewhat confusing because we're setting this up in Drupal, and it's not sort of pulling in segments, but you can sort of combine the two, right? So you're building these rules in Drupal, and saying, look, if anyone comes to the site, and they match these criterias, do this thing, right? And you can combine them, order them, stack order them, set defaults, all that kind of stuff. So this is all through the UI. So marketing people can do this. We've tested it, I can do it, so other people can do it. And it lets you sort of say, okay, I've set all this up in sixth sense, I know my segments, all I need to do is sort of set it up in the Drupal side to mirror, in order to show these things. And this is the most powerful thing of this whole presentation. This is the output from the sixth sense tracking script on your site, or on our site, or any site that's running it. So if you can see, this is saying, we gotta match, here's their region, here's their industry, here's their city, here's their zip code, blah, blah, blah, blah, blah. State, city, it also will do all those segments that we set up earlier. We'll show up here. So it's returning, they're in this segment, they're in this segment. And if you have the AI enabled, it'll say their score is a 90, or profile fit, or match fit, whatever. So right from the output script, it's doing all the work for you. We just need to say, what do we do with it? So we let sixth sense do the heavy IDing, so that smart content can show the right thing, right? Any questions on that? Yes, yeah. So we don't actually store any data on our end. So sixth sense is covered with their GDPR. And so if you're normal blanket site, we're usually, I can't remember the name of it, we're mostly using third parties for that part too, because they keep up with it and everything like that. So it falls under that umbrella, because we're not actually storing any data. If we get into first party cookies, then we will. That's usually wrapped into whatever enterprise company we're working with, like their GDPR platform. Yep, yep, yep, exactly. So you could imagine sort of a combination campaign thing that has some parts here. You might have anonymous and ads with sixth sense. You might have a satellite LinkedIn campaign, targeting specific roles for those audiences and segments that we've got running in sixth sense. You might do nurture emails through par dot, excuse me, direct mail and then PPC display, all that stuff. So then you send all that traffic to the site and then smart content can personalize some of these variations off of that stuff, right? So just showing some very specific examples, just examples though, right? So let's say you have a, this is a, like a hazardous material cleaning company, something like that, and they have vertical focus, right? So now you're skewing the whole homepage or the entire site rather with industry focus. So it's copy, it's imagery, it's pulling in secondary content here, it's calls to action, all that stuff. So if you have a sixth sense segment that's targeting that industry and they're in the awareness stage, this would make a good sense for the hospitality vertical, right? And all we're doing is setting up the segment in Drupal to say if segment equals hospitality, show X, right? Maybe a later stage. So it didn't change any of the media, but it changes the headline and it changes the call to action. This would be like later stage, maybe they came back or maybe I know that they only clicked on this ad, they have to be down funnel because I was retargeting so they clearly been here before, something like that. So again, you're kind of picking up the intent and saying, well, what would I say if I knew someone had already been here? It's like, well, I'm not gonna repeat myself like here. I'm gonna say, I'm gonna sort of push the offer a little bit harder and change the action to speak to sales. Different industry entirely, right? So that's like now we're talking about hospitals and we're pushing white papers about hospital expenses, all that stuff. So the idea with industry, specifically, most companies that we work with, I would say, Enterprise, V2B, they're usually vertically focused. So it's a good bet and usually they have those ordered in like the most valuable to them. So even if we're just starting with default and then one industry, that's the one to start with. And so you're only managing one variation but it's the most important variation and then you can lean into that and try to customize it. Now, we're not like spoofing anything. Like all this content is real. We're just trying to give ourselves like a tilt and a lens that says maybe hospitality and hospitals should have picked two examples that were different. Hospitals are maybe a small part of our business that we're trying to get into but we don't want them to feel that way. Like we're putting a lot of money and R&D into this. We really wanna get that first case study. We're gonna make it feel like hospitals are just as important as hospitality. That would be a way you could sort of alter that perception through website personalization versus them general message industries, hospitals, like counting on someone to do that. You're already like 30% drop-off rate. In sales? Yeah, yeah. Yeah. Yeah, good preview. Yeah, I'll touch on CDPs at the end. The other way you could think about this if you're doing like one to one ABM is like VIP stuff. Like you're sending video mailers with a vanity URL or QRs that are making a comeback. Something like that. You could really target to only people who you could not see this variation unless you had this golden ticket, whatever thing. That's something you could think about as well. Oh no.  