We're going to hear from Griffin Jardine. He's going to talk to us about another interesting topic. And hopefully, we'll learn something about sudden onset strabismus, basically, when you're worried. Morning, everybody. I thought this was always a challenge as a resident. I think you see a lot of acute onset diplopia and strabismus. And when is it non-neurological? Other ways to differentiate. I've made a little reference to Hamlet's soliloquy here. And I think it's one of the most famous soliloquies in all literature. I think it's fitting because he's in this existential debate about life and death. And life has this sense of powerlessness. Maybe he calls it the slings and throes of outrageous fortune of the things that we're kind of subject to.  And I think that's similar to imaging, right? We're unsettled with the unknown of not imaging. And yet I do think when you send patients down that path, I don't think it's benign. I think all the testing we do has associated morbidity. And sometimes it's just emotional morbidity that we're leading up to the MRI. The family's in a real panic about this being a brain tumor. And if it is a brain tumor, we need to catch it. But I think it's a challenging balance in medicine that we all do with probably frequently. So I think maybe it's a more controversial, interesting topic in things like mammograms and cancer screening where these lead to biopsies and incidentalomas. So maybe it's your business that's maybe not as controversial. But let me start with it. Just go through a couple of cases on this topic. So first case, it's a first year medical student, actually here at the U, with sudden onset depletion with all these patients' permission, I share other cases. So never has had double vision prior to this. And they're really a healthy otherwise. Are there any questions? What are the questions that come to mind for you as to whether or not to differentiate this from being something that's really concerning or neurologic versus something that's maybe less concerning? Any thoughts? But great question. No trauma. Anything else? Family history, so no family history or strabismus. That's a great one. And I think we're seeing so frequently the genetic piece to a lot of the strabismus that we see in clinic. Binocular, binocular. What does that mean, doctor? Just kidding. Yeah, great question. Binocular. His medical student just had his anatomy lecture. And actually he was very interested in giving me some of these detailed questions. So good question. It's only he only has it in a particular, when he looks at particular direction, which starts. Disturption. To the right. Why don't we jump into the video here? So this is telemedicine out of the best. He actually said this to me before going to the ER since he's kind of an acquaintance. So that's where he's doubles. The whole story is he's actually neighbors with my brother-in-law. And this came up in a conversation. My brother-in-law said, I think this is what Griffin does. So yeah, so why don't you text him? So that's the video. So now, does that answer your question? Image or not image? Who wants to get an MRI on this guy?  Kathleen, what a great thought. So let me get to that real quick. So here we go. You see clearly what's this called? What diagnosis or clinical description would you give this? Especially in right gaze. I know you all just eat, drink, and sleep through business, right? It's like the great topic of ophthalmology. So left, if you think overaction, which would look like what diagnosis? We're going to left. Fourth nerve palsy, yeah. So I asked him, well, how long have you been tilting your head? And his response was, I tilt my head. And Kathleen's recommendation, I say, can I just see your? Because he said, this came on on Sunday. I've never had it before then. And it came on Sunday. And I can now have double vision all the time. And I said, can I see your name badge that was taken six months ago as a student? Here's our question. Handled boy. He looks like he's really in this great existential debate there. So I get his name badge from six months ago. And what would you see? It's not a new head tilt. Yeah, Bob, the next thing. So he's got what we call facial asymmetry or mid-face hypoplasia. So in patients with congenital fourth nerve palsies, their face morphs and absorbs a little bit of the tilt. I'll give you some more dramatic examples here. But look at that one. So if you draw a line between their lateral canthi and the edges of their lips, you can see those two lines are not parallel in these patients of congenital fourth nerve palsy. Another one, here's the most dramatic one I've seen in literature back from 1967. That's from a congenital fourth nerve palsy, all that facial dysmorphism. So of course, I'm twisting the story here. I didn't get to see him first. But if I saw this patient, I would have not gotten an MRI. I think we've got plenty of data to suggest that this was an acute decompensation of a congenital problem. But the ED got him first.  And of course, everyone's a drug addict until proven otherwise in the ED. And he turned out to not be a drug addict. So fat-scanned photo album topography is what kind of differentiated this as a congenital congenital problem. So case two, another medical student. You should sense a pattern here. We're probably doing something wrong in medical school to cause all this to your business to come out. So acute onset esotropia in double vision. I'm guessing the same set of questions. So here we are, image or not image. Are there any things that you want to look for? I heard Benedict Cumberbatch played a fabulous hamlet. That's what they say. So what are some of the things you can look for in exams? Anything that you could use on exam to help differentiate this from a neurologic emergency versus a non-emergent issue? Great question. It is competent. Full ABduction in both eyes as well. Anything else on exam you're going to look for? Expound or why you would look for that? These great neurologists in the room. Yeah. Anything else? Psychopathic refraction? Yeah. Late in hyper-over. One of our big questions is with all these esotropias, there are an accommodative component here. So let me go through these exams and things that we saw. So I don't have pictures of this patient, but these were some of the features we saw here. What's going on here? Let's shout out what the finding is. So looking in either side gaze, what do you notice? So yeah, there's bilateral, inferior oblique overaction. Is this a bilateral fourth nerve palsy? Probably not, because this is esotropic patient, but they've got this inferior oblique overaction. As we're doing the testing, cover up one eye and uncover and we see the eye has just floated up quite a bit after being occluded. What's that called? DVD. For time sake, I'll jump ahead with latent nystagmus, right, the euclid one eye. And then you have a nystagmus that comes out and it's the fast phase beats away from the euclidur. So these are all features of a congenital strabismus complex. So patients who have inferior oblique overaction, DVD, latent nystagmus, and no stereopsis, they almost definitely had to have this from birth to get all those features. Why did this woman acutely decompensate? That's a question for the wellness committee at medical school, but we see the patients can maybe have some degree of motor fusion. But when they lack, when your eyes are crossed in the first year of life, the ability to be binocular and have sensory fusion is significantly disrupted. And that causes patients to have all these phenomena. There's a question that usually kind of ninches, or kind of, what was it, not, clutches. Clutches, thank you, clutches this, which is anyone, anyone, this is a good sort of thinking question, but any thoughts? How could you ask this question, ask a patient about their binocularity and their before this, because again, this came on on Wednesday, it's Friday. What's that? Sports. Sports, being able to, like, depth perception questions, yeah? Any others, any others? 