I look like a ghost guys.  Why do I look like I'm sparkling? Hold on. We're starting early because I'm just setting up the stream Let me see. Is it better if I just turn off the lights? All right, let's do this. Hi lemon 9 and early boy Lemon 9 I will turn on Riva tuner Tomorrow or the next time I'm going to stream beta right now. I just want people to enjoy the What the game looks like without any without without a sony without without clutter right now So I'm gonna switch between This scene with just our sponsor ad And me with a camera So I'll just be moving back and forth So we are playing the beta test. So hi everyone. I'm Rafael from hardware sugar and we are Playing the second day or I think it might be the first day No, it's the first day for beta testing for people who pre-ordered the game And we are gonna play battlefield 2042 and I'm gonna be honest. I am a big fan of the series I have played every single battlefield game ever since it started back in high school for me Which was battlefield 1942 when I've been hooked ever since I've played every one of them The only one I didn't play was um Vietnam because I didn't have a good pc at the time So right now the beta testing is open I think I can't join I can't I can't spawn there Let's see. Let's see if we can spawn here I don't want to walk all the way So there's only one map right now available.  So we're in uh, so one of my problems immediately because I I played the game like maybe two hours I played two hours Canina and I can already tell you that major weird you and in you Movements of these helicopters are kind of weird like like I don't know like it's kind of like they can do all kinds of In 360 some shit. Hold on. Let's get this guy. Let's get this guy Let's let's just start, you know, let's start fresh We're just gonna We'll just start.  Let's go Okay, who are we gonna spawn?    Then I was an emp shot All right. Hi Neil Castillo Hi lemon nine my hardware. My hardware is a 2080 ti Uh, actually with 2080 ti, which is it's older than then then you're a 3060 Ti and I'm pretty happy with it. I mean look you can uh, it doesn't Hold on.  Okay Uh, I'm happy with the 2080 ti for this You know, even if even if um Even if All right, let's skip this Yeah, even if I'm streaming right now on OBS, it's still this is on you the graphics are maxed out Let me show you guys So I'm on my monitor is the msi optics At the 164 hertz and then ultra graphs Ultra and I can still live stream it. So that's pretty good Okay, let's switch to auto. Let's switch to assault Uh, the game releases The game releases Hold on a second guys Got one.  I believe Hold on. Let's we go.  Like we got flanked No, I don't overclock my gpu. I don't overclock it because I feel like In the long haul, you're really shortening the lifespan of your graphics card. And oh, I'm totally fine with this Uh, it's an it's uh This is the standard default setting up to 2080 tia So actually I mean the graphics are pretty cool except for some of the animations like this the water's nice But look, oh, you don't see Don't see me making splashes Nice. God the accuracy of this gun is credible. Look, I'm just on iron sights and I got that But uh, one thing about OBS Um, streaming the game. I noticed is that It's greener the grass is greener in-game OBS makes it look very gray So like I took a video earlier with my cell phone camera and you can really see that My paka samsung galaxy kind of saturation You know You battlefield game the actual footage like right now we're just going through the foot. We're just going through a foliage And it's super green but on that it looks Looks And uh, one thing I want to say is I don't know how to pull up the map like there's a mini map here, but Uh, classic battlefield allows you to always open the map, which is even you press M But it's not opening up so Also, what would you call that this is this is the fastest I believe this Oh check out the those trees moving I think this is the fastest This is the fastest In terms of movement going on here guys. We're the bad guys Sniper Definitely they got inspiration from bad. Oh, there's someone coming here. I saw in the mini map the the howko. What's up?  You can't shoot them. Okay or bailing. Oh, it didn't bail It's a little weird the death animations Um, I know they're trying to go for the whole raggedy doll kind of fun.  All right, let's take this car.  How do you beat? Okay, right. I'm just gonna take this car and then how do I switch the gunner Okay, my top. Oh, no, okay. So if I ever want to switch the gunner, I just press f2 All right. Oh, here. Let's let's see if we can take some pot shots at this guy fail Let's go Ah, it's an interesting vehicle actually Oh, whoa So I haven't gotten the hang of any and driving the vehicles here better bag I suffer this Rugged terrain. Oh, oh, let's start sniping with this. That's what we got. What we got. We got anything here. All right Let's take out that base solo. All right, so Enemy base. All right, let's go.    Oh, let's get out of here Oh I thought I saw somebody parachuting down.  Someone's coming up. Someone's coming up. I see him in the red dot.  You're trying to shoot me with your little pistols Okay, we got it. Do we have this base? Oh, yeah, iblex. Yeah, super battlefield fans super as in the max.  Oh, man.  We're taking this guy out. We're taking this guy out Oh, what he's doing? He's he's hanging out on top. Oh, what are you doing? He's sound He's moving like some sort of computer ai.  I know how to shoot my gun First time ever I don't need to worry about loadout drops Oh, okay on the minimap. It says there's some red dude there. I can't tell if he's on top Oh, yeah, I'm a medic 1660 ti I think minimum this game I'm actually quite surprised Damn, uh, I'm I'm actually surprised how well the this game is running on ultra with my 2080 ti because So, yeah, I'm pretty damn happy Hold on guys. Let's get some revenge. Oh, let's heal up. How do I uh, self heal Self heal hold three.  It's just like rainbow six. Okay.   All right. All right. Yo, let's go. Let's go. Let's go Oh, man Come on. Let's go. Yeah, we got a gunner It's from that's my team kill. Oh, no, no friendly fire. Okay, let's go.   Look at my driving.   Oh, wait, let's run over that guy. You see him? I see him.    I'm losing control of the car. I know he's here somewhere All right. No, I think I saw him go behind here. Yeah, he is Environmental damage. That's a good point. Uh post battlefield bad company too They really tried to emphasize on destructive environment I actually haven't seen much of the How about the the buildings here?  Oh, we're on fire. Okay, should we bail guys? Should we bail dropping flares? Man, I really wish that they could fix that in they could put the map on I can't I don't know where the hell we are uh, so far Ah, you know what I saw a tank um Drive into a wall And the wall The wall blew up pretty well Oh, man as an anti-air gun. Uh, yeah, I think they well the new that new revolution is that tornado thing It's you know, we're not we're not sure yet if it's going to be worth it Oh, hey, check it out. It's raining there. I guess this is the closest you'll get to revolution right now on this map Uh, okay, so we're gonna try and run it Can you check out the scenery? I really like the way the you see the gun flashes in the background with the anti air It's very Let's see. Let's get let's see if you can't get this guy The foliage is thick Okay, that guy Oh, yeah, that's me hitting the trees. Shit. This guy's gotta shoot at me.  Oh, look cover. There's no cover here. Let's see what oh, hey, we can you can get that You know what? I'm gonna go for a light machine gun and What is this guy? Shit, okay. I'm on the helicopter ride. I don't know what I'm shooting at guys Where where where where are we at? Where are we at? Where are we shooting? Okay, back bail bail. It's that anti air cannon again.  That's an ally, but I saw something.  It's to drop people here at like behind enemy lines like b1 It's not smart to try and just keep charging Now if if only I could just get a ride That would make a lot of sense See where we oh, what's this guy? He's a tank. No, no. I want to ride If one of these guys opens up, I'm gonna bail here Do some spec ops stuff Oh, here we go.  Here we go Okay, I think that's the anti air Now if only this guy can get me close enough I'll bail The best evolution of this game is in this map is that rocket over there See, I don't understand this animation with the Helicopter and like it always keeps tilting forward. I see another I wish I could go faster Oh enemy copter I can't shoot at him needs to go higher and see if we can spot anything here Oh Oh, I hit him hit one Reloading agrenade launcher.  Where is that? Yeah, how about that?  Here we go Oh, I missed it Shit, I missed it.  Not everything But you know what? I will try it. Okay, I think I have a An RPG Assault, I guess the engineer should have I don't know what this is Uh, I think I might see for it. Yeah, let's let's try blowing something up for science Hi everyone clear draft trying that warzone double deploy Wait, hold on a second guys. We have a lot of people here.   You coming for me? Let's go. Let's go.   I got uh, what is this? Okay. It's a sub machine gun. It's an AK I think Oh, wait, that's a sniper right there All right, let's go let's take this Let's go after that guy. All right. Where does this go?     It really is a secret cavern Huh All right, all right I don't know where it's leading me to but this is kind of fun. Oh, it's him food.  Oh, man. I could have hidden back in the secret cavern Yes, my mealy, but I'm so far. I've only been able to Ow, but I've only been able to use my fist Like you're just punching hold on a second someone Someone just called me on uh, Viber I really hate it when people just don't know. Why can't you guys just message? I don't know who this is. Yeah We're winning the stream. All right. Let's go Oh, look at that. Look at this. Look at this cute thing Okay, I had that there. No, this is the mealy. This is the mealy. I don't know why I'm using my fist All right, let's see. Let's see onion. I would say I guess this is an rpg I'll say let's let's try putting onion. Uh c4 Yeah, it's like we're gonna money if it will blow up it will blow up.  All right.  Look at that debris. I dig it. Look at that debris Oh, oh Who's shooting at me? Yeah, at least I was a cool death.  Okay, cool. Okay, let's take this. Let's take the Let's take it Let's take it guys. Let's take it I join a team that's losing Hey, let's see if we take out the lights Nope Lights ain't working. You can't blow up the lights This is a massive map. I mean just look at that the hell's that debris Tao.  Oh All right, let's see if we can get this guy. Oh, there's a guy over here. Got him Definitely The game is more bluish than call of duty. Oh, did I see something?  I don't know man. What's this do? Okay, I open some. Oh, is it time to lose?  