Aloha. Welcome to Talk Story with John Wahey. Today we have an exciting guest and he's sitting on the side of the table that he's not normally used to. This is Dr. Chad Blair. He is a reporter and all around very important person with civil beat, which is probably Hawaii's outstanding political newspaper or document. I mean, you guys actually pay attention to issues as opposed to just writing. But anyway, welcome, Chad. Governor, a pleasure. Thank you. We are here to talk about a really important subject for everybody in Hawaii, everybody in the United States, maybe the world. And that is the freedom of the press. Now, our Constitution, the United States Constitution and the Hawaii Constitution both guarantee freedom of speech and freedom of press. I thought we'd start off by asking, Chad, what is the freedom of press? I mean, what is it? I know we have this vague idea that it means something that people can write articles. In your opinion, what is the freedom of press? What does it mean? Well, first of all, thank you for having an enemy of the American people. The opposition party? The opposition party on your show. I used that line the other day and I'm not done with it yet. I'm going to get some more mileage out of that. I think that's one of your greatest credentials. I do too. He's likely hired a PhD. I agree. In fact, it's a badge of honor right now. What does it mean? It's in the First Amendment, not the Fifth, not the Twelfth. It's the first thing that the founding fathers, the freedom of religion and freedom of press. Right, freedom to assemble. And the reason was because they felt a fourth branch of government, although I don't think it was called that at the time of the founding. But in addition to the executive, the legislative and the judicial branches, the three branches, they felt that a free press was essential. And of course, it was essential to democracy. Absolutely. And it was brutal back then as it is now. If you look at the Thomas Jefferson, John Adams contest in 1800, there were brutal things being said back and forth and things about Alexander Hamilton and Aaron Burr.  But he also said I'd rather have a good newspaper, essentially, than a government, because you can't have government without it. Because there's an expectation that these newspapers, essentially, these pamphleteers, in some cases, would keep the government honest by reporting on what they did. Thomas Payne, common sense. Okay, way back then there was, I mean, practically every town, every corner, there was somebody writing something, maybe like similar to the bloggers of today. So, you know, but what does that freedom of the press mean in this modern era when the press is also a business? Well, it's tough because, as you know, the press is in a whole lot of trouble right now. It's a broken business. The model is no longer working, advertising, classified. And because of that, you're seeing a number of newspapers fold across the country. It happened here, the Honolulu Star Bolton and the Honolulu Advertiser merged into one paper. And frankly, I think we're a lesser community for it. It was better to have two competing newspapers. Well, that doesn't mean journalism is dying. And what has been surprising to me is people like Jeff Bezos or Bezos for Amazon buying The Washington Post, people like Pierre Omidyar, the founder of eBay, founding Civil Beat and The Intercept and First Look Media. And now some are even looking towards a non-profit model to sustain it because it's difficult to get people to pay for news. Because you can turn on your TV, for example.  The educational aspect doesn't seem to exist. But if you ask me what it means to have a free press, it means you need to have an institution that can say to President Trump, well, how exactly did President Obama wiretap Trump tower before the election? Can you produce some evidence? And when Senator John McCain follows up and says, yeah, if you can't produce the evidence, then you ought to retract that. This just happened. Who else is going to report that except for the press? And you can't rely on a biased media organization like a Fox News, like a Breitbart, like an Info War to do that. Or I used to say, I now believe that the idea of a free press, I believe with intensity. But I've always believed that it was an important constitutional amendment. But now because of our president, I believe that it's even more important. But at the same time, though, as I was going around saying that we ought to have a free press, I was going to say, but I don't like this particular Breitbart, for example. I don't like them. But a free press encompasses these crazies. They do. And mind you, they're a price that we pay or something changed. We moved out of a society that had three television stations and PBS and daily newspapers. We didn't have the internet. And we didn't have blogs. We didn't have talk radio. And somewhere along the way, particularly in the 90s and the early 2000s, we started to go into our own echo chamber. And rather than all of us sharing the same snooze stories, Nixon resigned. Everyone agrees. In 1974, there wasn't another article saying, Nixon forced out of office by bad dudes. He was a great president. Yay, Vietnam. That has changed to where people cannot make the distinction between what is real and what is fake. And for the president to say, you are misbehaving, you are misleading, you are fake, you are dishonest, is really a remarkable turn of events because people were already questioning the media because let's face it, we got some things wrong. WMD on Iraq, we called it wrong. Well, it didn't help that the White House at the time was feeding us a bunch of BS. But that's what scares me the most right now is that people, when Trump says something like what he says, it's happening today that Congressional Budget Office says, look, Obamacare repeal is going to be 14 million people are going to lose their jobs. Trump immediately says, ah, that's not true. Not true. So who do you believe? Oh, I don't know. But when I ran for office, the