3D movies. 3D movies, those are such a rip-off. They're just 2D. Yeah, that's a great one. They always say, they always say, it's like the emperor who has no clothes. It's like, I guess I should be thinking this is normal, because everybody else seemed to enjoy it, but the movie sure doesn't look 3D to me. The movie is 3D. Yeah, yeah. I've had patients not tell me that they didn't pass the 3D component of their driver's license test. Oh, interesting. The one that I find is a really high yield is binoculars and microscopes. They always have to close one eye because they can't get the two images to fuse together. And she says, I've never been able to use binoculars my whole life. So again, I wouldn't have gotten an MRI on this patient because I think there's enough to suggest it. Then I had the luxury of the MRI, the ED already got a MRI and it was normal. So I think that is that question. So let's do a third case. Shout out, what are your concerns, thoughts on this patient, whether you image or not image? Ritual bulbar on the shutter? Yeah, so they didn't get a block for surgery, but that's a great question because sometimes we put the block into a muscle inadvertently and can cast your business. It was good. I mean, it was 20, 40, 20, 50 and she's now 20, 20 in each eye. Ooh, yeah. Look at that brow. What do you know about that right brow? I mean, she's really engaging that right brow. So this is pretty significant ptosis in addition to, you can see by the corneal reflex and ET. So what's your feeling on this one? Bayesian, what are you seeing so far? Who would image by raise of hands? Who would get an MRI? And this has been very gradual. And who would not image and just say that we- Do a sleep test, rest test. A rest test? So rest test is negative or she doesn't have increased. No signs of my seeing it, but a great question. So let's just show her motility exam here. This is a great example of classic floating saccades. Watch the right eye here. It moves much more slowly as the left eye darts over the right eye floats. So what's the diagnosis here? Right six. Yeah, right six, nerve palsy. Ptosis is on the left side now. Yeah, the ptosis wasn't as obvious here as it was in the picture. So on clinic, I'll kind of repeat the exam. It was pretty consistent right ptosis. So that's her MRI. So she had a baseball size meningioma. They got the MRI on a Friday and called her back in and did surgery on Saturday. With that degree of kind of herniation and midline shift. It was amazing that she was so well. Her personality had changed over the course of a year and she just thought it was aging. And anyway, she was, they got this successfully resected and she did great. It was slow growing, but it would be taking a lot of space. You can see it invading the cavernous sinus. And I think on her, one of the take-homes is she had multiple cranial neuropathies. And I think that's a definite reason to image. You can see here is where she would probably have the, where her cranial nerves were getting compressed. So her surgery, there's a lot of things you can do for a six nerve palsy. One that's kind of a newer thought is, because we wrestle between resecting and resecting the horizontal muscles versus transposing the superior and inferior rectus over to the lateral rectus, so that it can help pull the eye or supply abduction power. And then there's another kind of combination of the two where you transpose just the superior rectus over. So we'll put the superior rectus right next to the lateral rectus and then sew the two of them together about eight to 10 millimeters back so that that superior rectus is pulling or providing abduction power. But in most cases, the medial rectus has been contracted because it's the eye's been esotropic for so long. So that also needed to be recessed. And this is her after surgery. What's interesting is you see that she still has limited abduction as well as limited abduction a little bit. So unfortunately, we can't give these patients full range of motion, but we can give them hopefully what we call a range of binocular vision where at least they can look a little bit to the left and to the right and still have single vision. And she did well from that. Okay, one other case, a seven-year-old with Noonan syndrome. So I see her just as a part of screening, we see a lot of syndrome kids that have a high incidence of ophthalmic pathology and associated with the syndrome. And as I'm following her, she's developing this kind of small angle. It's actually meant to be intermittent there at first and then increased to 35 degrees over the course of about six months. So this is not an acute onset. Is there anything that you could think of that would make you wanna either get an MRI or not get an MRI here? No papillodema.  She has none of that. So I thought I was okay to not image and get into a meteororectal recession. She's a little under corrected and I'm not panicking because it's strabizma surgery. I wish it was more precise, but it doesn't always get exactly what we expect. So she's using it well. And then nine months later comes back with this. So now she's crossing more than she was even the first time around. And so now I think, well, we ought to get an MRI because that's a very unusual evolution. Still has full abduction. Do you have a full abduction? Still has full abduction, yeah. But you have a stroke. Got an MRI. This is tough. I wouldn't have seen this because I'm, but if you look right here, anyone wanna name that diagnosis? Yeah, Bob got it. So it's a Chiari malformation and it was considered by neurosurgery to be about type one and a half. So there is some kind of lower brainstem compression. And these haven't shown in the literature to be associated with a concomitant esotropia. So it's, I mean, this is, I share this case because I probably should have gotten the MRI the first time around. And it's not always obvious. You don't always get clear clues as to whether it's an image or not. So you'll get decompression surgery which has also been shown to correct at least partially their esotropia. This is a great study I think I'm trying to help navigate some of these complex decisions. So this was a number of cases that they grouped into different ideologies as far as sudden onset esotropia and what it ended up being. So Bob mentioned this, you know, if it's accommodated, meaning you find that they're really moderately or highly hyper-opic, that's a large percentage of the patients that we see that have this. You know, a decompensated esotropia, again, that's been in that category of it's an acute onset of an old problem or of a chronic issue. So we still see a handful of idiopathic causes. This is of course number four is the one that we worry about missing a brain tumor in these kids and 6% incidence rate maybe that, you know, one of the debates we have in medicine is what's, you know, we talked about the number needed to treat and maybe there's with imaging the number needed to detect.  