That's a tank. It's a tank dudes All right, let's just face it. Let's let's see if we can we can blow up the tank, but see for a minute do a suicide run Oh I random dude, um, I don't know yet actually I told someone that I would play and I would use msi afterburner tomorrow Because the beta testing is only is good. Is it I think it lasts like four days and then after that Beta testing is over and we all have to wait like November 18 So right now I'm just I'm just trying to get the feel for the game and to make some content out of it the plan co is I'm just going to The plan co is I'm going as I'm making a first impressions video of 2042 like I I already recorded my entire game experience earlier today and I saw so many bugs like some weird bugs like I saw a guy being swallowed by the floor when taking the elevator I saw the helicopter Merging with a mountain like it's swimming inside the mountain. It's a buggy game Graphics wise. It's a buggy game Hi, blacks. Thanks for the support. I'm looking forward to making my our first video game impressions video I Personally this game is very important to my heart not this game particularly but because but what But because of its franchise because I really only played two games Heavily in my life, which were fine three games starcraft warcraft and every battlefield game ever So I had 1942 I had I bought all the expansion sets of battlefield 1942. I bought battlefield 2142 I bought battlefield 3 battlefield 2 battlefield 4 5 actually I bought all of them But the games that I super soup the My favorite one among them all is bad company 2 Man, I don't know what happened to dice The manufacturer of the game but bad company 2 was the best like everything Was destructible and then all of a sudden After battlefield by company 2 they dialed back the destruction. Oh if you ask me I would rather have poor graphics, but it meant that more things blew up. Okay, so Let's see what the am I dead How do I change stuff deploy I'm still joining the game Oh Is this Ah, there we go. Oh, hey, so canina. It wasn't in it was nice and stormy now. It's back today Oh, there's some bad guys here. I see a red dot on my map.   Oh, come on. That's not realistic, you know, even in color even in By myself old lady even in an in even in modern in In warzone that ain't gonna happen Okay, medic package engineer Hmm. There's a grappling hook here thing which I wanted to show off Gadget Since he grappling hook guy since he grappling See you smg ammo crate. I had a bra. I had a grappling hook. Canina. I don't know where it went Or but I don't see it here. It's already part of the package. Okay, let's go see recon Okay, let's see if we can spawn here I out Okay, let's hear.    That's awesome And definitely that the map plays a very important part of the game experience This is like this is very different from the warzone style Nah Buildings and shit here. You have like a combination of both However, I want to play This is the original battlefield kind of game, which is the conquest one that you capture flags But I my favorite was On you the thing that you blow up Rush rush rush is my favorite Uh christen. Oh, you can if you download If you download origin or not not origin Because there's an end. There's a way. Oh, I'll post about it later But then in what maybe he won't notice that his car is being repurposed. I know I saw a guy here Get rekt Okay, is there a bad guy coming over here or else? What's this? No, this is sonyan. I'm not cheating. This is this is the this is battlefield tactics Ah, yeah, I'm not cheating there. Oh, oh boom He wasn't even Let's go. Let's go. Let's go.  Look at that. That's cool. Ha ha getting on driving there. All right. Let's go. Let's get that guy. Let's get that Yeah, I know I know cheesing here. I wasted him And look at that the animations are kind of weird He's dead Today is that beta release Uh, Parang Parang there was like yesterday it opened to some Specific people. It's not clear to me But today was the release for um people who pre-ordered the game And who have like this ea battle pass thing And then parang and it's open to everyone Regardless, we pre-ordered the game two days from now right now This is uh exclusive to the guys who pre-ordered and who have that battle pass thing But like, you know, even the map is big I've never You know, this is the fastest that my a battlefield character has Has been running. Look at this. It's like it's like call of duty warzone style of that sprinting Yeah, i'm at Matt lihao ko is correct In fact, I said Wait a1 estate is being taken. I'm gonna retake it. Okay. So if we got we got smg Oh, we got spot. We got up. We got a teammate. We got a teammate Oh Oh, sit.   This is what I love about battlefield like you literally Like you literally have to Hide if you see a tank and if you don't got yeah, I love the gunplay here, man I love the gunplay here because I get to kill more people Fine.  We got in here Oh Anyone here? Okay teammate over there.  Is that our tank? I don't think so. I think that's a bad tank.  I ran a ammo. No god. Okay pistol time Oh man I got it. Uh, I heard uh, blex. I heard. Ah, it's okay. What happened here? Blex, I heard that actually there might be a lot of cheaters in 2042 because It's like there's a leak There's a leak. Um, wait, let's see if we can get back in here. Come on. Let's support the team. Let's support the team He's all alone. He's all alone. Come on. Stay alive. So I can uh Uh, yeah, it's leaking. It's like my um My hacks now pass the 2042 and it was it was released like three weeks ago based on the news So, I don't know so Only time will tell yeah destroy objects. Yeah Yeah, but look at that light and then look at that wind. Look at that wind guys. Look at that wind You gotta appreciate the nature Oh, this guy this guy.   If you're a gunner, it's jittery Right this time. I'm in the tank But feeding go someone's like hiding on the gutter or something That's my rank I've done better guys. I've done better Oh man Okay, we've got actually this is pretty cool. This is frost things if you're if you go next to it your face fogs up It's pretty cool. I'm gonna now turn off my camera so you guys can see more of the game No, I just realized the cdk offers ad is totally on the gun turret But at least you see more of the oh, let's go. Let's get this guy. Oh his body is like roasted All right, let's waste these guys.  Yeah, why is it so jittery?  What was he thinking? What did he think was gonna happen? Yeah, it's kind of jittery yo ea dice. You got to fix this.  I'm not doing anything. It's like Dice. No, that was my kill. Oh, I'm gonna do it myself Horrible that's a horrible animation right there. Oh, oh man. I just curled an old lady I don't know. I noticed that it's major defective Mother Yeah, oh no matt that you call indy rip aim. It's sonyan.  It's the it's the It's the game Actually, if you guys played battlefield 1942, it reminds you of that defect with the tanks If you were like a gunner on the tank Every time the turret of the tank moved like if the if the tank pilot was moving the turret to the right Even if you're like facing forward your gun will move also to the right.  They I see a tank heading to a1. Let's see if we can take out the tank Um San Let's see for this tank Okay, here we go. Okay. I'm gonna let's see for this tank Objective of this gay of this match is to capture points. If you look at the bottom left at the minimap We have to remove all the tickets. I'm gonna wait, but but really the objective of this game right now Is to see for this tank is to see for this tank.  How is that tanks still alive? So I you miss out my expression there. Shit. Okay, let's take that let's take that tank out Come on. Let's go. Let's go. Let's go. Let's take out that tank Let's go. Let's go. Let's go.  He doesn't know come on. Come on. Where's he at? Where's he at? Yeah Damn, yes. Yeah, so to answer Casey Boyle's Question that is the objective the objective of the game is to blow up one tank If you can do that, it doesn't matter if your team loses if you blow up a tank with c4. Hmm It's nothing like it. There is nothing like it Hi, Joseph z the gameplay is a lot of fun. It's really a lot of fun Like I find shooting here more natural than an in war zone.   It's so satisfying Are we at? Oh, wait, you know, I saw here. Let's take the elevator up. How do you use the elevator?  All right, let's take this So far our team is leading I have red.  Yeah Come on. Come on. Come on. Yeah, let's go. Let's get let's get this game fixed Now if only I had more c4 By the way, you could reload while sprinting. That's weird. What does this do? What does it do?   What's going on?  It's going like it's like you're going to diagonal and lee It's like harry potter at though. Do you call the train station? What's Fix this please We got here.  I didn't want to do that All right shift.   Let's see if we can get him. Do you get him? Yeah, I'm gonna switch through the light machine gun the next in the next one Yeah, I mean look at that. It's an Got no cover here. Shit. They're coming for me. They're coming for me. They're gonna flank me nice Running out of ammo Doming teammates. Let's rush them. Oh, yeah All right Okay, this way I can switch the revive revive Oh Shit, I can't tell if those are our guys or bad guys. Let's go get it. Let's get a light machine gun and waste people mg Hey He thought he could run me over I still can't find it. Oh, I got hit by a tank. Okay. That's acceptable. I was like wondering how did I fly? Yo revive Yeah, nox. That's what I'm talking about. That's teamwork. That's teamwork boys Okay, let's see if we can see for that tank Nox look at this guy.  Let's go. I'm gonna see for that tank Birds get out of the way is danger zone Here we go. Listen. Let's go.  Oh, it was worth it.  He's bleeding out revive No, it was worth it Arvos I pre-ordered the game, but it'll be open beta. I think for everyone two days from now. I think Right now it's just this is this beta is for the pre-ordered people But mind you onion and gets a little bit tricky on the pre-ordering if you're gonna pre-order the game Get from steam if you want to play it tonight Because and if you do it or because how I bought it via origin and then Someone was kind enough to post the solution and how to be able to play the game to play the beta If you bought it from origin because I found my setup Wow, look at that you get some You get some leaves. Okay, we got here 13 kills Wow, this is a guy.  Okay, whoever has 37 kills. He's just spamming the tanks Sniping tanks confirmed Depends on what you're sniping with. All right, I think we're gonna win this game 830. Okay.   I don't know what that means, but uh, yeah, we launched the rocket Not bad not bad not bad so far Let me know if you guys want me to do anything to test out the physics of the game or If you want to ask about something specific, let me know But the last time I was excited about a battlefield beta game was battlefield 3 Okay, revenjan rpg. Where's your RPG? please Why don't you remove RPGs and then that way you're forced to always use c4 I was actually very concerned about this beta test because earlier this afternoon. I couldn't get a single game Oh, by the way, so there are three kinds of games Hard zone warfare and portal and portal is pretty cool because you get to use the old skins and the old Vehicles of all the past and not all but like three of the past battlefield games including 1942 RPG is you recoil less. Okay, matt. Thank you. Liwako Grappling hook is under assault specialist That's what I thought I wait hold on a second. I move. I forget. I wasn't searching actually one thing that um, one thing I haven't actually been able to familiarize myself with is that This battlefield has a hundred twenty eight players I don't go in that thing max was 64 players. It was 32 versus 32, but now this is 168 cap That is ginormous. I believe it was 32 32 For a long time Actually, you know that 32 versus 32 now in 64 players. I think that's been around since battlefield 1942 Anyway, so I was a bit concerned about this About this beta test because at 3 30 p.m. I couldn't get into a game And then it was giving me this error code So I thought it was my pc lag or already it was my download, but in the end Feeling cool. It's just dice having a hard time finding Finding finding a server or getting things were going Hi, John. John.  