You'll have to imagine it. The idea was, you see a lot of this personalization junk focused on one page, but when you think about website segments, they are across all pages. So when you zoom out, let me see if I can reload this because I think it might be worth it. Oh, there it goes, okay. It was just messing with me. Okay. Yeah, thank you. So you get a site, right? All these variations, all these subtle product pages that are slightly different. Now start changing all the calls to action. How many touch points is that? 100? And you only need one variation that swaps that out intelligently, right? And so this is the big thing that you can make a small tweak, like push this piece of content up here, right? A little secondary call to action. Change it to this in this case. You just have a hole there and you know we've got 10 things we're gonna fill that hole. We're not gonna overcomplicate it and change every possible thing on the Rubik's Cube, but that and the call to action might be enough depending on the use case. So that was sort of the point to make there. So let's talk about reporting and then into CDP and then I'll just look at the site specifically. Oh, there it goes. Okay, so this is my favorite thing about the collection of modules. These are all on Drupal.org. Is the data layer module. So you can, every time you see a variation on the website it pushes an event to the data layer. And if you're not familiar that's just Google Analytics and all it's event tracking. And so you can see this box down here. It just tells me what variation was seen and the label that I gave it in the CMS. And so by nature of having that I can say well if anyone saw that variation I know they're in an X which means I can create a segment in another word, a Google Analytics segment narrowing to that and then all my conversion metrics match. Now I can say personalization A give me against the default. Personalization A against paid traffic, whatever. Time ranges, all that stuff.  You're just injecting this one variable essentially and then building a segment that you can compare things. So you don't have to buy like DOMO and Tableau and all this junk. Just make it a lot simpler to get started which is the biggest part. Now the Holy Grail is the CDP side of things. So the customer data platform. It's like feeding this stuff back into or reading from a CDP like Aquia or Segment or Snowflake. One of those tools. That's something that we're starting to get into because honestly like people are usually behind on the CDP like everything I've talked about up to this point. People aren't quite there yet but they're starting to and so where we're focused on the CDP side is like okay for current customers something like what are your categories for what product you already have versus what the natural upsell is. Some sales force logic figures all that stuff out and then send it to the CDP like likely add on might be X. Then the personalization side says oh, we're gonna treat it like a bank. Like if you ever prevent to a bank website everyone has right. Like the home page is the only opportunity to ever catch an existing customer before they log in to their bank account. It'd be that kind of thing like recognizing that current customers are there. Promote our customer engagement event. Here's an add on that might work for you and you're kind of tilting that whole first experience for existing customers right. And sometimes we combine that with a login cookie that doesn't track there. It's not like a single sign on but it just says I have logged in at some point. Right if you have a SaaS platform something like that so then you can tie that into and then fork off into we're just watching our existing customers and what are they interested in and preempting how they might grow the account depending on your use case. Does that answer your question? Cool. Okay, so quick rundown on the modules. This is very tiny. But the first two are like really the content blocks. Data layer pushes that to the GA side. There's also an AB module. So within variations now you can do AB testing too using the same thing with GA. So that one's relatively new. UTM strings that's just one where it plugs in the option to track UTMs off of ad clicks as a variation and then both demand base and 6Ns. So those are all there for everyone to try and test out if you're going down that route. And let us know if you have feedback. The dev team and the product team on that side is always interested in suggestions and feedback and use cases so feel free to reach out if you wanna play with it. Then I'll show a site that we've got it running real quick and then we'll wrap up. So this is that demo site that I was showing. Right, so it's using Layout Builder. We've got all of our layout blocks here. This is persona one. I've got a UTM string here that shows persona one. I change it to persona two, right? It swaps out to persona two and that's it. It's cached as well. I don't know how that works. Our VP of technology is here somewhere. He knows how that works. So if you wanna come by the booth and ask him. But it's super slick and Google will also read the default version and not to this and you don't get dinged for swapping, right? So like the shady swapping. Yeah, you don't get dinged for that. So they have figured out all that stuff. But the idea is that, let's say you had a LinkedIn campaign, right? Like you could know only people who have seen this campaign would see this variation. Then we would, this block would talk to the data layer and say, hey, someone looked at me and then now we have our personalization segment. Right? So if I jump to, so this is our persona segment in Drupal, right? So you can see if campaign UTM equals persona one, I can open this up. If all the conditions are true, if any are true, I can add a condition that here's all the browser stuff. IP info, we have it installed on this demo site so you can look at in all this stuff. Here's our UTM, any of these terms, you can combine all these together. And then we have some default stuff. So this is it.  