press said I was going to lose. So who am I supposed to believe? And how did the press treat you when you were in office? Well, they treated me, I think, full on. The way I wish that everybody else who they would treat everybody else. But we also had to help them. We passed the open records law. Right. Thank you. Which, by the way, made life miserable. Oh, it did. For anybody, for me and others in office. But it was the essence of what they're there for. What I worry about is you now have a president that says that what we consider to be objective reporting, at least within the parameters of objective, is a lie, or is wrong, or is in opposition and deliberately says the opposite and the press, his press, follows it. Oh, Steve Bannon ran Breitbart. He's now the senior advisor. Some people say he's the spendalli. There was Sputin, the guy that's really running things back there. Well, this is a big concern. There was a poll just the other day saying that a majority Democrat still feel that news gets it right. And it's fair, and if it makes a mistake, it corrects it. But a majority of Republicans feel that you can't trust the media. There's even some indication that they trust Trump more than they do the news. That's right. More than they trust the idea of a free press. Now, what I'm leading up to is his secretary of state. What's his name? Rex Tillerson. Yeah, Rex Tillerson. Hasn't held a press conference. Never. Won't talk to the press. Won't let the press go with him to Asia. Won't let him travel as is the custom, right? But at the same time, there's going to be, I'm assuming, if it's like everything else, somebody from the Trump administration feeding news to Fox. So you have a little bit more than just taking an opposition view. What you have is the president of the United States, an administration, actually supporting the business aspects of one of the members of the press. You have Sean Spicer, his press secretary, leaving CNN and The New York Times out of a briefing off camera. That is really remarkable. You having the White House allow these other news, I'm going to use these quote marks, these so-called news services, to come in there and be treated on the same level as an NPR or a CBS or even CNN. I'll mind you MSNBC, I think, has its own biases. There's no question that there's a problem with bias in the media. But if you can't trust the media. But if you allow government to choose who listens to or talks to the people in government, then the cure, it seems to me, the way to achieve objectivity is to give everybody opportunity to say something. But not everybody has the same value of things to say. And I think what the media does, and I'll admit sometimes it puts, we put ourselves on a pedestal and we think a little bit like, we're going to be the ones that'll make the call. And we could learn some humbling from all that has happened in the last year and a half. But someone does have to be able to say when something is false, when what the president or Sean Spicer, and if that is then taken into doubt by millions or tens of millions of Americans, that's a very serious problem. And I'll point to that. Well, I think for politically, that's a very serious problem. For the country. I mean for American democracy, it's a serious problem. I'm, what I'm sort of interested in is the fact that after the Secretary of State announced that he was not going to have anybody traveling with him, what the media did, at least the mainstream media, was to have a meeting and sort of, oh, this is terrible. And but, you know, the reaction didn't seem to have been that strong against it. Now, true that on the federal level, there are a lot of the access that was granted to reporters was done by custom. It's not necessarily required by law, but it was done by custom. It was thought that this is the American thing to do. This is how our democracy functions, right? But, you know, all of a a sudden this happens. But he stepped one step further. And that is there was direct government sponsorship of players in the media, of the press. Now, how does a struggling newspaper or a struggling TV station or radio station continue to be the party of the opposition when their competitors are being fed the news? Fox doesn't have to go on the plane to Asia. Fox will get reports back every day. But CNN might have to. They might have to pay for it. So, now you also got an economic... I think it was Sean Hannity that was essentially flying candidates, maybe Trump on his own plane. You know, Fox actually has a couple of good people. Brett Baer, I think is fair. Chris Wallace is a good reporter. I think Megyn Kelly. Having said that, that's a den of sexual harassment, as we've been seeing since Roger Ailes was leaving there. One of the lessons that I've learned, and this is coming from a Columbia journalism review, as you know, there's a good one of the best journalism schools in the nation there. And the lesson is, maybe we got too close. Maybe the press got too buddy-buddy with the people in power. And I'll have to admit it. I like politicians.  Well, thank you. And I find you, as long as you're not reporting on me, excellent person. I love the fact that I have your cell phone and your email, but maybe it's too close. Now, you're out of office, but do we lose our objectivity when we start thinking of the lawmaker? We'll come back right to that after... Oh, it's a time for a break. A time for a break. Yeah. And by the way, folks, call us if you have any questions at<PHONE_NUMBER>. Thank you. Aloha. I'm Kauai Lucas, host of Hawaii Is My Mainland here on Think Tech Hawaii every Friday at 3 p.m. We address issues and importance for those of us who live here on the most isolated landmass on the planet. Please come join me Fridays at 3 p.m. Mahalo. Okay, I'm here with Brett Overgaard of the Faculty of the School of Journalism and the Department of Communications at UH Minoa. We've had a number of shows. We have a movable feast going on. And we talk about journalism. We talk about language. We talk about communication