Hi everyone, John Uh, you call Patch up. No, uh, you and in your patch mo you didn't upgrade to windows 11. Did you? Oh, I'm not gonna upgrade to windows 11. I'm gonna wait like four months and then after that, I'll check Hi, double you know, I didn't buy a new world I didn't buy a new world because I was afraid that my graphics card would fall I hear that during the beta testing lots of people's graphics cards burned up And yeah, I don't want to take that risk and then even now even now Hey Think the game is frozen guys It won't cancel Hey yo, itx adic. Welcome to the show Sayang, I don't know if you I think you you miss you're missing out on the gameplay for the tutors canina Yeah, so yeah, I'm not going to get I'm not going to get that game Muna until they fix that thing. Okay, I'm gonna restart the game Okay, ink to I'm gonna relaunch the beta test. So definitely I have seen better beta launch tests from dice Like when they did the battlefield 3 beta test man, there was like There was like no problems whatsoever with that beta test. I remember beta tested. It was operation metro I think yeah, I believe it was operation metro now. They had the beta test. That was an excellent game Yeah, and I hear you revenjan Yeah, and I hear you itx adic. Yeah, there's no way I'm gonna play that game Just to risk my gp. I don't even overclock my gpu precisely because I don't want to risk it You know, I'm at I don't know if battlefield one had a smooth I don't I don't I didn't buy I didn't I didn't beta test. Um, I didn't beta test battlefield one You know battlefield one actually great graphics. Yeah I just never got into the whole world war one style. Let's go. Let's go. Come on Let's get in here. So Hi Okay Full screen everything's working on ultra Do I dare? I haven't actually played cyber cyberpunk. Anton played it Oh, that's true. Everyone was giving cyberpunk a hard time Even though at but at least cyberpunk wasn't Breaking graphics cards. All right. Here we go guys. Here we go Whoo infield weapon customization. Okay t. Okay You know if you know the the origin of that Let attachment thing Animation was crisis one. They also had that infield customization thing going. Okay So specialist Who has the rpg? Very I know the assault I hold on a second guys. Okay. The assault package is supposed to have Wait The hell I'm stuck with the engineer. I am a switch. Oh, you see the helicopter spin We're just fine. We're just fine. What's going on over here? Fuckers. Oh, yeah, let's take them Oh, hey, there's an rpg if this guy dies. I'll take the rpg for every job What's he got here? only I do remembering how the rpg was With assault before I know engineer dot, but engineer from beret Yo, I don't want to just camp here guys, but hell look at those graphics He's gonna say That's pretty cool. Look at that.  It'll be weird if they if these bullet holes just begin vanishing Damn dude. Oh Ouch Right now. We're just testing the graphics guys And the shooting experience. Okay, what do we got here anyone here? If I go down, I need to have an objective the t button. Ah, yeah, that's a good idea I haven't I haven't tested out the t button yet. Hold on. There's a there's a Let's take them. Let's take them. Come on. Come on. Come on. My My machine gun against your uh, okay. Yeah, your cannons Your cannons one there. So yeah, let's try the t but I want to see if I can change specialist He's support. Oh, no, I want a soul. Yeah Gadget Repair tool ah a missile That makes sense. Okay. Come on. Come on. Come on Right here. Ah, this is the grappling hook. Okay, and this is an RPG. I'm taking him out It's away.  There's a guy here There's a guy Or is that our kind I got my rpg ready. Let's go. Let's go Damn, this is pretty cool. Look at how far you can see Okay, I see I see something. Yep. Let's take up take him out. Lock on Fire Fox two.   All right. Okay. Okay. Let's help the team. Let's help the team.  This is so slow Damn. Oh, fuckers. Got him. Need to reload 21 bullets So far, I think this is an even match. Let's go to d2 Okay, what does t do?  There we go.  Killing first Got him Okay, what's this? Silencer Anti-personnel.   There we go. I was like, where are my What iron sights? Okay. Thank you for pointing out Matt Now I can act.  That's cool Okay, let's see. Let's see what happens when you Yeah, classic. Oh Oh, yeah, okay, that's pretty cool All right, we're just we're just experimenting and having fun here guys Oh, let's take this guy out lock on Fire Fox two We've got some flares Fox one Come on take it eat it All right, let's take this car. Let's move out go Okay, I'm running shotgun Oh, wow. Whoa It's pretty awesome. You see there's so many people on this map Hey, good driver. Good driver.  Let's go. Let's go. Let's take them Oh Shit I'm taking this car.   Yes, it's ours. Oh, oh, yeah.   Come on. Come on. Come on one at a time. He's coming. Come back. He's coming back See them Oh, they call that. Yeah in the future. I think that the Tesla ends up making these humvee decent in these uh These military vehicles with mini guns on them. I bet they're all solar powered already by now Oh, oh, I'm so glad this one in that uh I figured out this t thing. Thank you for the points Should I jump right? I'm just like I'm just like I'm just looking at the world guys I'm just looking at the world. Let me see. Can I shoot people?  Oh my god Galing galing. All right. We deserve that. We deserve that This is what you get when you go sightseeing All right, let's go. Let's go. Oh enemy Around 60 meters from my position. Nice classic. All right now I have stalled the enemy from taking over our flag if you have The equal number of people on the on the on the flag Then it'll be stalled but the moment you have more yeah, like right now. There's one more of them But he also knows that someone's here somewhere So we need to play this Cat and mouse game. Okay. Hold on guys. Where's that tank? You can only move out without that tank there Okay, move out helicopter Oh, oh Yeah, I agree. I the exotic these these graphics are pretty damn cool Like any and I think comparing I don't know like what what gets me here behind the cat that the characters themselves don't look impressive It's really the setting that what is this guy doing? He's so far away.   Yeah, that was pretty gruesome Okay, let's try a different gun.  Wow, this looks pretty cool. Nice Let's use this as cover as I reload This is the scary part is you have no cover here On the chrome three Got him Got him. Ah, man Okay Hi T It's okay You know that same thing happened to me also in the battlefield vietnam game. I paid for the game Wasted I couldn't play it Because I do graphics cool.   Okay I know should we try and if you could just give me All right, okay, let's just watch him blow people up if he does swing by I'm gonna jump Come on. You can do it. Okay dropping.  I missed it Fuckers. Okay, hold on. What about this guy?  Oh, man, where'd he go?  Yeah, that's a good time battlefield too. Hmm Is that a br as well? I Chris alvarez. I mean br Let's take out this helicopter.  What's happening?    You can play warzone for battle royale and you can play this for your a different experience God look at look how dizzy Look how dizzy that can get you. Let's see if we can take out that tank.   Look at I'm parachuting down and I'm aiming like this.  They're gonna shoot.  Let's try a different gun engineer package actually this this is smart the The custom is the gun customization That way you can literally customize your gun In game not in the menu screen anymore Which takes you out of the experience Got him one shot dude one shot Oh Damn, that's not fair Hi, Lucius rex engineer gaming Oh, hi sign. He's gonna revive me Oh, we got throwable.  Yeah, the attachment system is pretty good literally like well actually it's So theoretically your character is carrying around all the attachments in his backpack, no But yeah, you know, I mean like sometimes you don't want to wait You want to just switch for the right moment? I don't know you're a real speck ops character if you do that Foregrip. Yeah, let's let's just check out the the grass guys. Let's check out that greenery and check out Explosions. Oh heat up Not used to this gun need to change this gun. Let's try and revive revive teammate Oh Oh, man I bugstick Not that I can see But my machete's not available online Okay, let's try out the medic package that way I can actually revive people.   I didn't say that. Yeah, battlefield is so realistic Idea, but you know, it's true like Stuff like that can only happen in battlefield 2042 like you can get up there if you see for the the vehicle sometimes While someone's there Let's see if we can Recoil less m5 Recoil less m5 What does that mean? Oh That's an rpg Okay. Wow. Look at this You could really like have a A team of people here and not see you at all. Look at that Did you did you all see that guy? I know I saw somebody here Got a dead body dead body Yeah, let's get up there guys. Let's get up there. Oh, it's a rock Go ahead lock on No, this is uh, this is a dummy rpg. Hang on. You know, you know, I'm gonna have me revenge on canina Okay, here we go. Let's take oh man How do you pinco? So far, I'm liking the game like I am not disappointed so far because Usually the graphical problems like, you know, you're falling into the floor that kind of thing EA patches is an optimum eventually I'm not too concerned about that And I can get used to this Yeah Maybe more vehicles.   Oh man, that wasn't the best part Let's see if we can get some anti air. Oh a a we need a long distance Sector b is under attack Let's get up there Oh, wait, let's see if what we can put on the oh, hey, you can put the I don't know what happens You know when you're here when the rocket goes up. Do I die?  Oh man. Oh man. Oh man.    Oh Uh I think you can but I don't think rocket launching the rocket will do anything I don't even know why what what that means when it launches. What does that mean? The research that's the farthest long range for this assault rifle. Right, let's see I'm actually excited for more for in for tighter maps So the gunplay here is so much fun, but it's kind of Uh, but I'm getting an irritated with all of these nightbirds Okay, it's just I cool.  All right, see what is my anion? Shaft I'm not really like a great fighter pilot guy See, okay, let's try out though. Let's see if we can dogfight Oh there. I see him.  Come on. Come on. Come on. Let's go. Let's go. Let's go. Oh Oh, there he is.  I lost him Is he at oh shit? We're really high up.  He's trying to shoot me Whoo, this is tiring I don't know how the experts do this Oh I have no idea what happened there Oh, damn. He totally like kamikaze into that rocket launcher Whoo. Well guys, um, thank you for joining me on this first beta test night of Call of duty of battlefield 2042 Let me know in the comment section What else you want us to do in the game and we'll try it out for you I will be streaming The beta test again to uh the day after tomorrow. So not tomorrow immediately But for the rest of you you guys can actually download the beta for free I think at lunches two days from now just to get the feel if you like the game And uh matt thank you for reminding me to do the tea So that we can cut so I can actually customize my gun. I was wondering how do I attach Augmented stuff to this. How can I attach like holographic and stuff? So I'm rafael mark resugar and thank you for joining the stream And see you guys later and uh happy wednesday. We are almost done for the week. Thank god and Also great stuff. It's all about many more covid cases. Not in let's just keep it up and stay safe everyone Good night. Bye guys