And then we have those existing conditions. So that if I go to edit the layout here. So here's the blocks that would be added here, right? So in the custom block library, I've got homepage header two persona two and I just manage it just like every other block, right? So I'm able to add content. It's just duplicates of blocks that we already have in place and then the rules will swap those out. So that is it. Any questions? Yes? Mm-hmm. And if I do visit the website. Yes. Out of the UTM. Yes. We likely saw a variation, A continue to be categorized. It will be B, it will be A unless you add the, we have a cookie thing, module as well. So that will save it, essentially save the session. But that's a binary tree. It seems to me that once I see that in the next time. Yes, next time you will. Yeah, yeah, in this particular example. Yeah. Yes, mm-hmm, yep. So that's like the question about first party. Like that's where we would set it and have it on our end to maintain it. Yep. We have another use case for this where we're doing filters. So we're like saving personalized filters. Like I'm interested in this type of content and then pulling in like a dynamic block of content, something like that. And then it's saving it so every time you come back it's tuned. So yeah, if it gets more technical than that I'm gonna direct you to the booth. And you can ask those guys. Any other thoughts, questions? Okay, cool. I'll let you guys out a little early. Thanks everyone.


I'm Sergeant Burns. I'm representing 21st TSE. My sponsor is Staff Sergeant Williams. I'm over here at the competition on day three. Very, very grueling tasks and stuff that takes you out of your boundaries, what you expect to know. They test your limitations on just your overall ability to adapt and overcome any situations and definitely live the Army values in order to get you through the tasks. Spending an eventful couple of days just can't keep pushing through and be able to see this to the end.


All right, so it's eight o'clock, so we'll go ahead and get started. We have Dr. Harry with us today. He's one of our faculty members here at the Moran. We all know him best probably for his ultrasound expertise in helping us with a lot of complicated diagnoses. He also works in private practice at the Salt Lake Clinic. Is that right? So we're grateful to have him here to talk to us today. He's going to talk to us about that dreaded 5 p.m. patient on Friday and how to handle those. So Dr. Harry, just call the resident. Yeah, that's what they're there for, exactly. Well, Randy and I both remember well from Jules Stein days that I think we sort of had a tradition for probably 5 o'clock with a famous Cornelholzer. For some reason, community area, it was sort of a tradition to 5 o'clock Friday, you know, late for your golf game, so send them to Jules Stein and they'll take care of it for you. So we start sharing these over there. I'd like to talk a little bit about some patients I've seen at kind of the late hour, out on patients and the things I've learned from them and maybe pass on a few things to you folks. This is a patient's 31-year-old woman. She lived in the Amana colonies near Iowa City. And she presented the emergency room with severe pain in her eye, hurt to move her eye, look over to the right, little proptosis, chemosis, edema, some double vision, and went to the ER, and their initial thought was orbital cellulitis, let's put her in the hospital, high dose IV antibiotics, get this taken care of. But on the way there, they had her stopped by the eye clinic. I just started my fetalship there in ultrasound, so I saw her and she'd had a CT scan, kind of early generation CT scans in those days, so it wasn't really that helpful. This was a scan, kind of amorphous, what's going on up there? Is that diffuse orbital inflammation? Is it something else? So it wasn't really obvious. So they had me refer to the ultrasound and I put the probe on and I pointed towards the lateral rectus muscle. And it's pretty obvious right away that the muscle is thickened. This is the lateral rectus muscle. Here's the tendon exertion near the globe. Here's the muscle belly. The A scan shows this great, big, thick muscle, very low reflective. So I really hadn't seen this before, at least this kind of presentation, so I called Dr. Osano, who I was training with at the time, and described the findings to him. He says, oh yeah, it's myositis, which we see all the time. And really this was a diagnosis I really hadn't been very familiar with in my residency. That was the early days of scanning, really you didn't have the capacity to really define these entities in the orbit as well. So he started on high-dose steroids. Well that was a challenge, trying to talk the infectious disease folks into, you know, here's a patient presumed infection, or we'll say elitis. I'm talking high-dose prednisone. And so they finally agreed to compromise antibiotics by IV, but also high-dose steroids at the same time. Started at 80 milligrams that night. The next day she was dramatically better. Really had shrunk down and 90% improved. Pain was pretty well gone. Immortality was returning, so discharged in a couple of days and sent home on maintenance steroids for a couple of weeks. So I was sort of introduced to the concept of myositis, and really hadn't been familiar with it, as I said before. What is myositis? Basically it's inflamed muscle, and the age range is quite a range from three years old to up to the 80s. And it's more common in females for some reason. It's usually acute, unilateral, often just one muscle. But there may be chronic, recurrent cases. It can be bilateral. It involves multiple muscles in these kind of recurrent cases. It's the third most common orbital disorder, following grays and proliferative conditions. It's actually a subcategory of orbital pseudotumor. Again, we kind of learned that with modern imaging techniques. Now we can sort of characterize, you know, is it myositis, is it altichloritis, is it scleritis, dachyritonitis, so we're able now to subcategorize these different entities that we used to lump in orbital pseudotumor. Example here of a scleritis. So here's the scleral layer thickened. Here's the muscle inserting with the tendon insertion. So adjacent scleritis and myositis going together. So a lot of these so-called pseudotumor entities that we used to lump