That's, I don't think anyone would fault you for that. The, but in these cases, so you took from four down to this bottom point here, these patients all had either papillodema, a really large angle esotropia or they were older than six, which in Pete's, yeah, seven year old starts getting pretty old. So the, my patient that had the Newton syndrome was seven. So they would also, based on those criteria, probably should have immature just based on her older age. But yeah, I think these are not easy cases, but there's a lot of clues and cues you can use to at least try to give you some positive predicted value before you go into getting MRIs as to which who's likely to have pathology and who's less likely. The, some of the principles I use are again looking for those congenital clues I went over. Number two, a neurophthalmologist taught me this, it was two strikes in your out, which is if you see, you know, concomitant strabismus, that's one strike, but by itself that often is an isolated phenomena. And for every one case I saw of that Newton syndrome case where there was a brain tumor, I feel like I've seen 30 cases where sudden onset esotropia, they were totally fine. Everything else was actually normal and their normal brain MRI or we didn't get MRI and they continued to be fine. And I think the big issue of medicine right now is this big fear of malpractice lawsuits and missing something. And my personal experience is, is that when we partner with the patient and make it a joint decision, they feel like they played a role in the decision enough that it wasn't any one person's fault. And that Newton syndrome patient, for example, I had talked to her about her, my concerns, whether the image or not to imagine, the mom and I both kind of elected not to get the MRI the first time around. And she wasn't at all upset the second time around when we did get the MRI and found that syndrome, because I think she felt like I was being completely transparent with my thinking with her. And of course, not every patient is that maybe kind and forgiving of the things that we do that or the mistakes that we make, but I do find that that is quite protective. Patients typically don't sue because you miss something they sue because you abandoned them and didn't explain it or did communicate clearly. Any thoughts on this kind of question or comments? Or the, Bob? Well, I think this is great. Using a thoughtful approach to work through things, work with the patient and the family is absolutely what you need to do when you're right on target. This is great. Thanks. I think it's, anyway, in pediatrics, we have the added kind of concern or morbidity associated with imaging that they're put under anesthesia. It's kind of a big deal, it's a big deal to families. And you can see parents on ice always, their pupils dilate every time you talk about getting an MRI on their kid. And from that moment till the time they get an MRI, they're in panic mode about what the MRI is gonna show. And so I think that decision should never be taken lightly and again, it's not always straightforward. Go ahead. I was just gonna say, even an adult, the downside of an MRI is a lot bigger than it used to be with the structure of health insurance now where a lot more people have fight-inductible plans. So you order an MRI and someone might be paying a few thousand dollars just out of their pocket to get the MRI. So I think they at least like to be involved in the decision and know why it's being done. Yeah, totally agree, Brian. By a raise of hands, who here has found an incidentaloma that really caused a lot of patient distress on an MRI that was unrelated to the pathology? Yeah, I think it happens all the time. And I think when you find these things, I don't know if we're really, sometimes it's a serendipitous discovery of a brain tumor that we thankfully caught. Boy, we were lucky that this led, that's the secret of events happened. But a lot of times it just is something that they've got to worry with and they're already maxed out on their stress. Anyway. The other issue that's come up is similar to your unit's patient. The patient who's got comethythetropia has a key artery, but without other neurologic findings that would mandate that the key artery be fixed. I've had the neurosurgeons come back and say, well, straighten the eyes out and I'm not gonna decompress it because I didn't think there was enough reason to do it. So that is an issue and so that if they're being decompressed and it's gonna help, that's great, but it hasn't been a universal thing. Even with the key artery, you find it and you say, well. Yeah. Bob, I'm really curious, your long-term experience with that because I've also, the neurosurgeons that I've talked, I'm also surgery is a way better risk profile. It does. If esotropia is an isolated neurologic finding, what I found is those kids ultimately needed decompression in the end. Is that what you found out? Yeah, it is. Ultimately, they get decompressed because I think at the very least what we do is we cause them to look at the kids more closely. They're looking for other things that they can relate to it. And so I think bringing that to their attention, most of the kids where I've had pushback ultimately have been decompressed. And when they're decompressed with recurrent esotropia after one eye muscle surgery, they straighten out and Jack Walker, who was the initial pediatric neurosurgeon in the Intermountain area, was convinced that decompressing key arteries and untethering cords, both resulted in straighter eyes. And the patients that we jointly followed through spina bifurcate. Interesting. My patient, I think if I would have gotten the MRI the first time around, I would have had that same debate. They said, two miles, deutervous with surgery, it's a low risk. So in the end, it probably would have changed management because we would have gotten to this point anyway where the hysteria came back before we would have done a decompression. But now I think it's pretty clear that they need it. But let me turn the rest of the time over to Rachel. Oh, this last point, you know, it's interesting. We all take it off to say first do no harm. And that can be interpreted out of their way, right? First, don't miss anything because that can be harmful. Or don't over test because that can be harmful. So it's a really interesting dilemma that I think we all struggle with. And I think the more that we collaborate and part of the patients, the better. And we also have to figure out how we're, you know, got to fight the fight against de-conversations to business and medical students. Probably just not too much. Okay, thanks everybody.