Hi there. I'm Kathleen Diggree. I'm so glad to be here. Last year we didn't do this because of COVID, but this year we have learned how to do things virtually. We're doing an update that we actually do annually about what's new in research around idiopathic intercranial hypertension. For many people, this is a new diagnosis. Some people have had this diagnosis for a long time. I'd like to review things that we all need to know, and then I want to talk about what's new, and I try to point out some of the new things that are going on. I'm going to start with this case of Sharon who's 34. She was sent to us because she had headaches and disc swelling. She had recent weight gain. Otherwise, she's been very, very healthy and doing actually very, very well. She has symptoms of dimouts of her vision, a whooshing noise in her head, and headaches that are more severe than her normal headaches. Her visual fields are not normal, and we're going to talk about visual fields because it's important to understand how we do the evaluation and workup. There are many people who get just an acuity and don't get visual fields. This is not enough to follow people with idiopathic and acrenial hypertension. I hope there are people who are support people to our patients tonight because it's important to understand all the things that patients have to go through when they have this diagnosis. When we looked in the back of her eyes, I'm going to use my arrow to point out, she had bilateral optic disc swelling and this is not normal. I'll show you what normal discs look like and then what swollen discs look like. Her nerves were swollen. We looked at her imaging, and we saw that she had what we call an empty cella, and we'll talk a little bit about that. She had extra fluid around her optic nerves, and a lumbar puncture was done, and her opening pressure was 350 millimeters of CSF. But she had normal protein, glucose, and cells. The question is what should we call this? Idiopathic endocrinial hypertension has had many names over many years. It started out with the name benign endocrinial hypertension. Well, this is not a benign disease. Then Dr. Corbett, one of my mentors, named it idiopathic endocrinial hypertension, and idiopathic means we don't know what it is. Then the group in England and Australia said, well, let's call them pseudotumor cerebri, pseudo meaning false tumor, like a brain tumor cerebri in the brain syndromes. That's stuck a little bit. When we think about it, the idiopathic form is the primary form. This is what most people have, is the form that comes out of the brain. We'll talk about what we think causes it. Then there's a whole group of things that are like mimicers or secondary causes. The reason so many tests are done are because we have to figure out is there venous sinus thrombosis or some other blood clot in the veins? Are there medical disorders that are going on like the parathyroid hormones or chronic obstructive pulmonary disease or heart failure or sleep apnea? We'll talk more about that. Iron deficiency, anemia, and then there are medications that have been reported to cause intracranial hypertension, like growth hormone in children, vitamin A, lithium, anabolic steroids, sometimes things like noreplant and marina have been associated with it and then there's some other medications as well. And we try to keep up with all the case reports of what things could trigger this high intracranial pressure. But keep in mind that most of these are idiopathic. Now this is a common disorder. It's not really common, but it's as common as multiple sclerosis in obese individuals. So everybody's heard of multiple sclerosis, but most people have never heard of idiopathic intracranial hypertension. And just remember that it's not rare in obesity. It starts about the time of puberty in both girls and boys. And it goes up to about age 60. Usually pressure settles down by then, slightly older in men and it's way more frequent in women, eight to one. So for every man, there's eight women that have this. And in the idiopathic intracranial hypertension treatment trial that I'll mention, 98% of the people enrolled in the trial were women. So it's really a woman's disease. In children, usually girls and boys are equal, but then after puberty, girls take off and have this more frequently. And there is a genetic aspect, although we don't have any genes identified. The symptoms, if you've got this disease, you know what they are. Number one, headache. And we're gonna talk a lot about headache because that's the part that disables most of the people. Transient visual obscurations are next.  Back pain, dizziness, light sensitivity or photophobia. Pulsatile tinnitus, like whooshing noises, like psh, psh, psh in your ears. Neck pain, visual loss, cognitive changes. Diplopia is double vision and ridiculous of it pain is pain that goes down the neck or the back and into the arms or to the legs. That's a lot of symptoms for these people that have this disease. Headache is the one that seems to be the worst. 94% of all people have headache and they can have pain in their neck and shoulders, pain with eye movements. And what's frustrating is how bad the headache is is not correlated with how high the pressure is. So it's kind of a frustrating symptom to have and I'm gonna talk a lot about that. Now, this is a study that came out just this year and they tried to ask patients who had this, which symptom bothers you the most? And of course, not surprisingly, headache. So this dark brown is the most severe symptom that bothered people the most. The next symptom that bothered people was depression and that was present in almost a half of the people who had it.  And they asked a lot of other questions but these were kind of the main findings that bothered patients the most. I mentioned the whooshing noises, like this buzzing or whooshing, like a river running in your head, hearing loss, dizziness, but hearing symptoms are really common, like half the people get this. So now I'm gonna talk about what are the findings? So when you go to a provider and what do they look for? Well, the first thing they look for is visual acuity. That's how well we see, but only 13% of people, so only one in 10 about will have a change in their visual acuity, meaning that they won't be 20, 20 when we check their eye chart. It's not an adequate screening tool because that is the last thing to go. The acuity is the last thing to go. That's why we have to do what we call visual fields. Now visual fields, for those of you who have never done them, are boring. They're really boring. You put your head in a ball, you push the button when you see the light, you have to stare for a long time with both either eye, and it takes some time and it's boring. So imagine yourself having a headache and not feeling good or anything else, and you still have to do this test, and that's what we require our patients to do because that's one of the key measures that we monitor is a visual field. So up here you can see this visual field up here where I'm circling this big blind spot here on both sides of the both eyes, and that's a typical finding that we see. Now we don't like that because a field should look more like this. This is a much more normal visual field, but sometimes they're really bad, like this one has got a really bad defect, and then look at this right eye is really constricted and bad. So these are people I have to like, oh my goodness, I gotta do something right away. And we see all kinds of defects on these visual fields, but they help guide our therapy. It even predicts visual outcomes. So if you come in with a good visual field to start with, you're likely to have a good visual field throughout the course of the disease. If your visual field is bad to start with, we worry a lot because then we are worried about it. So when we get the visual field, this is a visual field with kind of a big blind spot here. We're looking at all kinds of things. We look at how many false positives, meaning how many extra clicks you did when there wasn't a light, or false negatives, meaning you saw the light, but you forgot to click it. We look at any defects. We look at the mean deviation. We have all these parameters that we look at in this test. So this test is an important test. Even though it's very boring, it's still important and we have to do it. Now the other thing we do is we dilate the back of the eye and look for papillodema. Now what are we doing going into the back of your eye? Well, we go through the cornea, we go through the cornea and the lens, and we go all the way to the back of the eye. So in this cartoon, I have to look all the way through the cornea, the lens, and I'm looking at this structure right back here called the optic disc. And the optic disc is the thing that swells. It is connected to the brain. And when there is increased pressure, that pressure goes along this optic nerve and pushes on this optic disc, and it creates papillodema, okay? And that's what we're looking for. And now some people have very, very little or no papillodema, like this person is pretty normal, okay? I can look all the way around that optic nerve and it looks just great. It's not swollen. But now look at this person. They have kind of a C-shaped swelling. There's some folds in the retina.  So this is not good. And then the swelling can get worse so it's all the way around the nerve. And then look at this one. It's all the way along and there's some hemorrhages and the veins get kind of big. And this is what I'm looking at. I'm looking at papillodema, okay? And that papillodema is this swelling of the optic disc and it's due to the increased intracranial pressure. Now, so we see somebody, we do the acuity, we do the visual fields. We look in the back of the eyes and we are very careful about what we're doing. But then we need to do imaging.  