in general. And we talk about the effect of that on the country and on individual people. Brett, it's so good to be able to discuss this with you in our movable feast. Oh, it's my pleasure. This is a great opportunity. You'll have to come back again and again. Okay, deal? That's the deal. Brett Overgaard, I'm Jay Fiedel. We care about everything. Thanks. Welcome back to Talk Story with John Wahee and our guest, Dr. Chad Blair. And we were just talking about the fact that maybe over the years some members of the press and of the political establishment may have gotten to be too friendly with each other. I was talking to someone the other day, and it might have even been you who said this, that back in the day, Jack Burns, whose son, Judge Jim Birch, has passed away, would actually meet casually with reporters, but it was all off the record. Is that right? All off the record. In fact, that it used to be, he would sit right on the Capitol. And especially, well, at first, he was at Eolani Palace. Then he would sit right on the front stairs of the Capitol, right where the Lili Eolani statue was, is right now. And reporters would gather around, they would take notes, and he would actually talk. The attribution was off the record. The substance was open to anything that they wanted to be discussed. Now, Jack Burns, on the other hand, was very much, you know, he didn't hold that many press conferences at the same time. But he probably had one of the best informed press scores in the country here in Hawaii. We're not talking about that now on the national level, because what you're talking about is deliberately keeping reporting away from the issues that they're interested in. Burns never dodged the issues. He just never wanted to be quoted. So after a while, you kind of figured out who was actually saying these things. This is back when guys like Tom Kaufman doing great work and Tom still around today doing books and video. Oh, Budsmizer, George Chaplin and all these guys that were here. And in fact, one of the interesting things about back then, we had three separately owned TV stations, not only two different newspapers, but three different stations. And it's all changed. Now we have three stations owned by one company, and the three main stations are owned by corporate mainland interest, and that's a concern. So what you had was you had C.S.A.F.T.L., Bob Berger, and I forgot who they are. They were doing editorials on their stations, often in opposition to each other. Now it's all about a severe weather channel and what's the traffic like? Getting back to the idea of excluding the denying access, actually, Hawaii had a similar case, getting back to when Frank Fosse was the mayor, he had a war with the advertiser. Richard Verrecca, was he on the advertiser? No, Richard. I think it was Star Bolton at that time. But he kicked him out of Honolulu. I think he was with the advertiser. But the argument that Fosse had was that they both were owned on the business side. The joint operating agreement. Right. And in fact, I was treated to two hours of why that's a sin with Frank. And it makes sense, but it still was not something that people went along with. They said, okay, no, we need two newspapers, not one of them. Okay, so what Frank did was he banned Richard Verrecca, as you were going to say, from attending his press conferences. So that is a mild version of what is happening now on the federal level. The advertiser took that to court and won the case. And our Supreme Court basically said, you can't deny access. Otherwise, you don't really have freedom of the press. Because access is an important part of this freedom. How do you think our U.S. Supreme Court, especially one that's going to be five to four again, Republican, would weigh in, should such a similar case at the federal level? Well, what would happen, let's you and I speculate. So instead of just going to a meeting, all these media people got together and said, we're going to file a lawsuit and we're going to do it in California. And we're going to come up, we're going to do it quickly. Because the trip is coming on up, we're going to need an injunction, we're going to need something. And take it up there, have the Ninth Circuit Court of Appeals, get that referred to a divided Supreme Court, which four to four says we don't want to hear it. Sends it back to the Ninth, right? Well, it means that the ruling stands and that becomes the Constitution. But I don't see that kind of aggression. I wonder, though, if such a test might happen. Remember, Trump, as a candidate, said he even wanted to revisit libel laws. Absolutely. I mean, he evolved people, the things that are said. That scares me a great deal as a reporter that what I say, I mean, there's already restrictions on what I can and cannot disclose. I have to be careful about sources, using anonymous sources. I'll tell you something, though, back to this idea about whether we should be friends with the people they're recovering. Neil Abacromby, you know the former governor, he supported him. And he was having a press conference when he was in the fifth floor. And I've known him a long time. In fact, those of us who like Neil often advised him that he should not have as many personal press conferences. It might have been wise because he said, you know, let's get rid of the pro bowl and I'm going to roll over the AARP. But I introduced a new reporter. I said, come along to me to the fifth floor. I'll introduce you to the governor. And he went right up and asked him a question and said, can you tell me about Lanai? We had heard that Lanai was being sold to Larry Ellison. And Neil Abacromby did not give him a straight answer. And I was writing home with this reporter afterwards who said, the governor of Hawaii just lied to me. And I thought about that for a moment. And I said, that reporter is doing his job. He is being critical and skeptical. Whereas I was like, hey, this is the governor. Yeah, he's this nice guy. But in fact, that's not our job. And that's something that I do think we