The following is a presentation of TFNN The power trading hour with your host David white Call now toll-free at 1-877-927-6648 or internationally at<PHONE_NUMBER> Now David white Here there we are And welcome to another excellent edition of the power trading hour with me your host and as always it doesn't What or when matter where me is or you is as long as you and me are here at the appointed time? Yeah, I don't know why All this stuff keeps get getting reset But it certainly does Um, yeah, I know Everybody there anyway the time and I know I'm a little bit blue today So we're gonna fix that in the settings right now You never know when you're gonna get everything reset Come on mr. White balance There we go Anyway eight seven seven nine two seven six six four eight as we've made our way through the Issues so far today You can email me at path at TFNN comm but let's just get into the sit rep today We've got a reversal And we talked about the reasons for it yesterday So far all I'm seeing is the same pattern that we have almost every options. I mean not at options, but every Window dressing and that is if you go back just look in the charts go back and look at a couple of days before window dressing and guess what There's always a Plop down now could it be more than that it certainly could But we talked about that yesterday I wrote about it in the newsletter this morning and that is before Window dressing they generally shake the weak hands out. So could it be both? Yes, but I'm not a big fan now. I did take the long position where we had some decent money in it in the Tech insider and got out of it about ten o'clock this morning. We also went ahead and bought the spy Three the 390 puts and Most everybody from the emails. I'm getting from subscribers should have gotten in to those around two dollars or less And of course, they're printing more than seven bucks today So in a for a long time one of the biggest days we've ever had in the newsletter So well, we'll continue to look at that I am both an equal equal opportunity long and short position person if you are stuck on one side of the other I think You're missing the boat and that is if you want to be short You're probably long term going to be right But you better be able to go to the top of a mountain and ignore everything Because you're going to have a hundred times where it's going to have a big bounce like we had over the last few days and weeks and months You just get them and they tend to be very sharp and everybody thinks that the everything is over and that's That's Not it so You know the problem I have is that everybody wants to short and they short and they short and get Stopped out and get stopped out and stay stopped out instead of waiting for some kind of signal to reshort or just walk away Quit talking to anybody and just stay short Sit on your hands Forget turn off the screens and walk away because that's the only way I think you're not going to throw all that money that you do make being short away Anyway path at tfnn.com so you can always check that out We've got some emails already coming in But that's kind of it at the moment. So do we know whether or not this is just the standard? Pop down before fun buying well, I Would say that at least for me. I don't I I don't have any evidence other than it being that right now We forecast it. We did it in the newsletter at 9 o'clock. We had an update at 10 We went short. I don't know I mean this as far as what I'm seeing is some of the most predictable kind of action in the market For the patterns that I like to trade now.  There's nothing risk-free in the market But this morning was risk-free. That's it now one of the reasons that are a couple of the reasons I talked about in my newsletter this morning To be where wary was a very low trend number in the in the AmEx Now the as we've talked before and we'll probably repeat very often part of that is That they are mostly the longer term Or let me put it not longer term they've been around longer ETFs and they're not a lot of the tuples and triples and they tend to be mostly long and You know, there's what 250 or 300 or so Stocks on the AmEx most of them have moved off, but the ETFs continued to To trade there and it's a probably for the trend and the tick I love that one the best because it's very tough to jigger around and Looks fairly and it looks fairly consistent, but trading the extremes of that is one thing we also put out that the put call ratio on the VIX was extremely low and Before any of this happened said to watch out for Some severe air or clear air turbulence That's what they call air pockets if you're a airline transport pilot And why they tell you to keep your seatbelt on and that is they may know something's out there You can't see it. There aren't any clouds They're in any lightning. It just kind of comes out of the blue But you know, they can kind of predict it with what they have now or know that it's out there But you may have some bumps and and turns But just out of the blue kinds of stuff like happened today for a lot of folks who didn't see it coming Did I know a hundred percent that it was coming? No I thought it was anything that I think a hundred percent is probably wrong 80% I tend to see a great deal more so Let's see got a few emails in here. So I'm just going through see if there's anything. Okay The Apple doesn't far of fall far from Qualcomm Of course on any bad day, there's always some stocks that do well So let's go ahead and pop this up. It's another thing that we've talked about for a long time now Looming inflation we are purchasing powers eroded. 