are now broken down into these specific entities. Pain is, most patients have pain in the orbit, around the orbit, but about 5% don't really have much pain. So these are atypical. And you'd expect pain with all of these, but there are some that don't. Usually, motility impairment with double vision. A key finding always is, does it hurt to look either to one side or the other? Now a lot of patients with eye pain, so it hurts to look around. I say, well, does it hurt to look in one specific direction? That sort of helps to localize if it really is. Myositis kind of picture, compared to some kind of diffuse orbital pain. Proptosis, usually not extreme, but mild proptosis. Eyelid edema, conjunctival hyperemia, and chemosis are also common. Difference of diagnosis. Graves disease is certainly towards the top. And a lot of patients, there's kind of a spectrum that I see. Graves is inflammatory by definition. And you can have acute grays presenting with almost a myositis type picture. So you can have generally grays kind of muscles, but you can have one or two muscles that are quite inflamed and low reflective, consistent with a myositis kind of picture. So this can be a lot of overlap with grays disease in these patients. Vascularitis, coidosis, what we'll say, ullitus, oral tumors, infectious entities such as herpes, Lyme, sister socosis, and also association with giant cell myocarditis, lupus and Crohn's disease. So that's kind of what you think about when you see myositis. But most of these patients, already in my experience, don't really have anything systemically going on. It's just isolated to the muscle. You can work them up to all kinds of tests, but really just a good history and physical utility kind of pins down the fact that it's isolated to the muscles in the orbit. As far as involvement of muscles, one series stated that the medial rectus is the most common, followed by superior, then lateral, superior oblique, inferior oblique, inferior rectus and inferior oblique. So that's kind of the order of muscle involvement, but it can involve any muscle, and again, several muscles sometimes, and sometimes bilaterally. So therapy, the best treatment, of course, is high dose prednisone with rapid tape or either IV steroids to start them off if they're really extreme or high dose oral steroids and usually rather dramatic response. Now, the question always is when to taper the steroids, when to stop them, if the flare's up again, what do you do? I've had pretty good luck with endomethacin as kind of a, not as a primary therapy necessarily, but when they're starting to taper their steroids to concurrently start endomethacin towards the end of the taper of steroids. So to try to avoid a flare up. To a lot of these patients, dramatic as they respond to the initial therapy and they get better fast, they can flare up again. That's not uncommon to have recurrent myositis. So I think in the methods and maybe have a role in that to helping prevent that kind of recurrence. Antitissue and necrosis factors are popular now for arthritis patients, infusions, and even subcutaneous injections now of these, and they've been reported to help in cases of myositis. In methotrexate, I had one patient that had recurrent myositis. I had those steroids every couple of months just kind of getting cushionoid kind of symptoms. So we decided to try them with methotrexate and just responded dramatically. He's had no recurrences over a couple of years now. So that's a good kind of backup drug. Again, not primary, I think still steroids are the primary treatment, but this can be a good backup therapy. So in large muscles, what do you think of? Again, Graves is number one. Most common cause of unilateral proptosis and also a lot of proptosis is Grave disease. Myositis we're talking about, infectious causes, vascular lesions that can, especially with fistulas, CC fistulas, can actually increase muscles size just by congestion of muscles, metastatic tumor. Sometimes you get into the muscles. Lymphomas, rabdomyosarcoma, acromegaly, amyloid and lithium have been reported to sometimes cause increased muscle thickness. So these are all things to think about when you have enlarged muscles. It's kind of a montage here of three kinds of disorders of the muscles, at least two kinds. This is a normal muscle by A-scan. So here's a normal patient with A-scan to the muscles. The tendon's up here, a little tiny blip down there. Here's the muscle starting to get thicker. Here's the maximal muscle thickness. As you go back, you scan the probe along the muscle towards the apex. So this is a normal looking muscle, normal thickness, normal internal reflectivity, sort of a high irregular reflectivity. This is a Graves patient. So Graves patients, again, the tendon looks about the same. It's really not thick and engraves these normally. As you go further back in the muscle here, you get maximal thickness, so it's quite thick compared to that muscle. And reflectivity is really important with these patients. Reflectivity and Graves patients tends to be heterogeneous. It's not homogeneous. It's more kind of a mixed bag. You get high and low spikes based on the pathology correlation. And this is a myositis patient. The tendon is quite thick compared to the normal muscle and the Graves muscle. So that's a key finding in myositis. You look for tendon thickening.  