need to be more careful about. And I say this as someone who has too many people that are friends and politics. Maybe because I came from the political background, right? And also lawyers, my lawing background. And so we exist in a world where it's possible to like somebody, but totally disagree with them. That's true. You know, and totally be completely on the other side of an issue. So I don't necessarily see that as something, friendships as being something negative. But if it affects, if your feeling has to be negative in order to say something negative, then maybe as a person, you know. But unlike a lawyer, we're not getting $700 an hour to defend someone we may not like. You see, that's when I started to decide that maybe I should have gone back. Unlike a politician, we don't have to compromise and trade horses to get legislation back. So you don't need to be a friend. No, what our job is is to tell the truth. And if our affection for someone, our loyalties, is interfering with that, then we're failing the people that we're serving. Well, yes, absolutely. But I think you need to distinguish between loyalty and telling the truth. Loyalty and friendship, in other words. Loyalty should not be there if you're a reporter. If you want to be loyal, go work for the guy that's being the governor. But friendship may actually help you get the story. There's no question that it has, and it continues to do that. I had one editor tell me, John Temple, the founding editor of Civil Beat, worked at the Rocky Mountain News for many years. And he said, even when I wrote a story, or we ran a story that was brutal, and he mentioned Ben Nighthorse Campbell, remember? Right, right, right. Native American from Colorado. And they ran a brutal story, which was true. And what John told me was they'll actually respect you more when you just do your job. Even though you may think, I'm being a jerk and saying something bad. He says, don't think about that. Report the truth. I'll give you an actual case. What are my friends now? I mean, I consider him a friend, and hopefully he thinks I'm a friend of his. Is Richard Baraka, who was a pain in the butt when I was in office. We got to be friends, actually. But I do remember once, I remember this incident. And maybe Chuck Friedman, who was my communications director, might also remember this. He wrote an article. And actually, the article was one that very few of the other reporters got. But in my opinion, he got it correct. He got what we were trying to do. I don't even remember the subject. But I do remember thinking, oh, this guy's doing his job.  What? Nice article. This is absolutely. Now, that's set off an alarm. What did I do wrong? The next day, I get totally smashed in some report that he was doing. And so Chuck said, you never should ever tell. At least Richard, he wrote a good article. Now we have a problem with social media. I wrote an article about a David E. Gay press conference the other day, and his administration tweeted out the story, which to me is an indication that they liked it. And then that made me immediately think, whoops, I might have failed or something. Maybe you crossed the line. Yeah. Which brings us to- Which I don't think I did. Because I'm sure my editor is watching right now. No, I'm sure. But this is what brings us to today. So now we have social media. So we have a president that cuts off all the access to what we call the establishment media or whatever, how else you want to call it. But he tweets every day. So people are beginning to think that instead of reading a newspaper, I follow his tweets. And how does the system survive in this kind of a context? You bypass the media altogether to get your message. You know, I don't know if that's going to entirely happen. Even Donald Trump, remember he would actually make up names and call reports to give them tips about himself. He reads everything that is said about him in the New York Times. The problem is his staff actually tries to give him all positive articles, but he goes out there and he watches the shows and he knows what's there. I think even he realizes he cannot bypass the press because the press, in many ways, made him who he is today. But he has two formidable weapons. Yes, he does. And he's taking on a free press.  Because those two formidable weapons are to pick and choose the businesses you want to support. And the second is to bypass their communication just outright. Because what happens if people stop subscribing to the New York Times? See, what happens at what point does the shareholders run into the New York Times and say, look, guys, you know, be nice to them? Well, let me add this positive note on this. The New York Times subscriptions have actually increased substantially. Because, as you know, journalism has been losing a lot of viewers, but it has actually kicked up. And there is a sense that this is a rare moment for the press, where it has to rise to the occasion and frankly take on saving the country. Well, I think and I'm hoping that the one positive side following up on that is the fact that it may become good business to be against the president. That's what I'm hoping too. And that's, by the way, that's how Fox News billed itself as being against the incumbent. And then all of a sudden, you know, maybe CNN might be finding it or somebody else. But whenever I hear someone say, oh, this news service is biased, that the New York Times or the CNN is too liberal, I think, well, just ask Bill Clinton back when he was president whether they should have covered Monica Lewinsky. I mean, the press gives it as good as it can to just about whoever is in office. Well, hopefully that'll continue, you know, and I didn't think I would actually be saying this, but we desperately need a free press. Unfortunately, we're running out of time. I was hoping to take this home and, you know, find out how free is the free press in Hawaii. But at this point in time, I want to thank you. Thank you very much for being on the program, talking about a very important subject.