And that's really important, okay? Because if there's obstruction, then it's gonna give you a headache and it's going to cause papillodema and all these symptoms. So that's why imaging is critical. You cannot make the diagnosis without imaging. And many times not only do we look at the images, but we get a magnetic resonant phenogram and I'll tell you about why we do that later. Now, what do I look for when I see the MR scan? Well, in this person, you can almost see the swelling going into the eyeball. See, this is the eyeball and here's a dilated nurse sheath. And that extra fluid is like pushing on that little poor optic nerve causing it to swell. And I'm seeing all this extra fluid. Sometimes it pushes the pituitary down and causes what we call an empty cellar. And an empty cellar is where the pituitary sat, but the pressure is so bad that it's pushing the pituitary gland to the side. Now, there are normal people that have empty cellars. So it's not 100% a sign of high pressure, but it's something I always am looking for. Then we always do a lumbar puncture for those of you who don't have this disease. This is another very unpleasant thing to do. You get put on your side, you get measured with this manometer and then we take the fluid out and then we measure how high the pressure goes and we look for pressures that are over usually 250 millimeters. Some people use centimeters. So then it would be like 25 centimeters or 250 millimeters. Sometimes the lumbar puncture can help the headache and the whooshing noises, but sometimes it doesn't do anything. In fact, it can even give people a headache. We're always looking for sleep apnea because there are people who have increased intercranial pressure due to sleep apnea. And if we fix the sleep apnea, then we can fix the increased intercranial pressure. And Lisa Ord put out in our handouts the Berlin questionnaire. It's a very simple questionnaire. And if you've got a lot of positives in this questionnaire, you should talk to your doctor about sleep apnea because if you have sleep apnea, you're at high risk to have increased intercranial pressure. And sometimes you have to do sleep tests. Another symptom that people often complain about is cognitive changes that some people can't think. Their brain is fuzzy. And I'm going to talk a little bit more about this. There have been many studies that have showed slow reaction time, processing speed problems, and thinking can be slowed. And the cognition can be slower and, but it can be related to multiple other things like how high the pressure is, how bad the headache is, if that person has sleep apnea, and executive functioning. Executive functioning is kind of like, how do you plan your day? How are you productive? So a lot of people say, I'm just, I feel like a blob. I can't really get anything done. Now this graphic came out this year and I said, I'm going to put this in this talk because they did a study with 66 women with idiopathic intercranial hypertension. The gender and age matched and body mass index matched and we're talking about body mass index, weight matched the people.  And what they found was the attention and executive function, the sustained attention and being responsible for tasks was impaired in this disorder. And then what they did, if it was acute, if the person was just diagnosed, they repeated the test after the lumbar puncture and they were better. And then as time went on, they got a little bit better after 12 months, even though they still had the disease, it was a little bit better. And they found that the things that affected the cognition were how bad the headache was. If a person had comorbid depression, which again, remember I said depression was the second most common thing that patients who have this disorder are concerned about. Sleep apnea, a lot had sleep apnea, how long they had the disease. And then they had some blood tests that showed some abnormalities. But a lot of this got better when the person was treated. And you can imagine if you have impaired attention when you're being asked to do a visual field, for example, how hard that's got to be. And it can lead to poor performance. And that can actually give us falsely abnormal visual field. So we have to be really careful about the cognitive changes. Now the question I get asked a lot is why does this occur? What in the world is this about? So I'm going to talk about genetics, the venous hypothesis, glymphatics and lymphatic drainage, obesity. I'm not going to talk about vitamin A, but we do know that people who ingest a lot of vitamin A, like if you eat a lot of polar bear liver that has vitamin A in it, you can get increased intracranial pressure. So don't eat polar bear liver. But, and I'm being a little bit facetious, but we don't recommend high vitamin A dosages for people with this disease. So what's the genetics? Well, we definitely know that there is a genetic predisposition because we all see people who are like a mother, son or mother, daughter, sisters, brothers. We've had twins, one was symptomatic, one was asymptomatic. We definitely need more data. And at the Moran Eye Center, we actually have a genetic study going on. So if you have anybody in your family that has this disorder, we want you to participate in our studies. It's not a big deal. You can spit in a cup and we can get the genetic material, but we're looking to see, because if we could figure out the gene, we could figure out how to cure this disease. So if you have that in your family, please let us know. You can let Lisa or know or let me know and we'll get in touch with you. Now, in order to go on, I have to give you a few facts about spinal fluid, where it's made, how it's made, and where it's absorbed, because otherwise none of the rest of what I'm gonna talk about is gonna make sense to you. So the first point is spinal fluid is made in the chloride plexus.  And it produces a lot of fluid, okay?   So that's a lot of fluid that's being made and reproduced and absorbed and made and reproduced and absorbed.  Now, these are like little cauliflower's sitting in the middle of the veins. And the veins are what drain our blood of all the arterial, so the artery goes into the brain to give the brain a lot of oxygen and nutrients. And then the veins take all the waste products out and dump it into the veins, which goes down into the heart, which gets recirculated in our blood and then back to being an artery again, goes through the lungs and gets oxygen, et cetera. So we think that a lot of absorption of the fluid goes through these, what we call arachnoid granulation, these little cauliflower's that sit in the vein. So if we put this all together, the fluid is made in the chloride plexus, it circulates all around and then it gets absorbed in the arachnoid granulations. Now, if the pressure goes up, these veins get collapsed or stenotic or they get kind of closed together, okay? That increases the intercranial pressure and then that even further pushes on those veins. And we know that obesity, I'm gonna talk about that and fat cells participate in this. There are also inflammatory factors that participate. And then I'm gonna mention this lymphatic, lymphatic drainage that is in addition to those arachnoid granulations that picks up the fluid. So the venous hypothesis is, as the venous pressure goes up, the intercranial pressure goes up and this is true. Our venous pressure goes up, our intercranial pressure goes up. So for example, at trumpet players, people who are body builders and always doing valsalva maneuver can have increased intercranial pressure. Interestingly, individuals with obesity do have increased venous pressure. And then all this venous sinuses get compressed and as they're compressed, the pressure goes even higher, okay? And so that is the hypothesis about this. So that's the venous hypothesis. Then we know that there's lymphatic and lymphatic changes. Now, we used to ignore this, but this is like lymph drainage from the brain and it also goes into the venous sinuses. And at night, these lymphatic channels are extremely active and they dump that flow into the veins. And this is normal and that's why we need to sleep. All animals, mammals, all living things, almost all living things need to sleep. And part of it is to get rid of the waste from the day before. And we think that the waste place is this lymphatic. So it's extremely important. And there's now some evidence that maybe blockage of the lymphatics play a role also in keeping the pressure up. It could stop the egress through the arachnoid granulations and it can also stop the egress through the venous sinuses and increase the intercranial pressure. Now, I have to talk about obesity because about 80 to 90% of people with this disorder are obese. And weight loss makes it better and we're gonna talk about that. And there are all kinds of associations that come with obesity, orthostatic edema, venous sinus pressure changes, sleep apnea, polycystic ovarian syndrome, metabolic syndrome, all this stuff comes along with obesity and our disease, IIH. I'm gonna just show you this, but watch the red, which is 30 to 35%, but watch what happens. We're gonna go to 40%, these are the dark red brown and now more and I'm in 2015, 2016, 2018, 2019, 2020. So our country is becoming obese. Even Utah has 25 to 30% of our population is obese. Now, how do we even know what obesity is? And everybody talks about BMI, so body mass index. How do you compute it? Well, you put your height in and your weight in and then it can compute and you can do this and there's a calculator at this website or we have a handout that we've given you also that has a BMI chart. Normal weight is 18 to 24, 25 and overweight is 25 to almost 30, but obesity is more than 30. And I'm gonna talk about this BMI in relationship to certain treatments that I want you to be aware of. So here is how you calculate it. So you have to take your height in inches. So let's say I'm five foot two, so I'm 62 inches and I weigh up all, give or take, depending on how many clothes I've got on, maybe 120 pounds. Well, I'm in the normal weight category. Now, if I weighed 164, then I would be obese. And that's how you calculate your BMI. I go up like this and I could see that I'm in the 30 obese range. So here's my height. Here's my weight. I can calculate my BMI, but if I weighed 170 or whatever, then I'd have to calculate a higher BMI. Okay. Now, the reason obesity is really important is obesity increases the incidence of this disorder. So if you're normal weight, if you're normal weight, then you have a much lower chance of getting this. Only three per 100,000. But if you're obese, it's 20 per 100,000. And the fat distribution does differ between men and women with this disease and also can differ with the pressure. Now, we are learning that this obesity thing is also associated with other metabolic disorders. And this I think is really important because we're learning some new things about this. First, abdominal adiposity. And that means that the, and I'm trying to admit some people here, maybe Lisa couldn't do that. The abdominal obesity, which is what is in our gut and makes our stomachs a little stick out, affects our central venous pressure. So that can raise the venous pressures again. And then venous hypertension can lead to this increased intracranial pressure. But what's interesting is we're finding there's more metabolic changes than what we realized. Insulin resistance is increased. And this is really important because that makes us much more susceptible to getting this disorder, okay? So the other thing is that the inflammatory markers can also get increased as well. And so this is more than just being overweight or obese. There's metabolic changes that are going on. And I wanna use this slide, this was just recently published, that this truncal obesity, so this is the fat that lives underneath our, what we call our stomachs, our bellies.  