And it's quite low reflectivity. Here is really important. A-scan is very helpful for that because lots of things can look big on CTs and MRIs as far as muscle thickening, but I can actually characterize the muscle with the A-scan as far as the pathology. So that's very helpful to be able to do that. This demonstrates, again, the concept of the normal muscle based on normal muscle architecture. Scepta, muscle fibers, fat. So you get some interfaces for reflection of sounds. So you do get some reflectivity inside the muscle. It's kind of a medium reflectivity kind of in this range here based on normal muscle architecture. You go into a Graves muscle. You get kind of an inflammatory edema along with normal muscle fibers. So you get, again, interfaces reflect sound. You get kind of a mixed bag of interfaces. You get some high, some low. So you get more of this heterogeneous reflectivity inside the muscle, which is typical for Graves muscles compared to a normal muscle. And the myositis muscle, diffuse inflammation, kind of replaces the muscle with inflammatory cells. And the more homogeneous a structure is, the lower the reflectivity on A-scan. So, again, vitreous is quite low because it's homogeneous. There's not much in vitreous to reflect sound back. So in the muscle with a lot of inflammatory cells, you get low reflectivity based on the pattern based on the inflammatory cells. So those are different architectures of muscles. So basically, when you see a patient, you suspect myositis is very easy to put the ultrasound probe on. And I do two views. I do kind of a longitudinal view with the white mark on the probe facing towards the limbus. And you get kind of this long view of the muscle. Here's the tendon here. Here's the muscle belly, quite thick. You can do a cross-section of the muscle. You do a transversory where you put the probe parallel to the limbus. Go across the muscle here. And here's the muscle being cut across in cross-section. And here's the A-scan, showing, again, thick muscle, low reflectivity. So that picture is very characteristic of myositis. So when you end out, grab that probe and check those muscles out. Because it's really easy. Five minutes in the clinic, you know, you save a lot of work up, you know. MRI CT scans are, you know, helpful, but really quick diagnosis. Five o'clock Friday afternoon patient. You got a cinch. Start the steroids. Better than it took a couple of days. It really is a nice kind of a tight package to be able to help a patient and make the correct diagnosis. Okay, and present another case in illustrating something here. This gentleman presented, again, late in the day. I'm not sure if it's Friday or not, but it was a late patient, had-on patient. 47-year-old gentleman with decreased vision in the right eye, noticed a few weeks ago. Vision was 2060. Right eye, left eye was 2020. Normal intracur pressure, normal examination, except for the fundus finding. And he had a branch of vein occlusion on examination of the fundus. Okay, so I'm going to get to pick on residents. Dan, any thoughts at this point? Friday, five o'clock, you're sitting there. He walks in with an add-on, dropping vision. Do you see this picture in the fundus? What's your next step? Okay, photography's gone home. Five o'clock. Okay? There's my man. Okay, you know, five o'clock Friday, this is really not super-emergent. You can certainly wait until Monday, get an OCT or whatever, having to see a retina. But the blood pressure cuff, okay? They dusted it off. And he denied any history of medical history. He said, well, I'm healthy. I don't like to see doctors. I think I saw a doctor. Well, I think about 70 years ago, I think. So, well, let's check your blood pressure. 250 over 160. So, I called the emergency room. I said, which hero do you want to go to? And you want to go to West Valley. So I called ahead, which, again, is a trick that you'll learn that if you send them to the ER just without any notice ahead of time, they'll sit there for two hours to get checked in. They'll finally see the doctor.  But by calling ahead and just alerting the ER doctor to what you're expecting. So this guy's got really high blood pressure and getting him right in, managing him. So he was admitted, he was to the ER and they started him on medication. I followed up a couple of days later and he was improving while responding. So blood pressure is easy to check. Something easy to do at that five o'clock hour. We can all do. So branch vein occlusion, good prognosis on younger patients, females or fewer nervous risk factors. They tend to do better than the older patients, the male patients, multiple risk factors, and poor initial visual acuity. These are all things that are going to make the prognosis worse for branch vein occlusions. About a third of patients end up with vision better than 2040. Two thirds have vision worse, macular edema, ischemia, macular hemorrhage, vitreous hemorrhage. These are all things that can make the prognosis worse for branch vein occlusions. Mild obstruction may show just scan. Hemorrhage is very subtle, especially after a certain time period. But it's complete obstruction. Looks very impressive. Extensive hemorrhage, retinal edema, caught in wool spots. It almost always occurs at AV crossings. That's the classic teaching about branch vein occlusion. And the further from the optic disc, the better the prognosis. These are all things that improve the prognosis. Systemic association. These are all things associated with it. As Dan mentioned, blood pressure is certainly got to think about. What are we doing? Atherosclerosis, diabetes, cholesterol. This group here is probably the vast majority. Most patients have vasculopathic risk factors. And they usually have a history of something like this in that context. There are less common things, homostastanemia, lupus, protein, CNS, antiphospholipid, Factor 5, Leiden, syphilis, Waldenstroms, polycythemia, multiple myeloma, leukemia, lymphoma, sarcoidosis, and TB. These are things to think about. But, again, they're rare birds. Most of the groupers in this group up here have the common risk factors. So, Paul, Bernstein, do you work up for branch vein? Do you do much when they walk in the clinic acutely? Do you bother with much work up? Certainly with blood pressure. I don't. Is there one more than another that you're seeing that with? Is it just generally across the board? So, they have to stop it whatever they're doing. At least that discussion with them. So, one source said extensive testing is not really indicated except in the usual presentations such as bilateral or younger patients as Paul referred to. Anyway, generally, again, they're in that general risk category in older patients. If that's the