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Tom O'Brien is here to help Tom O'Brien has been successfully trading markets for over 30 years a frequent contributor to TD Ameritrade Network and CNBC Tom O'Brien founded tfnn over 20 years ago to help educate investors just like you Tom's daily market newsletter market insights is published every morning when the markets open to give you the competitive Informational edge you need to succeed These newsletters are packed full of Tom's advanced technical analysis in our gear to deliver comprehensive strategies for a successful portfolio Get Tom O'Brien's newsletter market insights today and try all of our products and newsletters 30 days risk-free with our money back guarantee at tfnn.com tfnn educating investors Toll-free at 1-877-927-6648 internationally at<PHONE_NUMBER> As we're back here, we continue to kind of come out See we got some more emails here Okay Pete says your market timing has been pretty good Do you think we peak today or do you think we have more one more push higher into the fourth? I like I said, I don't think that there's a whole lot in here that tells me that this isn't the standard pattern of washing everybody out Before they push it back higher now Could we get some kind of technical signal today that says? That there's a lot more to this I would think that it would be in the volume and we've got about 7.4 billion shares now So is it good? Yes. Is it blowout? No so Again You know, we've got to see kind of a market that is You know, you can look at it half Half full or half empty. I am short. I'm not long anything We got out this morning by the hair of our chinny chin chins in the long-term news letter and in the short term We went and put as they say when it's raining money put out some buckets and we did that in the spies I'll be out probably with those puts today by the end of the day But generally you have about 24 hours or maybe a little bit longer if this is just a Wash out, but I was looking for something around where we're at now 3820 ish 3825 ish for the low side before we started heading higher into fun buying and Weird things have happened now could this could we do nothing and not bounce we could but my guess is We're probably seeing a lot of folks Get out of Positions going into a three-day weekend that fun buying will probably be when we come back on Tuesday So am I gonna want to get in front of this a great deal and expect we're gonna have a big bounce Maybe in some short positions, but not in a whole lot. Anyway, we're talking about Qualcomm and Apple We've talked a great deal about Qualcomm being in the black arts and in electrical design This has a great deal to do about Stuff that you just can't put calipers around it's a lot of feeling It's a lot of intuition and Whether it's a I kind of think of two big examples in the past and that was Trying to go past the speed of sound with an airplane and Dale Earnhardt who was really good at Restrictor plate ratios at Daytona 500 and Talladega They said Dale could see the wind and really understood how to use it and and everything else and of course A lot of the people when they were trying to go supersonic They started to kind of understand it but they had to break a lot of the thinking that they had before and some of it didn't make sense and When you get to Qualcomm they are in that part of electronics. That's not digital They are in radio frequencies and just a lot of stuff does not work at all like people think But that's kind of it anyway I'm expecting a great deal more than we've got today. No, you still have a downtrend in a bear market That downtrend if you just drove along drew a line from the high back here at 191 on February 3rd Down to today's high shows that you're probably just coming up to a downtrend line, but again This is a company. I'd probably more want to be long than short when we find a bottom There are a lot of stocks that are just horrible and generally you want to short the week and go long the strong and Qualcomm is not the weakest out there Okay, we got that handled Do I think visa we'll take out its highs By 715 Okay It's hard to say. Oh, this is wrong Let me do that. So I get the Get the title correct. Okay, you've got what amounts to a little bit of a reversal signal You could get back down to 195 Hard to get very bearish on Anything that makes money on higher interest rates as visa and Mastercard will but you know throw the baby out with the bathwater The problem is I wouldn't want to be Long any of these until I look at options Probably the first couple of days in the next week So There's that because we could either go sideways we could go a little lower, but I'd rather see Tuesday morning come back in and be maybe long this then be long it in the next three days a lot of risks Not a lot of reward You've got something that looks like kind of a little bit of a reversal pattern There isn't much volume today though 2.4 million shares compared to 7.7 million shares up just two days ago Like I said, I think that there are probably better shorts out here He's got the 210 calls The big problem is just how much are you gonna burn up in premiums in the meantime? I'd rather probably Like I said, I bought puts today, but I'm getting out of them before the end of the day and cash in the register More than likely I would say or there's a better preponderance of evidence Saying that maybe we just go sideways or a little higher and the real money comes in Tuesday for fun buying It's not coming in today, and we've seen this pattern before so nothing new there Okay,<PHONE_NUMBER> Okay Prime day deals are leaked. Well, they shouldn't do that. They should be sealed Okay, what else do we have here? Okay, now so that gets me to that was there anything else my list of stuff on Nike Out here one of the reasons I kind of decided to pull the trigger to was watching Nike and watching the the roasting of people that were short this early in the morning and And We're gonna find it out I have it here I just can't remember where everything is Anyway You're back down Options showed about 105 to 110 going into earnings last night So I was kind of surprised that they ran all the the shorts out this morning But one of the reasons was when I saw all that and it started to fade very quickly Is when I started to really change my tune and figure that this was a trap while you're back down to 102 95 for the low of the day and you got a ton of volume so watch out Energy was a little bit more on the way back down to 123 82 I wouldn't a big fan trying to play this overnight But it seems like there's more pain Coming their way. We'll be back in a minute If you want to take advantage of this sector now is the time to subscribe to my gold report The gold report is a comprehensive look at the metals sector as well as the markets that move gold Which is the currency and bond markets new subscribers get a 30-day money back guarantee So you have nothing to lose every Monday morning I published a gold report with coverage of gold silver bonds the XAU HUI GDX as well as more than 30 different mining equities To see for yourself the types of profitable trades that are recommended within the gold report sign up now by visiting Tfnn.com don't miss out on the next great gold trade sign up today Tfnn has just launched their new trading room the tiger's den hosted at discord Tfnn has been educating traders for more than 20 years with live programming hosted by a variety of professional traders during market hours And now they are expanding their reach with the tiger's den available to all tigers and tigresses for just one dollar for the year There's no catch or added costs when you join our community of traders in the tiger's den You can look over the shoulders of tom o bryan and the other tfnn hosts while they analyze charts during their live tiger tv programs And join an interactive trading community with hundreds of members exchanging ideas