And then our fat that's in our arms and legs and all that kind of stuff, that has also got, that's our subcutaneous fat. That has different characteristics. And what we're finding is that this fat can secrete things that make us have more fat and make us more prime for weight gain, not weight loss. Even when we try to lose weight, we gain weight, even though we're trying to lose the weight. And so this is a metabolic problem. And these researchers in England and Denmark and here in the United States are really working on this metabolic problem with this because I think this may hold the key to better treatments and helping us understand why people get it. And we do know that as the BMI goes up, the pressure goes up, there is a correlation there. Our eye pressure, inner ocular pressure is not correlated by our BMI. And then another important point that just kind of came out in 2019, the kind of at the end, right before the pandemic started, so I didn't get a chance to give this information to you, is that IIH confers future vascular risk factors. And this was a big population study done in Great Britain where they looked at almost 3,000 women and they matched these women with IIH to controls that were the same weight, same age, and they found that heart failure was increased risk, heart disease was increased risk, stroke was increased risk, type two diabetes was increased risk, and hypertension increased risk. All of these are part of this metabolic syndrome of vascular disease. So it's important that we get everybody treated with IIH and we watch out for these other risk factors as people get older, very important. Now, what's the evidence that weight loss is helpful? Well, the first evidence came by Dr. Neuborg. She was an internist and she put people on a rice diet, imagine eating rice. So nine patients with high pressures and papillodema and then she put them on the diet and then she said from December 1968 to February 1969, they lost the weight and their papillodema went away and almost all lost the papillodema with this rice diet. Then Harvey Sugarman in 1995 did bariatric surgery and got profound weight loss and normalization of pressure. Other people have found this too. Alex Sinclair did this an amazing study where she put people on 425 calories. Can you imagine how little that is?  So it's not a lot of calories, okay? But people stuck to the diet, they got rid of their papillodema, they decreased their necraneal pressure and even their headaches got a little bit better. Now the new treatment for weight loss is kind of bypass surgeries and they're a bazillion of these. I mean, they do a little lap band, they do these little pouches, they hook things up differently and they're using it for people who have obese, for diabetes, metabolic syndrome, sleep apnea and so on and so forth. And there's more and more of these being done. But this study just came out this year in June, again by the Birmingham, England group, they randomized patients over five years and they had over 600 people or no, they had 60 people and they randomized them to one arm was just Weight Watchers, current Weight Watcher program versus bariatric surgery. Now all of them had to have a BMI over 35. So it wasn't just like into obesity, but it was definitely obese. Then they measured the pressures before and after and they dropped 60 millimeters in the bariatric surgery program and they lost about 46 pounds. Their quality of life improved by seven points, their headache improved somewhat and it continued for two years. So these graphs just show you the current weight loss program, but then if they did the surgery, they had a percentage greater percentage of body weight loss and their intercranial pressure went down as well. They had no deaths, they had one complication and that was an obstruction. But it was an important study I think that tells us that we can get improvement in the pressure by losing weight. Now I wanna switch gears and talk about why we use acetazolamide and everybody who's got IIH has at one time been on acetazolamide.  Utah was part of this trial, the University of Utah was part of this trial from across the whole country, studying, putting people on dimox, which looks like this or a placebo. And then we watched what happened with the visual field and that's how we studied this. We entered 165 people, there were only four men in the group. The average age was about 29, 88%, almost 90% were obese and their BMI was almost 40, okay, average 40. And the average acetazolamide dose was 2.5 grams. Now many of you are on 500 milligrams twice a day, that's only 1,000 milligrams. So we pushed it up to 2,500 milligrams. And we followed the visual field, I've talked to you about visual fields and how to read them. Now these people could not have bad visual loss, okay? None of them had severe visual loss, they all had mild to moderate visual loss. And at the end of the trial, the people who were on acetazolamide did better than the people who were on the placebo and diet alone. And the diet was a program run in New York, a very good program for helping people lose weight. People did lose weight, in fact, a lot of people lost weight, even in the placebo arm, people lost eight pounds. But the acetazolamide and diet group lost more and the papillodema got better. And remember I told you that papillodema is different grades and many of them, the papillodema kept getting better and better over the six month period of time. Those who had the worst papillodema had the best effect in their visual fields compared to those who were on placebo. And there was only one treatment failure out of all of those patients. And six of them were in the placebo arm and only one was in the acetazolamide arm. And the quality of life got better. So we measured quality of life and the quality of life got better in all the different ways we measured it. So that was really a success. But the headache didn't improve. In this study, the headache did not improve. So that's why I've got to talk about headache kind of at the end of this. So the spinal fluid pressure did also drop significantly compared to placebo as well. And their adverse effects from the acetazolamide were not too bad. Two people had kidney stones, one had some changes in their liver test, one had some little bit of pancreatitis, but nothing was severe. Some allergic reaction, but most people tolerated the dimox acetazolamide very well. So now what we do with everybody who comes into our clinic is we put them on acetazolamide, we recommend weight loss. We do the visual field, we watch the papillodema grade and of course get the spinal fluid and all that. And we try to get that acetazolamide dose up to a level that will help get the pressure down and also help people do better. And this study went on for an extra year and found that people continued to do well. And those who were on placebo switched to acetazolamide and they also did better. Now there are some other treatments besides acetazolamide. Some people say to me, well, I just hate that drag. It makes my fingers tingle and my toes tingle and I just hate it. Makes soda pop, tastes terrible. Well, there are other drugs but they're not all studied like acetazolamide. So furosamide is also known as Lasix. That can, it's a very strong diuretic, sometimes been used. Amelioride is a, it reduces fluid production out of that chloride plexus we talked about. Octreotide inhibits growth hormone. This is just case reports. The two new drugs that are out there being studied are glucagon like peptide one receptor is a big long name but this drug is being used for diabetes and promoting weight loss. We need to study it in patients with IIH because it does reduce intracranial pressure in rats but we don't know if it works in humans. The other drug is this 11 beta hydroxy steroid inhibitor that treats obesity and metabolic syndrome. And there are studies ongoing in Europe on that. This study is being looked at very carefully because it's a potential treatment for type II diabetes, for obesity, metabolic syndrome and it's been found to actually lower the intraocular pressure but we don't know what happens with intracranial pressure and it's not available on the market at all yet. All right, now I'm going to switch gears to headache which is one of the most, yes? Before you do that, there is a question in the chat about the cognitive issues caused by acetylzolamide. She asked about the cognitive issues. Cognitive issues caused by acetylzolamide. Well, remember acetylzolamide causes some cognitive issues but IIH causes a lot of cognitive issues. So separating out which is which is a real big problem and those studies that were done on cognition were done on people that were not on acetylzolamide yet. So we know cognition is affected by the IIH itself and acetylzolamide can affect it too. So good question and thank you for asking it. And we will get to your questions, I promise you and feel free, Lisa, to interrupt me if there is a question about what we're talking about. I don't mind at all. So headaches are the most difficult part of treatment. Many people report severe headaches, 10 out of 10. And their headache squares are terrible. And what we find is that acutely, the headache is bad. And then the problem is even when we lower the pressure and we get everything looking a lot better, the headache is still the same. It becomes kind of chronic. What did we learn from the IIH TT? We found out that almost 90% of people had headache. 