case, I don't do a lot of extra work up. So, think blood pressure. It's easy to do again. We have those available, most of us, and it's easy to get one to check there. So, you can really, in this patient, I think we probably saved a life, I think, with that kind of blood pressure we had under a 60 diastolic, we're talking stroke, myocardial infarction, in the near future. So, hopefully, that can make a difference in his prognosis. Another patient, 91-year-old, again, add on late. This actually was Friday, 6 o'clock Friday. Sudden loss of vision left eye. He had a history of prosthesis in his right eye. Trauma years ago, lost the eye. And so, he suddenly loses vision. Started about 4 p.m. He calls his daughter. He's on watching television. And he says, I can't see. So, he got to the office by 6 o'clock and he had hand motions in fairly as all I could pick up. And by history, he had a vision of 2050, at least in the past. So, sudden loss of vision. So, this isn't him, but this is a similar case. So, what do we see in there? Yeah, a cherry red spot. And what makes it a cherry red spot? What is causing that? So, it's a neurofiber-lagradymid, pretty much. And that doesn't really occur in the macula. You don't have any neurofiber or something. You're showing through exactly. And what's this phenomenon? Can you see it? The fluorescent shows it better. What's that called? Box carring. It's pretty dramatic when you see it. This is another case showing the box carring. Just kind of the blood cells just kind of lined up. Marching through the through the arterioles. So, at this point, Jim, since you're already responding, at this point, so, what are you going to do with this guy? 91 years old, one eye. This is his only eye. He's got obviously a central but an artery occlusion. What's your next step? So, digital massage. Anything else to reduce pressure that you might try? So, those are kind of classic things. Even more heroic is to do an AC tap. You know, paracentesis, try to reduce pressure by taking out some aqueous and you get a pretty dramatic reduction of pressure that way. So, those are things that, certainly, you're in the literature. So, at that point, let's say nothing's really happening. What's your next step? What do you worry about in a 90 year old with sudden arterial occlusion? Okay, GCA workup. So, what can you get right away? We have a lab. We have a CBC, looking for what's especially with CBC. Bladelet, right? And then, cedrate and CRP. The cedrate was 70. I got within an hour, I got a cedrate. We have a lab there. So, at this point, 70, cedrate. This patient with the presentation. So, high-dose steroids. That'd be an obvious thought. You're not going to be hurting him. You know, putting him in the hospital for that with that age. But that certainly isn't going to hurt him just beyond that for a couple of days. So, you kind of sort things out and consider a biopsy. But in this case, again, the trusty ultrasound. I put it on. And this is a drusen. So, this is a patient with drusen. This is how they look. This is not him. This is him. This is a a pacification back behind the lamina crevosa. So, it's actually not a druse. This is in the central blood and artery. So, it's an embolus stuck in the central artery. So, I picked it up and just, you know, met it with the ultrasound. So, right away, I've immediately narrowed the diagnosis down. This is not... No real history of headaches or scalp tendon or anything. The 70 is probably a red herring with that age anyway. So, it's embolic. So, does that change your thinking at this point? Embolus to the artery? Okay. And I called the ER. I talked to the doctor directly. You know, waiting a long time, getting checked in and things. He said, we got a patient with central artery occlusion. I treated him like a stroke patient, basically. Just, you know, a sudden occlusion, a one-eyed patient. So, I discussed that with him. And this was just later. This became a couple days later. He was in the hospital. This is carotid angiogram. And this is his left side. And that's a big calcific plaque sitting down there. Carotid artery reconstruction. So, definitely that was a source calcific plaque in the carotid artery with the emboli flipping off to the ophthalmic artery, the central red artery. And this was, I asked the radiologist, I went down and looked at it, and I said, can you see that embolus on the CT scan? He looked really carefully. He could not see it. So, I think it's small enough that ultrasound was able to pick it up. It was missed on CT. It just wasn't visible even though looking for it. So, ultrasound was very sensitive in this case to be able to pick that up. Okay. So, Dr. Hay rate Iowa study has found irreversible cell injury after about 100 minutes after occlusion of the artery. So, that's kind of been the dictum that if you can't help them within a couple of hours, you probably isn't worth it, but still other literature says it's up to 24 hours. So, again, you've got one-eyed patient. That's your only chance. So, I would be fairly aggressive. I think the things you mentioned, digital massage, things like that are worth trying. They're really iffy in the literature. There's not really good evidence that they really do a lot. Have you heard of carbogen, anybody? 