Hello everyone. So today I just wanted to make a quick video, a short video, because there's something that that a couple people are doing that they really should not be doing. And that is to pay for phone calls to the US and to Canada. And I realized there are actually quite a few people out there who are paying to make sales calls or to call clients or prospective clients or whoever it might be in the US and and in Canada. And there's no reason you should be doing that in this day and age. So I just briefly wanted to go over this with you and explain how to make free calls to the US and Canada and why you should all be doing it. First of all, sorry, it's very easy. And it's all through Google. Basically, there's if you go to voice.google.com, then you'll get it. But it also works as an app on any one of your on Android or iPhone or whatever you have.  And what this does is you download it or you access it online or whatever it is. And it gives you a US phone number, you get to pick your US phone number. In fact, at least when I picked it, I get to I got to choose I think the last four digits and the area code or something like that. Anyway, you get to customize it a bit. And then you have your own US phone number. And if you for those who lived in the US or Canada, you know, that calls within the US and Canada, basically everything that has won as an as a country code, which is the US and Canada, all phone calls are free because they all count as local calls. So once you have this US phone number, that means that a, you can make free phone calls to anywhere in the US and Canada, you can do it from your computer. And you know, I would do this off and do it from my computer with my headphones like this and just speak to them, or you can do it from your phone, which I would also do. You can use a Google Voice app and use your phone like a phone where you make phone calls, you know, like, like it's the 1990s. This allows you to make free phone calls anywhere in the US and Canada, but also it gives you a US phone number, which then if, I mean, you know, this is depending what your type of business is and what you want to do and everything. But if one of your languages that you translate into or from is English, it might not be bad to have a US phone number. You could have potential clients in the US.  What you can do what I did with mine is I set it up so that if I didn't pick it up, it will go to a voicemail. And so usually that's, that's what would happen with my, with my Google Voice number is it will go to a voicemail and my voicemail, you know, basically said, it's me. I'm not here right now. Please leave a message after the beep. And Google is great because then when they send a voicemail, you get an email, you get a transcript of it, and you get a link where you can play it directly from your Gmail. So when someone calls you receive an email from Google Voice saying that you received a new voicemail and you click on it, and then you can see the transcript here. They're usually pretty good at trying to understand what the person, the message that the person is leaving. As you can see, this is perfect. But otherwise I can also play the message and I click on play message. It opens up Google voicemail. And then I can just play it here. And that's it. So once again, there's no reason you should be paying for phone calls to the US. Plus, you get a free US phone number. So why not have a free US phone number and it won't hurt. And it definitely could help you get new clients or deal with potential clients or colleagues or whatever you might have in the US. So I just wanted to put that out there in case for those people who don't know, now you know. And so it's something that you should keep in mind and possibly take advantage of. And that's pretty much it. I mean, there's no, if I'm missing something and there's a reason why people can't do this, then let me know. But there's no, there's no payment after a while. You don't have to like do anything weird or whatever. And you can just use Google voice. So it just kind of surprised me that more people aren't doing this and that people are still paying to call the US. Now to call other countries, what I usually do, what I have been doing is using Skype. Skype, you do have to pay something of the way it works is that you prepay, put money on your account and then it gets used up when you call internationally. But it's pennies on the dollar for as compared to just using your phone. Even if you get some prepaid calling card, usually I haven't found anything that's consistently as cheap as Skype. And so I just recommend using Skype. I know they do have other apps. So I know there are these apps out there and what they'll do is they'll provide, you know, cheap phone calls and they'll say, oh, the first 30 minutes are free or the first, you know, X number of dollars worth is free for your phone calls. And so I know there are people that'll sign up for that, use the free amount and then sign out and sign back in using a different ID or email address or stuff like that and keep doing that so they can keep getting free phone calls. I've never done that. To me, it seems, I mean, it seems pretty dishonest, quite frankly.  And I don't, I don't spend that much on international calls. So maybe that's why I've never really found the need. I have few, I can't recommend any place to do it because I don't know the names. I'm sure if you search for it, you can find out apps or whatever that you can use this. But I'm pretty sure they don't want you to be using it this way. So, you know, use it at your own peril. But for me, I use Google Voice for any phone calls in the US because it's free. And I use Skype to call internationally everywhere else. And it's been working fine for me. And so that's what I've been doing. So I hope this, you find this video useful in terms of making international calls and also for receiving international calls. So if you found this useful, please let me know by clicking like and don't forget to subscribe. And you'll get more videos that hopefully you can find useful as a freelancer, as a freelance translator. And otherwise, I'll talk to you next time. Thanks. Bye.