41% had migraines in their background and interestingly only 18% of the general population has migraines. So something's weird about this because the people who get this disease, 41% have underlying migraine too. The headache phenotype, what it sounds like, what the headache sounds like when you hear about the headache, mostly it sounds like migraine or probable migraine, sometimes tension type headache. A lot of people had medication overuse headache, which means that they took analgesics more than three days a week. And their quality of life was affected. But what was amazing, headache disability didn't correlate with the opening pressure, the BMI, how obese somebody was, whether how much weight they lost, what papillodema grade they had or what their visual field looked like. And even more frustrating, there was no difference between the pressures of those with headache and those without any headache. Remember, there's about 16% without headache and the 84% with headache. There was no difference in the pressures and those people at all, they still were elevated. So some people are more prone to headache. Treatment of headache is weight loss still because it can actually, even if you're obese and have chronic migraine, losing weight is helpful. And then having a diuretic like acetazolamide plus a headache migraine treatment is helpful. Doing a lot of lumbar punctures, the study was done on this recently, showed there was little gain and you have to watch out for medications that make weight more, but also medication overuse. So these are the diuretics that we use, acetazolamide, methazolamide, ferrosamide, chlorothaladone. These are diuretics that we can use. And then these are migraine treatments that we use. Now the new kids on the block are to pyramid has been studied and shown to lower the intercranial pressure in laboratory animals more than acetazolamide. So frequently when people have very little papillodema we will go right to to pyramid if they have very bad headaches and get them on that medication because it will not only help them lose weight, stop the headache and get the pressure down. It does all the things we want it to do. The other new kid on the block are the CJRP monoclonal antibodies. These are antibodies to a little receptor that makes headaches of migraines worse. And so once a month shot and that is the prevention for the migraine and that's been seen in a lot of patients. We've had some luck with it in our patients and it's being studied up. There were several studies more recently published. And then anabachillinum toxin or Botox has been used for individuals with a lot of chronic migraine symptoms with IIH. And so that is also a recent study that came out. Now, any questions about headache and IIH? Cause that is the bugaboo. And I wanna make sure I answer that. We did have one other question about diamox and the fatigue that it makes it really hard to exercise with so much fatigue. All right, and that is true and fatigue accompanies IIH as well. And yes, it makes it hard to exercise. And just even a little bit of movement. The best exercise I have found for people is swimming. Number one, you don't have to fight it. You can just float around. Just being in water is great because you have to keep a little calories burning to keep yourself warm. And you don't even have to move hardly to burn some calories. So it really, swimming is a, and most of my patients that do swim find that that helps the most it's less fatiguing than walking and running and all that kind of stuff. Good question. Any other on the headache side of things or acetazolamide side of things? Doesn't look like it. Okay, now I wanna talk about visual loss which is the thing we work out. You can't treat visual loss with lumbar punctures. You can't treat visual loss with gastric bypass. It's not a treatment for visual loss. They used to take off part of the skull on people with IIH, we don't do that anymore. So really there are three treatments for visual loss. One is optic nerve sheath decompression. I'll go through each of these either unilateral or bilateral. The second treatment is shunts and they do have adjusted adjustable valves that are gaining popularity. And the third one is venous stents where they put a stent in the vein to open it up and keep it open. So now let's talk about these different treatments. First the ventricular peritoneal shunts. They do lumbar peritoneal shunts but they often will fail. Then the new shunts are ventricular and they go down into the abdomen. This is how many times shunts get revised. These are lumbar peritoneal versus ventricular peritoneal. How often they get removed. And the problem is that shunts often have to be replaced. The new programmable shunts work a little bit better because you can actually dial and a pressure but then you have to work with a neurosurgeon and sometimes that's kind of tricky. Optic nerve sheath fenestration is usually straightforward. You can come in above the eyeball or on the side of the eyeball, behind the eyeball of course, and make a little window and then let the fluid out and that just releases the pressure on the optic nerves. Now the problem with this is it's not available everywhere. It may not help with the headache as much and there are some complications with that as well. But for people who've got vision like this, black is bad in visual fields and you do an optic nerve sheath fenestration, it really, really, really does well. And there's been some new studies out there that maybe the people with extremely high pressure do better with shunts than with nurse sheath fenestration. But it really depends on what's going on and if you have visual loss or not. So the new treatment is this venous sinus stenting and what they do is they go in through the veins and they put a little stent in the middle of the vein to open it up, okay? And the problem with this one is if you get a blood clot in that vein, it's bad news. If it restinoses another spot, it's bad news. The stent never comes out of your brain. So it's there for life.  But it's being used now for refractory patients. It can't get any relief any other way. I recently kind of reviewed this with a neurosurgical review. This guy put these data together. So I've made a chart for you. And you can see that the papillodema gets better in everybody, no matter what procedure you do. The visual fields improve mostly in all people. The headaches improve the most with either the stents or the shunts and all of them have complications, some severe. The stents, they had death. So it's not an ipsy-pipsy procedure. Shunts fail, 43% failure rate, so that's not great. And optic nursing fenestration can have some failures but probably is one of the safer procedures that we can offer. What is gonna happen in the future? Well, we definitely need to understand the mechanisms of the pressure, the genetics, these arachnoid granulations, the glymphatics. We've gotta find better ways to improve quality of life. We've gotta find better treatment for visual loss. And for sure, we've gotta get better treatment for headache because that seems to be the most disabling part of this disease. I did wanna tell you about some resources. I'm gonna tell you about the novel library. Novel is a website that you can go to.  There are other websites. And we have a website here at the Moran called the morancor.utah.edu, I'll show you that. This is a new book that just came out and I've looked at it and it's written by a neuro radiologist who does stents. So guess what? He's really promoting stents, but he's got a lot of good information in the book too. And I let you know about this. It's the first guide that I'm aware of for patients and families, aside from the pseudotumorcerabri.com website. Now the novel website, novel.utah.edu, this is a joint venture with the University of Utah and the North American Neurophthalmology Society.  And it gives you all kinds of diseases, multiple sclerosis, myosthenia, and of course, pseudotumorcerabri is in there.  It can take you to the Medline, and you can look up new articles about pseudotumor and it has all kinds of other little networks that you can join. If you go to the patient handout, they've got it in a big, large print viewing. They also have it in Spanish, French, Hebrew, Italian, Chinese, a whole bunch of languages. So if you have a friend who has this and speaks a different language, we have it in multiple different languages. And I just did this literature search just last night, 5,302 articles, a lot of them in the last 10 years. So there's more being discovered about IIH and pseudotumorcerabri now than ever before. So we're working at it, believe me. We're working at this here at the University of Utah. We're working at it nationally and internationally as well. Medline Plus is a free website. It's run by the National Institute of Health and the National Library of Medicine. You can just go there.  And it gives you all kinds of new information with illustrations. I highly recommend that. And then this is our morancor.utah.edu. And this is where this video will be for you. My lecture in 2019 is still on the website. And we have stuff for patients as well as educating our residents and fellows and things like that. But you can get more information at our website too. And with that, I'm going to stop sharing and also look at everybody and say, thank you for being here. And then I would like to, I wanted to save some time for questions. And then I know Lisa's gonna hold kind of a little group discussion about what works for people, what doesn't work for people. Cause a lot of you have learned tricks over the years about how to manage your disease. And it's always good to share. And then to learn that there's so many people that have this disorder, right? That it's not just, you're not alone. There is one question and it says, Dr. DeGray, you just saw my daughter, Katie, her IIH has resolved, how often does this happen? And what are the chances it will reappear? You were amazing. Good question, okay? That's a very good question. So here's the deal. It can go away forever. But what are the risk factors for it coming back? The number one risk factors weight gain. So it's kind of like, if you've got this disorder, you have to just be very careful about not getting into a weight gain issue. I think we have to pay attention to these metabolic syndrome issues that accompany this disease a little bit more because I don't know that we're being aggressive enough with this. And then I always tell people about medications that can re-trigger it, like the tetracyclines and like vitamin A. And some of these medicines that are out there, I'm just a little bit more nervous about that. But the biggest, the number one recurrence factor in all our patients and then the literature is weight gain. We've got a couple more questions here. Can you talk about the differences between low pressure symptoms, maybe from a leak and high pressure symptoms? Okay, so the high pressure symptoms, we've been talking about headache, wishing noises in the head, dimouts of the vision, pain between the shoulder blades, blah, blah, blah. Now, it's interesting that people who get shunt sometimes get low pressure headaches or after a lumbar puncture, you get low pressure. Low pressure headaches are positional. So for example, if you're lying flat, you're okay, but as soon as you're upright, it's really bad. The kind of headache you get doesn't help me at all. The appearance of the MRI scan is critical because the MR will be completely different, okay? The MR of high pressure will show an empty cellar, will show this dilated nurse sheath, blah, blah, blah. The low pressure will show me coning down almost like a carry-like malformation. The pituitary, instead of being empty, will be plumped up. So there'll be actual other symptoms or signs on the MRI scan that will help me as well. So that's a big deal. Another question. What are the risks for the dehesions that I experienced with long-term IIH? Okay, I'm glad you brought this up, but next time I will put this whole topic in. I gave a talk in Denmark this summer where I brought up the conundrums of IIH and one of the conundrums I brought up was individuals that have chronic IIH get these scooped out, not just the cellar scoops out, but the base of the skull gets like eroded through and then leaks occur, it leaks go in the ears, leaks