5% CO2, 95% oxygen. Sometimes that is said to help by dilation of the central arteries in the CNS. So, what do you think, Judith? Anything that you've central artery occlusion? Is that something that's kind of a hopeless situation? Have you ever had any cases of anything, did anything for them? Well, they're recent. You're exactly right. So, even medical legally, even though it probably doesn't work and we probably know that it doesn't, I think at least make the effort. I think the usual. We got bad air though. It's probably equipment. Probably once in 10 years. Something like that. They often will come to the emergency room and then there's not a clear diagnosis and then there's sort of the I thought I didn't do it. I did digital massage. I gave him a couple of drops of lume again and sent him to the ER. I asked him to get carbogen, which they could never get. I guess that's something he just don't do. They just don't. Right. Yeah, the paper bag. Right, right. Well, I called the ER and I pled my case and I think I convinced him enough that they did actually give TPA and they got the stroke folks there and within two hours after he got there he got some intravenous. They didn't enter arterial. And history was he got to the ER and his vision was completely gone. He blacked out at the time he got to the ER and he's back down to about 2400. The last check. So, I don't know. That did something. Or what happened. But at least in that case it might have done something. Anyway, presentation about early 60s. Patients with visualized emboli with their route obstruction have a fit for six mortality rate over nine years compared to 20% for age matched population without emboli, 27%. Emboli seen about 20% of patients with central blood and artery occlusion. Emboli definitely makes a difference in mortality and ulima prognosis for these patients. So, in this case it wasn't visible. It wasn't in the arterial tree on the ophthalmoscope, but I did see one on the ultrasound. High pretension about two-thirds of these patients, orthosclerosis in about a half. Cardiac valvular disease in about a fourth. And think of that in younger patients, certainly older patients you think of carotid but anybody probably below 50 or 60 think of the valve and echocardiogram probably trancisophageal, echocardiogram. Tempolar doritis with visual loss. Most of these patients have AOM but about 40% will actually have a central blood and artery occlusion. So, somebody to always think about, you know, tempolar doritis, et cetera, CRP, platelet count, good history. So, embolism associated with poor visual acuity, higher morbidity, mortality. Cholesterol emboli are the most common followed by calcific bacterial tauke. Cardiac emboli are the most common cause in patients under 40. And coagulopathies from sickle cell or antipostal listed, most common under 30. So, these are again things to think about with the presence of emboli. Other causes, hypercoagulable, collagen basket disease, oral contraceptives as you just mentioned, polycythemia, besets, syphilis, migraine, low pressure in unconscious patients. One of these horror stories about having surgery for, you know, back surgery for hours on the head against the pressure and they woke up with blind in one eye or both. Inner tube valve, what does that mean? My first year as a resident at Jules-Stein, I was called emergency room and there was a young lady, they had been in the swimming party, she dived through a big inner tube, the valve caught her in the eye, came in with light perception vision. So, I called the staff, by the time we finally got to the OR, about three hours later, we did a canthotomy that really never got any vision back. So, I guess the current dictum is, Bufi was here, he would say, do it right there. Anybody done that? Done an emergency canthotomy? Yeah. Okay, a lot of hands going up. Okay, right, just right there. So, anyway, that should have been done in this case. We probably know more now than we knew then, but at least at this point, that was a dramatic case in my experience. That's the inner tube, that's not hers, but that's an example of one, with a big valve sticking out. So, don't dive into that. So, laboratory, what do you think about it? Again, we talked about working up for hospital temporal arthritis, ER, CRP, fibrinogen, antifossilifid, PT, PTT, protein electrophoresis, blood sugar, cholesterol, triglycerides, lipids, blood culture, endocrinitis, septic emboli, all these things to think about in this setting of artery blockage. So, treatment, we talked about a little bit, digital massage, lab, dimox, topical agents, carbogen, TPA, and hyperbaric oxygen. That's something that's kind of now coming into four. They do have that capacity. So, whether we should have done it with this, it wasn't given to him, but that's something to at least think about. Some reports of possible success with that. Some improvement in vision. So, most patients end up with counter finger to hand motion vision. If they have a psilorentinal artery, they can gain vision about 10 percent, will gain 25th year better just in that little island of central vision. Neobascarization of the iris within about four to five weeks and 20 percent in the disc two to three percent. So, it's not as much as with central vein occlusions where you get the neobascarization problems. So, think humblest. Certainly, here's a hull and horse plaque. So, if you see it, that's evidence immediately. But in a case like this, again the ultrasound was helpful. Just the B scan, just put it on there. Just takes a couple of minutes and look in the area right behind the disc and see if you can see any kind of a high reflective thing like a plaque. Okay, another case. Brian, pick on you for this one. This is a patient with long standing glaucoma. I've seen him for years. He had cataract surgery in both eyes doing a while. Just came in for a routine follow-up on his glaucoma and no real symptoms. He said, my vision is doing great. Since the cataract surgery I'm doing fine. Pressure was 15 or so. I did a fill, just kind of a follow-up fill. And the previous fill a year ago had been pretty well like this. And this was his left eye and this was his right eye and this visibid. But the previous year, his right eye had been kind of like that, a little peripheral depression. But now he has this kind of a defect going on. Any thoughts on this patient? Good? Good thoughts? So you're sitting there at five o'clock. So what are you going to do at this point with all those things you're mentioning? Right, dilating. Critical. Which I did. But again, long standing glaucoma I didn't dilate that well. Just overpatient. Pseudophagic. So it's kind of hard to see the periphery real well of the retina. And so did the ultrasound and shallow detachment corresponding to that area of the field defect. So