Well thank you for the introduction and thanks for everyone for making this popular 8.50 in the morning session with me. This is joint work with Venkata Coppola and the talk title as we have it is about getting chosen CypherTech security for attribute based encryption but Venkata and I decided that if we could go back in time we'd actually title it something a little bit more like this which emphasizes just a way of going generically from chosen plain tech security to chosen CypherTech security. So that's going to actually be the core of our techniques and also what I'm going to focus on the talk today. I imagine most people in this audience are already familiar with the concept of public key encryption. We have a setup algorithm which generates a public and secret key pair where the public key can be used to take a message, create a Cypher text with it and the public key and then the decryption algorithm takes this input the secret key and can be used to recover the message. The first formalized notion of security for public key encryption was due to Goldwasser McKally who came up with indistinguishability under chosen plain tech attack and intuitively this says that an attacker if given a Cypher text of a message of its choice will not be able to distinguish this from another Cypher text let's say one of the all zero string. However, over time what we discovered is for in real life there's more active attackers than one that just sits there and looks at Cypher text and to capture these in deployed systems we need to have a stronger definition and the right one has turned out to be something called chosen Cypher tech security where we're going to give an attacker oracle access to a decryption algorithm where in the security game we can ask for a decryption of any Cypher text of its choice other than the challenge Cypher text that it's trying to figure out. Okay so over time I think our community has actually been really really successful in getting chosen Cypher tech security you know usually we started out with some number of theoretic constructions of plain CPA security but then over time with different innovations pretty much for most assumptions I wouldn't say all them for most ones you think of we now have chosen Cypher tech secure variants. Now one thing that's interesting though is can we generically go from CPA to CCA security so I give you any CPA scheme never mind how it's built is there a way to transform it or to make a chosen Cypher tech secure scheme from it now there's some what I would call minor roblox to doing this so one barrier is that this earlier work showed well any scheme that does this generically in a black box way the decryption algorithm must call the encryption algorithm okay but I'm gonna call that kind of a weak barrier because number one you can and number two most schemes actually do do this right like this that get chosen Cypher tech security do something like that but in general I mean people you can debate this a little bit but for going from CPA to CCA generically the main path of main technique we have is non-interactive zero-knowledge proofs and the two you know somewhat draw so that that's a great idea of course but perhaps the two drawbacks with that is a you need a nizic which they're not always so easy to come by and b the nizic approach needs to usually prove something about the encryption circuit gate by gate so this is a non-black box technique and tends to be you know not as efficient due to this okay so in this in this talk I'm gonna we're gonna talk about going from CPA to CCA generically now however in order to do this we have a new approach and we need one extra little ingredient which is a certain type of pseudo random generator that we're gonna call a hinting PRG so through the talk I'll talk about a construction and at the end I'll touch on what exactly is this little extra ingredient we need to be able to make the leap from here to here in order to explain things I'm gonna build things up I'm gonna build things up incrementally the first thing I'm gonna do is start with the CPA scheme and then go to another chosen plain text secure scheme this one will have some of the structure we're gonna need later on and then I'm gonna go to chosen ciphertext security one which essentially means that all decryption queries must be before the challenge ciphertext and as far as going to the full result we're just going to punt this to the paper okay so as warm up we're gonna go from CPA to CPA and I warn you on its own it might look a little bit odd it won't make sense why you'd want to just do this for a chosen plain text secure scheme but the point is we're going to be laying out the structure for what we're doing okay so let's think of n as our security parameter and to build a scheme we're going to create n pairs or two times n public key and seek public keys and secret keys okay so we're going to have what I would think of as like a zero row of the public keys and the run row and I'll keep this layout as a theme throughout the talk and we're going to also generate the corresponding secret keys the first thing we can do is actually just delete we're only going to need the zero of the secret keys so there's going to be a public keys our public keys going to consist of all these two times n sub public keys and our secret key will be n of these secret keys okay so let's let's look at how encryption is done the first thing you're going to do is you're going to choose a random seed s let's say of n bits and you're going to run s into a prg I'm going to call this h and this is going to give you a value z zero so we're going to take the message we want to encrypt and blind it by z zero like x or it in with with z zero now for someone to be able to decrypt we have to communicate s somehow okay and the way we're going to do this is in a bit by bit encryption and also an x almost what you would think of as an extra redundant way it's a little strange so just imagine that for each bit let's say the first bit I'm going to encrypt imagine just the string no in the in the first index and zero position I'm going to encrypt a no to say no the first bit is not one and then yes it is a zero and for the second bit yes it is a zero and no it's not a one you know it's a bit strange as it is but that that's the way we're going to do it so we're going to just keep on doing this bit by bit in in our slide here we're going to imagine that n is four bits for presentation purposes okay now so that's an encryption we have the message blinded by z zero and these sort of yes no ways of encoding s and to decrypt is pretty simple right you just um you have all these zero keys in the index so we're actually going to decrypt just using this top row and essentially just ignore this bottom one and we can learn si if there's a no I assume it's a one and if it's yes it's a zero so I go through index by index and I can recover um s and then once I have this I can run s through the pseudo random generator once again and and and recover z zero and then recover the message by x or in it out so this is not too difficult as it is okay and the security proof for just the cpa scheme is pretty simple what we're going to do though and when what's going to be useful later on is we're going to essentially want to erase information about s if we erase information about s we um we can hide m right and the way we're going to erase information about s is we're going to uh we're going to instead of we're going to essentially add disinformation so we're going to do a hybrid via cpa security to say yes it yes