come out the nose, leaks come out other places. And it isn't being studied. So the problem is the ENT guys see the leaks and then they fix them or this neurosurgeon sees the leak and he fixes it. But then the neuro-ophthalmologists don't often even get to see the patient because they don't have papillodema because they've self decompressed themselves the whole time. It's a conundrum and it needs to be studied and we need to be working on this one because I have a feeling this is what happens if you continuously have that high pressure this is like another one besides metabolic syndrome and all that jazz, another thing is these CSF leaks. And the researchers that I was meeting with all agreed that this was a conundrum we don't have a good answer for yet and we've got to figure that one out but I'm going to add that to next year's talk because any literature that I have on that I will present. Dr. DeGruy, this is Debbie Quigley, the one that was asking that question. Is that something that you're going to be talking to patients with long-term IAH about? Well, if I follow I'm long enough but sometimes they just disappear and they're doing great. They go off into the Netherlands, not the real Netherlands like Colin, but they go out. They go out and I never get to see them again. And so it's kind of like, okay, they're done one and done, you know? So I think it's not recognized enough and we have got to do a better job of understanding how often do people with IAH end up with the leaks because we don't even know that. How often do these leaks start? I mean, we don't haven't even done the imaging on people who do have chronic IAH, because we know what they have, we don't re-image them. So we have a lot of stuff to learn on this. So it's a really important topic, but I have to say we're ignorant on this. It's not a good situation. Another one. Is the positional always consistent with low pressure? Could it ever feel better sitting up and worse lying down? Yes, unfortunately, it's not 100%.  So it's not 100%. It's just that most people with a low pressure headache initially will have this positional most people. But as you found out, not everybody even gets a headache with IAH, I mean, so you see it's not, everybody is not everybody's the same. Can stress affect IAH? I had a bunch of stress in September and all of a sudden my symptoms all rushed back. I'm visiting my doctor next month as that's the soonest I can get in. Well, stress never, stress doesn't cause IAH, but stress can lead to extra eating. Like some people eat more frequently when they're stressed out. So a little bit of weight gain can definitely push you over. Stress can make headaches worse. It's not the cause of headaches, but it can make them worse. So it is true that stress can play a role and but watch the weight gain. That's the number one cause of recurrence. Is it true that low sodium diets work best for IAH? There's a lot of reports out there on low sodium diets. It hasn't been studied, but a lot of people go on them. So that is something that I've heard. It's just not been studied. So I try to give you, when I give you information, I don't wanna just give you like piecemeal or hearsay. I wanna give you stuff that's been actually studied so that you know, that it's the real deal. But I'll keep an eye out on diets cause it's another important thing. We used to have people go on a keto diet cause you could lose a ton of weight. And there's all kinds of diets like this and low sodium diet. So I've heard a lot of people do that too. So here's a comment. I have high pressure and I can't take naps. Yeah, I've heard that one before. Some people take naps sitting in a recliner chair so they're not completely flat, but they're kind of just partly lying down. And has there been any studies between food intolerances or allergies in IAH? No, lots of studies on food intolerance and allergies with migraine, but not so much with IAH. I'm not aware of any big food intolerance studies with IAH. Anyone else have any questions? Because we wanna make sure that you get enough time to talk to each other too. Cause there are some people here on this call that have been through this for many years and get some advice from some of these very wise people. I just picked one up. You mentioned something early on about iron deficiency anemia and IAH. Can you explain more about that? Okay, it's an association. We don't understand why people get it cause not everybody with iron deficiency anemia shows up with IAH. But there is this strong association with severe anemia like your hemoglobins like six or seven, something like that. And high pressure, but it's not a hundred percent cause you can see a ton of people with a hemoglobin of six or seven and they don't have high pressure. It's just an association, just like not everybody with tetracycline or minocycline gets IAH either, right? They don't get increased intracranial pressure. It's only a few people that do. And we still don't understand why do those few people get that? And I think it's this genetic predisposition piece that we're really missing in this disease. And that's why we're really going after genetics because I really do think that it's important. Looks like one more question came in and that is do antidepressants have an impact in IAH? Well, antidepressants can be very helpful because remember depression was one of the things that make people feel worse. And if you treat the depression, you feel a little bit better, you have more motivation to do things and get out and move and so on and so forth. So yeah, it does have an impact and it does improve depression and IAH has depression. Migraine has depression associated with it as well. It's not, it's real and it's not caused because you don't like your mom or dad or your sisters or whatever. It is caused by brain chemical changes that are occurring. It's often familial. If you have family history of depression, it can run in family. So you have to kind of know your family history because that really helps you too. With any chronic pain, depression was kind of him. Absolutely, where's you down? And if you have any questions about good practices for mental health, Lisa Ord is number one in my box. She is amazing. So you've really got a good treat here because Dr. Ord knows a ton about everything. There's one more that came in. I've had high pressure which has greatly affected my vision and caused damage to my optic nerves. I have been on medication for a long time now and am considered treated. Next month I'm expected to stop medication. What are the implications of it coming back? I still have bad migraines even with medication. Okay, so remember I said we have to treat the headache piece of this. And if the pressure is under control, completely under control, then that's not an issue. But if you have visual loss, you really have to follow carefully with your neuro-optimologist or eye care provider because you aren't going to get to swell as much in your optic nerves. If you've already got visual loss, then they have to use OCTs and they have to do all these fancy tests to follow your swelling. And so if you go off the medication, you wanna make sure the pressure is down. The headache piece, remember, is often is treated more like migraine. And there I would talk with your provider about going on some of those migraine medicines that I mentioned that are very, very helpful. Topiramate is one and that also treats pressure. The new monoclonal, CGRP monoclonal antibodies are good for treating migraine. And then if you've got chronic migraine on a botulinum toxin or Botox is really good for chronic migraine as well. So I'm going to, Lisa, you're the host, right? Yes, I'm not. Okay, so if I leave, I don't knock everybody off, right? No, and I will stop recording so that our support is not recorded, okay? Yeah, and we can even take some of the questions out at the end so nobody's name appears. So, okay, I'm going to leave. I just wanna thank you all for being here. And if you have family members that wanna be part of our study, let us know because we're trying to come up with the genetics of this. And I could figure that out. I think we could cure this disease and where all of us here at the Moran Eye Center are here for all of you, okay? Thank you.


Islands are hot spots for biodiversity, but they're in danger. Human activities are disrupting the natural habitats of numerous island plant and animal species, causing them to degrade, fragment, or perish altogether, including here in the islands of Japan. In response, the Japanese government has recently committed to a 17% expansion of its network of protected areas, spaces such as national parks that support long-term conservation of biodiversity and natural resources. The proposed expansion is one of the common global strategic plans for biodiversity, specifically the Aichi biodiversity targets. The problem is that experts have no comprehensive, ecologically justified way of determining which areas to include. Now, a team of researchers from Japan and Finland have devised an analytical framework that could make Japan's protected area expansion as efficient as possible. Traditionally, planners have relied on an intuitive approach for each at-risk species, create an account of past losses, current major threats, and the cost-effectiveness of conservation actions. It's a good approach for individual species, but it misses the complex way that species interact, leaving pockets where protection is less than ideal. Instead, the international research team pursued a more balanced, multi-taxin approach. They first clarified patterns in biodiversity for all native Japanese amphibians, birds, freshwater fish, mammals, reptiles, and vascular plants, more than 6,300 species in all. They then performed a conservation priority analysis to determine which areas should be designated protection areas for each taxon. Finally, and most importantly, they combined all that data into a single mega-analysis that accounted for overlaps between species from the six taxonomic groups. The result was a map of what conservation looks like when operating near maximum efficiency. For each species type, the analysis revealed the areas that should be prioritized for conservation planning. Importantly, it also showed the gap in coverage of Japan's current protected area network. The current network accounts for about 9% of the country's land area, but on average protects only 10% of the areas where species are found. Fortunately, Japan's proposed 17% expansion offers much room to make improvements. If designed to cover the areas where conservation efforts are truly needed most, the expansion could double the species coverage of Japan's protected area network. More work is needed to refine the analysis, such as factoring in insects and conservation costs as that data becomes available. But the results are promising. Comprehensive, efficient, and balanced, this new approach to determining conservation priority could be a powerful way to boost current protection efforts. And importantly, it contributes to the post-2020 global biodiversity framework. An international effort whose vision for biodiversity by the year 2050 is a world living in harmony with nature.