always think about that. These can really fool you. And especially it's hard to see the fundus. They can be really tough. They're shallow and they're just really kind of subtle. So this is superior. So he's a risk for spreading in the macula. So got him to the retina. Specialist. But always be thinking of shallow detachment in these kind of atypical cases. So detachment in general, 6% of people have asymptomatic atropic holes which do not detach. A lot of this was from the work of Norm Byer who was at UCLA when we were there and did a lot of this stuff with able to watch these things and they don't progress over time. Most of current patients age 40 to 70. The lifetime risk in the U.S. is about 1,300 or anybody to get a detached retina. Not getting all the different risk factors. Increased risk in high myopes. More than 6 diopters. Family history. Cataract surgery with vitreous loss with detachment. Rate of 10% trauma. And 15% in the other eye develop detachment. So Randy, current cataract surgery, high state-of-the-art FACO. What's your thoughts on detached retina? It used to be taught. It was pretty high with we used to do it. Is that pretty well evened out now as far as you know? We've done a lot of good studies on that in relatively large ones. So it turns out that if you're over 60 years of that age and you're glow anterior it seems like the big risk still continues in some services still up there. It turns out that treating everything prophylactically ahead of time doesn't work. If you break capsule which would really clean up vitreous risk and it would appear it's hard to find a pair of that. If I am large break capsule and you have to do dispersive viscoelastic in the chamber stabilize that hold it, high speed cut or make sure there's no strands in place group still left. The same for yagcapsillotomy too with that group I can't tell you this. So again, yagcapsillotomy you know where people are using relatively low power. A big series on that about six, seven years ago. Majid, you deal with these high patients all the time, ICLs and refractive procedures. Do you worry about RD? Do you send them all to retina doctors first to clear the retina or how do you approach it? You're probably inducing problems sometimes too with some attraction. The evidence is that you are inducing other treatment. Exactly. Okay. Clinical findings, hypotiny compared to the other eye, tobacco dust pigment, Schaefer sign, 70 percent and shallow detachment. Difficult to detect as we talked about. Here's another patient. This is an airline, commercial airline pilot in his fifties. He had kind of a visual loss in one eye that really couldn't be figured out. He went to a neurologist, had a CT scan kind of this weird shape thing in his right eye. He had previous trauma. He was pseudophagic years ago but 20-20 vision. He's kind of these weird vague symptoms and again hard to see peripherally because of the dilation problems with the previous trauma and IOL. The sound shows a shallow detachment, just that really thin, just really tough. Even in the best case where you can see well, in a case like this where it's hard to see, it's tough. So I hope the sound can really be helpful. So treatment, 85 percent, treated within one operation, 15 percent required, two or more. Is that accurate, Paul, in your experience? Is that a fair figure? We call it 95 percent. As far as first attempt. Failure, all the breaks not seen, breaks, PVR, macular on 90 percent, 24 year better vision. An example here of a patient with a mild vitreous hemorrhage hard to see but ultrasound can be helpful to actually find the retinal tear and that really can help to kind of speed things up. If you see that then you want to move more rapidly on vitrectomy and try to reduce the traction forces. So beware of the shallows. They're dangerous. So be thinking that. Always be aware of the funny things. Patients can't really tell you, I've got to attach retina. I see a shape or something funny. You know, you really can't see a good funnest exam. Ultrasound is just so quick and easy to do just to pick these up. So always be thinking that. Just a final word here. This is a project we did in Mongolia just this last fall. This is a gentleman that he had one good eye, lost the other eye from trauma years ago and diabetic and he had a vitreous hemorrhage about a year ago and he been to different doctors in Mongolia and there's no retina doctors in Mongolia at that time. So he was 12, he can't help you, go to China, go to Russia, they can treat you there but he couldn't afford to do that.  So just kind of lived with it, just kind of got by. And so our project was to actually train a retinal surgeon. We identified a young Mongolian ophthalmologist about a year and a half ago and sent him to LB Prasad in India for a 15 month fellowship. Really hands on and very good training, excellent training. And I went back with Jim Howard, local retina guy here in town and we took supplies he needed and kind of mentored him for a couple of weeks and did a lot of patients. He's done over 200 patients. I found out since we were there and he has an ongoing retina practice. It's made a big impact on the country and this just shows our first patient. This is a gentleman I showed the sheep herder who's undergoing a surgery. The vitreous hemorrhage is pretty simple with the tractor and a good case to start out with for this young surgeon. And so it did his case and here's the smiling Dr. Munkhaza that we helped sponsor to train. It just shows the impact we can have in third world countries. I know certainly Miranda's certainly premier in doing these kinds of things throughout the world but it's just very satisfying to be able to sort of and again have this ongoing even though we're not there. He's still there doing cases and we're still supporting him. That sort of thing is very gratifying. So I appreciate the opportunity to do that. So any questions, discussion? What kind of a potpourri? Just again, think of these things. Friday at 5 o'clock so kinds of things to do. Thank you.