the first bit was a zero and yes the first bit was a one and essentially say it's both things um this is sort of an encoding technique that I got inspired from um Gargan Haji Badi from a paper about a year ago uh where they use this I thought kind of was a clever idea for trapdoor functions of adding disinformation right um although I won't go further into uh exactly how um they did their thing okay so you add yes yes yes and and then when the information about s is um gone we'll kind of do in the cca proof we'll do things a little bit differently and um then once the information about s is gone we can use prg security to hide information about the message m okay so that's a pretty simple proof um as it is okay of course this is only just warming up towards chosen cypher tech security so let's see how that works uh to do this we're going to have three building blocks the first thing is the chosen plain text scheme I should like the with the sub cypher text I showed you earlier um we're going to use that again but it's going to have this additional property where um if you happen instead of having the secret key if you happen to have the randomness used for encryption you can also recover the message and it's not it's not too hard to show that this property is buildable in a very easy way from regular cpa security uh the second thing we're going to do is going to we're going to have a prgh that's going to have this hinting property that i'm going to uh talk about at the very end and finally uh we didn't we explained it a little differently than this in the um original paper we're going to have a commitment scheme that is um equivocal okay and that's also built from pseudo random generators okay so a bit a bit commitment scheme is going to work as follows there's going to be a setup algorithm and a commitment algorithm the setup algorithm outputs some public parameters commitment algorithm takes his input public parameters message is and some randomness for the commitment it's going to be hiding the commitment should not reveal the message um binding it should be hard to produce openings for um different messages and also equivocal in that we can generate the parameters in a different way than the normal setup which actually does allow a commitment to both a zero and a one but the way i'm the the way i create these parameters should be indistinguishable from the normal mode okay so let's let's build the scheme public scheme uh the public and secret keys for the scheme are essentially the same as before but i'm just going to add the public parameters for the commitment scheme in there otherwise they're the same as what you just saw uh next for encryption the high level ideas are in addition to encrypting the seed s as before we're going to commit to it bit by bit and then we're going to add a lot of checks to prevent malicious cipher text or or at least limit the damage that they can do in the cca game and along with this we're going to have a more elaborate way of saying yes or no okay so let's let's see how the encryption scheme works i'm going to do things as before but also choose um randomness for the commitments so n and random um so x one through x n are going to be uh the randomness for the commitments and when so we're going to have yes or no encodings of s and bitwise commitments for for each of them so over here we're going to have commitment to one zero one zero under the strings under the randoms x one x two x b x four and now in order to say now in addition to saying yes and no like before when we say yes we'll kind of do yes but then also give as the message the commitment randomness x one and x two and so on and so forth so the no values will be done as before the yes values are going to be done a little bit differently and moreover for the um we're going to expand things even a little further we're going to imagine that our prg in addition to just giving us this blinding value z zero is actually going to give us um randomness for the encryption so these would be the z one through z n so here um the x values are the randomness for the commitments which are the messages of the little encryption schemes and the z values are going to be used as the random coins for this the sub cipher text now the note the no cipher text will also have randomness here but it's just freshly chosen it's not related to this it's not related to this prg value okay okay now let me let's let's see how um decryption works just by example so what i'm going to do is remember i have the all zeros key or i have the the zero half of the cipher text so what i can do is i can use my decryption keys to recover what's up here and i can use this to map into a what i'll call a candidate s value so if i see a no i can say well no okay it's not a zero so that must be a one um and this one claims to be uh claims to be a uh a zero so i'll write that down and so on and so forth so now i would cover s at this point but i can't trust that the cipher text uh was i can't trust that what i did was a good thing or can't lead to some attack instead of just using this s value what i want to do now is do some sanity checks on it then in order to do the sanity check the first thing i do is i plug the possible s value like at this point an attacker for example could have given me two nos or you know try to um or give me a wrong commitment uh i'm going to take this s value plug it into the pr the prg get these z one through z ends and i can check each of them the first thing i can do is use this randomness to try to recover uh the x values to check all the commitments that's the first thing i'm going to do and the second thing i'm going to do is actually now that i have the claim randomness i'm going to re-encrypt at least all these yes values not the no ones i'm going to re-encrypt them myself and see that they actually match up with the cipher text so this is um actually using re-encryption uh which has been used in other contexts like fukusaki oga moto and other ways in order to check um validity of the cipher text themselves okay so so really two sanity checks uh you recover the x values you check first check the commitments um then you check the at least half of the encryptions the half that you can now you might ask well why why go through this whole you know what why why would we bother going through this whole um process of you know all these checks and it really comes through this first step of the security proof um as i told as i explained things uh in the actual scheme we're going to use the zero version of the secret key right with this really for each pair of public for each uh index there's a one a zero version and a one version i'm saying use the zero version all the way across it turns out that after we do all those checks what you can do is um you can use uh the secret key according to any string uh these checks mean that attacker can't tell what secret key or what secret key half for each index you're using um when you're decryption if you do all these checks so the first thing we're going to do is actually if we let s star be the seed for the challenge cipher text we're going to do a hybrid stuff in a security proof where the decryption oracle will um now decrypt along s star instead of the all zero string and if it was succeeding in breaking the scheme before it should still be succeeding after doing this um after doing this switch okay that's that's the first step and then the second thing we're going to do is change the commitments to be equivocal so there's like for each one there's a coin x1 that will let's say open it