Interact with other tigers and tigresses as they share trading ideas news analysis and discuss the market action all trading day Even at night and on the weekends the tigers den at discord is accessible on mobile or tablets as well So it's always at your reach to sign up today and become a part of this educational community of traders Just visit the front page of tfnn.com Tfnn is excited about our new software charting program the art of timing the trade charts In collaboration with tom o bryan and using his best-selling book the art of timing the trade your ultimate trading mastery system David white has programmed an outstanding piece of software that will complement any traders methodology Using this first-of-its-kind program the art of timing the trade charts allows you to scan thousands of stocks for Fibonacci formation setups including guardleafs abc's butterflies and much more The art of timing the trade charts is designed to help you when scouring the markets for stocks Just beginning to form the trading patterns that many investors spend days weeks or even months searching to find And right now we're offering licenses available at only seventy nine dollars a month We are so confident that you're going to love this new charting software that will even give you a 30 day Unconditional money back guarantee don't miss out on this incredible new piece of software Get your copy of the art of timing the trade charts today by visiting tfnn.com This segment is brought to you by think or swim for more information Just click the think or swim banner on the front page of tfnn.com As we return to question in the den when I buy vixx calls And the answer is I don't think so again, um Maybe something happening. I don't see but All that's happening is exactly what I thought was going to happen Which we were going to come down to some point that was fairly close To the lows in the 3800s. We got a little bit too much too fast And if the volume shrinks we see some support then You know Then maybe we have an opportunity to buy some stuff for fun buying next week Maybe the whole thing blows up, but as I say many times I don't have to know that if I drive like I'm in fog Then I won't out drive my headlights or my vision and right now I don't have to make a decision But most of these Kind of episodes that happened right before fun buying where they wash out all the weak hands right before The markets roll much higher And I still suspect that there's a good chance of hitting 4000 on the sb cash before we Head back down even lower But You know Right now I'm short Making money. I'll be flat by the end of the day Uh taking some of the biggest profits In a long time that we've had that weren't on options exploration day Uh for being able to buy something on a tuesday and seeing it go from two bucks to the mid sevens Uh in a day or mid eights now, excuse me um And yes, I'm slowly selling into all of this as it goes by But I'll be out before the end of the day and we'll see what happens tomorrow But uh seven and a half billion shares Not a blowout so far. Maybe we'll have a lot more volume that comes in But uh, I just suspect we're probably going to hit some kind of low in the next 24 hours that's probably Uh a low it may be buyable It may not be and we may just kind of go sideways with everybody selling everything and headed to the hamptons for the week, but uh I will go spill my uh Go sell my ill-gotten gains somewhere else eight seven seven nine two seven six six four eight uh question about micron uh Still the head of the pack um Again, like a lot of these you want to see the high volume lows retested in this case the june 17th low um There's a lot of reasons that I wrote about in the tech insider on friday That I think uh both memory and video card companies are uh are Why I wouldn't buy them now right at the moment um long term have uh some good profit potential going forward Now Does that mean that because I like the business i'm buying the stock the answer no But if I like the business and I can get the right price That's where those two things line up But uh high volume lows get retested And so you're looking at 53 60 one more time.  You got up pretty close to this double gap Uh right at about 60 150 ish um and uh that goes from a long existing gap uh before The 10th of june and then that gap down that gapped over that existing gap down Then you have yet another double gap Here where you're sitting on it right now But um to be long I wanted to get back into this candle and what was the high of that candle? High 56 32 So you need I wanted to get back into that candle Do so with a whole lot less volume that 24 million shares Which I don't think in the middle of the summer would be problematic So there may be a buy back down in there in the 55 Uh dollar area if it comes back on like 10 million shares or something That may be a place that you can get long for the fall once uh all the discounts for all the bad news are in For a market<PHONE_NUMBER> I'll get some more emails here Uh to two smh's I'll take a look Okay Um Well, you came fill this gap about halfway. You're down today You wanted something less than eight million shares. It's not bad. Um The real yardstick is eight and a half million shares or 8.44 million shares back on the 17th Uh, you're almost in that with about 3.4 3.5 million shares So let's say you end up with 6 million shares today Which would be a fairly decent close against the 8.4 million share low There may be some kind of viable low out here soon enough. Maybe it's next week Again, I'm not a big fan of getting into Markets unless I'm looking for short squeezes Into a three-day weekend, but there may be some of those. We'll see how that Shots up. Okay Okay Did I miss any other questions about the vixx? I'm going through the den Look through my emails. Don't have anything else. Okay Uh question about the ibb from ron Keep them coming at path at tfnn.com or post them in the den Um, so on the ibb actually had more volume than the previous i Previous high on june 8th came at 1 19 64 3.2 million shares 4 million shares one Let's call it 1.8 million shares yesterday. You're down on 1 million shares today ideally Not a bad day very light volume so far. We'll see how the end of the day comes in but You know if you got a decent retest or re Yeah, a retracement 1 14 31 is just a 382. It doesn't Hurt the bull case on this. You had some very decent volume on the way up compared to the way down So there's more things saying That biotechs have had lows That don't need to be retested Uh, you tested the 105 low of may 12th that had 4.7 million shares with 3 million shares You had a couple of doji's out here, uh, which are either bottoming signs or halfway Downsigns and it did rally So it's giving you from fairly good signals and you have to look at the glass probably half full But i'd see 114 on the ibb maybe Ish 112 40 is a 50 percent retracement on that bounce and then that may set up an abc But uh, things may get better in that Uh, when will I have tim ward on again? Uh, we'll have him on on thursday. Uh, I talked to him on monday So he's feeling good and he will be back Uh to to okay What else do we have here? Uh, yeah, get your questions ready for tim And we'll have it on great Okay to Question about ccj Let's take a look at that. Um You know, you just had a bounce. Um, I do like this the way that this made a low as we said before though when I Am looking at a stock. I want two things. I want the previous if I want to go long I want the previous volume to be significantly less And you had that what you didn't have was the energy on the way from the top back down to the bottom Uh, less than from the bottom up or more than the bottom of the way top So you've got kind of big signals a little more energy on the way down Lighter volume that's pretty to be as slow. So you may need a little bit more solid Back in the market for buying or selling real estate in the bay area Including the surrounding st. 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It can seem impossible to keep up with all the information David white's investment newsletter the technology insider is designed to give you all the information You need to understand the technology that shapes today's markets and tomorrow's future David white has made his living staying on the cutting edge of technology His weekly newsletter will give you specific recommendations for value tech stocks As well as entry prices target prices and stops to set for each trade Dave delivers his weekly newsletters every friday with updates throughout the week You can get the technology insider at tfnn.com for only 37 dollars and 50 cents Sign up for david's newsletter the technology insider and get an inside look at everything the technology sector has to offer Try it risk-free today with our 30 day money back guarantee tfnn educating investors Are china a shares hot or not? If you trade china a shares now may be time to take a closer look trade chu or chad Directions daily csi 300 china a share bull and bear etf's china a shares in either direction Visit direction investments.com today an investor should consider the investment objectives risks charges and expenses of the direction shares carefully before investing The prospectus and summary prospectus contain this and other information about direction shares to obtain a prospectus or summary prospectus Please contact direction shares at<PHONE_NUMBER> The prospectus or summary prospectus should be read carefully before investing an investment in the funds is subject to risk Including the possible loss of principal the funds are designed to be utilized only by sophisticated investors such as traders and active investors distributor four-side fund services llc This program is brought to you by vista gold traded on the nyse american and tsx under the symbol vgz And as we come back i'm getting a update out to subscribers and of course, uh As I type this out You can think about going and uh Buying some of those tiger dollars and uh subscribing to either one of my newsletters and of course you can uh You can also uh get the art of timing the trade chart All three of those Are available through your tiger dollar purchase and a way to make a save a little bit more money on the subscription Uh two two two. Okay got that out Okay Okay Hi david kin. I start buying amd for a bounce. I looked at it for one of the other dinners Today and options really show, uh about 80 bucks Um for a fairly decent support now Not uncommon Uh, you had the same energy on the way up then you had on the way down So you want uh probably another retest of the lows, which are getting now may 12th $83 27 cents 130 million shares You break that by four bucks and get back into the trading range with 105 million shares Now today you got about 75 million shares. So you really want that to come in less than about 100 million shares uh today And you really don't want it to go beyond that But uh options uh have a fairly good five dollar range or they did at one o'clock So at least option market makers think that maybe the bulk of the destruction in amd is over But that does not it mean it's going to bounce right away It could just kind of go sideways and burn up a lot of premiums on puts Again, this has been a market where they've taken you to heaven and held so many times You are starting to your head starting to spin So what I'm saying is that after this move We're either going to blow up tomorrow, which I don't believe Or we're probably going to go sideways for a while and then maybe see some overly shorted stocks start to move higher But the real move in the index is probably on tuesday when we come back Unless there are a bunch of redemptions now Um people have to buy If you're a fund manager, you gotta buy And that's the last two days of the month or the first three days of the month So you can buy the fifth sixth and seventh the way the calendar has um, but uh You know what? That means that as far as Going into this weekend Could it be hard to get any kind of bounce could could go lower So i'm a fan of probably waiting until you see the whites of their eyes and that may be fridays close Uh, if you're thinking about buying some calls or something Again, the problem with that is you're going to get three days of burn for your option premiums So generally what I like to do is come back in that monday night of the fourth And if you I don't create a lot of futures But that may be one way of doing it the other way is to wait till uh tuesday morning a lot of times You know after a three-day weekend it'll just kind of go sideways for a little while And then you're going to start seeing the money come in about one o'clock for fun buying But uh, I think a lot of people getting uh the court cart way ahead of the horse Mostly because of the way of the three-day weekend And fun buying comes in this time eight seven seven nine two seven six six four eight. I look forward to your call um Anyway, yeah, I think you know A five dollar range. Maybe if you bought calls on the thing because you're at the low end of 80 bucks Uh, maybe it bounces to 85 bucks next week, but it's uh, I don't see anything saying it's going to 110 Uh, of course, uh options, uh exploration really starts, um on The eighth So you've got a little bit before you really get back into that cycle and I get a little bit better Visibility Okay I'll get back to that Okay, we got that Okay, uh question about streamers and what do I think of it? I'm disappointed in disney. They tend to have some very good numbers for the theme parks Um subscriptions, I think just because of the horrible job they've done on star wars Uh, people like me have uh canceled their subscriptions Um, not for any other reasons other than the fact that they made a horrible horrible disaster out of uh Those latest star wars venture and the only one where the executives didn't do anything with it and ignored it Uh, the mandalorian is really the only good thing. Everything else is just horrific I couldn't make it through the well the third um addition of uh This latest star wars venture. It was horrible. Uh, a lot of this stuff looked Just looked cheap and bad The script didn't make any sense Um, and a lot of the other stuff they have on there just doesn't appeal to me either. So, um, you know To tell you the truth uh hulu and paramount have gotten a lot more of my uh, uh, my interest as of late with, uh, um The orval uh for sci-fi and uh just last night. I only got to watch a little bit of it But, uh, what is it the murder? What is it called? Steve martin Thing with uh the murder Oh god, I can't even remember the name of it. It's season two of it. I really liked season one It's uh, a lot of things don't blow up and there's not a lot of special effects But I were maybe somebody in the den Knows what i'm talking about murder Mystery club murder. Ah, I'll think of it in a minute. Steve martin though I can Steve martin and uh martin short. How can you how can you not like those guys? Anyway, it was cute and fun And uh, they've done fairly well at least in the first one I saw Maybe somebody remembers that murder Mystery. Yeah, anyway, it's on hulu<PHONE_NUMBER> Okay, so anyway, um Netflix Um, yeah, I don't see a lot in these streamers Um these things gonna need Uh, the probably the good thing is that you do have a high low volume low in Netflix It would probably be the stronger of the two between disney and them um You didn't ever actually pierce the high volume low of may 12th and in a bear market With lighter volume. Sometimes you get a bounce Uh, but uh, my guess would be that you really want to see in a bear market You really want to see those lows tested with lighter volume And pierce the low not just get down there in the volume all dry up You're probably going to get a bounce in this case 164 to 192 But does that mean you're out of the woods? Probably not you want to get back into that candle. You really want to pierce it And go below it and then come back up Uh question on my trade yesterday that I didn't stick with Which is wheat Uh to to um you got a little bounce out here. I still like that, uh The downside is the energy came in but I did get a lighter test Out here of that $9.49 low got the 930 yesterday 4 million shares compared to just under seven So maybe there's something uh out there in the grain Vista gold owns and operates the largest undeveloped gold project in australia the mount tawd gold project Vista gold just completed their feasibility study resulting in a seven million ounce gold reserve Vista gold has all major permits approved and has retained civc capital market assistance in evaluating alternatives and in completing an accreted Transaction vista gold trades on the nyse american and tsx under the ticker symbol v gz Vista gold executing a strategy to create shareholder value You might think that if you want to be successful at trading in the stock market You're going to need a crystal ball after all it's impossible to predict the future, right? Like any endeavor in life before you decide it's impossible get some advice from the experts You might find that it's not so impossible after all for daily market overviews that give you direction on the key indices Selective stocks and commodities subscribe to the opening call newsletter at tfnn.com The opening call newsletter is written by basal chapman creator of the trading methodology known as the chapman wave The chapman wave up down sequence gives you an edge in identifying price turns finding the peaks and valleys and stock prices Get the opening call newsletter by basal chapman and your inbox every day First time subscribers also get a 30 day money back guarantee if you're not satisfied Let us know and you'll get a full refund within 30 days of signing up tfnn.com educating investors Everything in the universe is governed by the fibonacci sequence This mathematical principle is responsible for everything from the most aesthetically pleasing artwork to patterns in the stock market To stay on top of stock patterns You can take advantage of sign up for the fibonacci 24 7 newsletter at tfnn.com When you subscribe you'll get a weekly report from veteran day trader larry pesavento on stocks You need to pay attention to and you can trust larry's analysis After all he's got 45 years experience as a day trader larry will also provide daily charts videos And data on the key markets that he's tracking expect notifications from larry on market movement You need to act on at any time first time subscribers also get a 30 day money back guarantee If you're not satisfied, let us know and you'll get a full refund within 30 days of signing up Subscribe to the fibonacci 24 7 newsletter today tfnn.com educating investors Catch tom will bryan professional trader and educator founder of tfnn also a special guest on cnbc Tom will bisect and dissect the markets the tom will bryan show next on tfnn And we come back in question if i've been to disney land and uh Lately and i haven't been to it and probably 20 i'm gonna say 20 years I took my nieces and nephews there probably in 2002 that was the last time i was there I'd gone to what a great deal um Our conventions were already in the always in the orlando convention center generally in the uh Like early may in june And so i was down there every year for like 10 years for two weeks Half a week to set up the booth Trade show half a week to unpack the booth and get it shipped back and during that time There was always a lot of time to go do stuff stayed in the P body right across the street from the convention center there if you're familiar with orlando That's the one where they bring the ducks in in the morning And they waddle all in and they they get to play in the pool all day and then like at 5 30 they Take the ducks out that was always One of the nicest hotels and treats that we had every year But uh, I went to a lot of those things in orlando But I really don't have any desire to to go to them again But uh, yeah, I just hear that they're absolutely packed out and the Waits for the lines for everyone including disney are huge there, but uh Yeah, not going Okay, so what are we getting as we wrap up the day to day? Um Let's go ahead and look update everything Okay Okay hit my target. I took uh all my uh puts off of the spies we bought this morning So I'm all cash. I can do anything. I want tomorrow. Probably not going to do anything tonight Um, we got a couple earnings tonight. I don't think it's going to matter much Uh as we go into it, but uh, um, you know, we're off 66 points with about 1.7 percent dows off 405 nasdaq's off 298 The volume is good, but not hugely strong 8.1 billion shares. We did 18 billion Uh on the last options exploration day. So again, uh pretty tough to get all wound up one way or the other for me I'm going to try to stay semi-neutral out here, but uh That's kind of it. Um, anyway, we'll see you tomorrow. Maybe there'll be some more action then But that's it. So when you can and I did today Out when you have to we'll see you here tomorrow same bad channel same bad time Building wealth trading in the stock market seems impossible to