to one and a coin x1 prime that will open it to zero we're going to then change this is a high level of view there's a little more details to these steps so we're going to have an opening for both the zero and a one and then we're going to use cpa security to actually um put that value in there so this is equivalent to me saying yes it's a zero and yes it's a one yes it's a zero and yes it's a one i'll do this for each little part adding this disinformation to lose um to lose information about s um now okay at this point it looks like all information about s is gone right like i i at least in the message space all information about s is gone and it looks like you know we're almost pretty much done here right we can plug in the same argument as before and however there's one little catch and this is a little this is a bit subtle that there still is information hanging around about s in the random coins here right because here the random coins for this thing are just freshly random chosen and the random coins here are derived from running this prg on s and if you follow it if you follow it you see this kind of the fact that there's a zero it's in this one position here and the zero position here and so on and um and so on and so forth now there's really this um lingering information that's kind of annoying about s and we need to get rid of it we want to be able to go from that to something where they're let's say all fresh um all fresh coins and essentially the way we get rid of it is by the security game of the hinting prg it um essentially it does this for us okay well let me explain what these hinting prgs do uh we can think of it as going from n to n square n square bits or n different blocks each of um length n bits um so here's the security game we have imagine a challenger takes a random seed s runs it through the prg and gives you z1 through zn i'm going to throw out the z zero value just for simplicity all right then it also chooses ran just completely freshly random blocks v1 through vn each of these is n bits now what we're going to do is we're going to swap zi and vi if s i is equal to one um essentially here we're going to place the z the z blocks um according to the the string s so the first bit was one replacing this one here then we're putting the second one there and then the third bit is a zero so we're going to put it up top we're going to arrange it in this way which really maps pretty much directly with the way i way i had the scheme and the question is can can an attacker distinguish this distribution from one where all these um two times n blocks are just uh chosen uniform length random all right uh and that's why we call the hinting prg because the layout of where the z's are are an extra an extra hint um so good news is that we actually can create we actually can generate these from standard number of theoretic assumptions we do it from learning with errors computational diffie helman uh the constructions follow pretty directly from some early work on similar similar mechanisms were used in leconic ote or a committee in hash batch quit uh this type of work uh but one differentiating point is those works needed some asymmetric cryptography at their core so while we can do number theoretic assumptions you know we could also just take an aes based prg and hope it's hinting secure and you know it seems like it would be but uh one one can't get number of theoretic proofs there uh okay so this this is an overview of what we did we had a process a new generic way of going from cpa to cca security and the only thing not implied just by public key encryption was this additional hinting prg and of course it's pretty tantalizing to think uh you know could you just somehow get that from public key encryption or pseudoram generators or or something like that uh i i i don't it's still kind of tough uh and i like to wrap up by just tying it together uh tying things together some other some other works here i mentioned earlier there's this work of a hajibati and garg on trapdoor functions there's also follow-up work to theirs that was concurrent to ours that um improve these trapdoor functions in a way i think it um appeared recently uh interesting part about the construction is we recover random we do we do do this like fugusaki okamoto or lots of trapdoor function or whatever way of recovering randomness and we re-encrypting but we don't recover all the randomness those no ciphertexts we don't encrypt it we don't recover it and i'll argue this is actually a good thing uh the limitations of work is we don't get a trapdoor function but maybe this is a good thing right like we don't want to run into those uh impossibility results in doing it uh the transformation works equally well for attroup-based encryption which is why i think we kind of used the title that um ended ourselves in the attroup-based encryption um session of the talk so almost the same construction you could just plug into attroup-based encryption and it would give you the right thing uh a neat thing is that works have already built on this so i think tomorrow we're going to see something on reasonable designated verifier nizics that need to uh use our particular cca structure to get their um to get the result is you know one piece of putting things together um also some work uh not uh a little bit later today will show how they can take this hinting prg assumption we had and instead use encryption uh symmetric key encryption um that is key dependent message secure and it turns out that since they do this they can also get in addition to diffie helman and lwe there's also a learning parity with no way of bringing this framework um down that's kind of interesting uh it'd be interesting to see how that goes okay so um yeah this is this is the this is the high-level picture of what we do going from cpa to cca with hinting uh plus hinting prg's uh obviously one way of exploring things is to try to get new ways for the hinting prg's or maybe use the framework maybe you don't need hinting prg's maybe use a general framework but uh tweak some other parts of it it's hard to say and i'll just know in another way there's been a lot of interesting progress recently and it seems that now we have a new path it could be worth investing more time into exploring it okay well thank you very much for your attention if you have a question please come to the microphone


Hello people of the internet, my name is Johnny and welcome back to some more Five Nights at Freddy's Security Breach. We're hopping right into Episode 2, we just escaped Glamrock, Chica, Monty, Roxy, basically every single Glamrock and Matronik and we're now in the main lobby. I'm gonna avoid the clean bot, or the staff bot, cause last time he called Chica to us and I do think she's now wandering around somewhere in the main lobby. So we do have to be careful, our current objective, what are we even doing actually, food storage, what? Attention kitchen staff, all food materials must be securely stored at closing. Chica has been caught eating some from the kitchen garbage after hours. The maintenance repairs are costly and will come out of kitchen staff paychecks from the management. Interesting, oh wait, oh there's so many. We paid for the Glam Freddy Mega Deluxe Pizza Package and Freddy broke down as soon as he got on stage. We paid to have him at the table and sing happy birthday but he was supposed to give her the cake, my daughter's birthday has been ruined, I demand a refund. So we're getting a bit of backstory from some customers, I'm assuming. Okay, so I need an entry pass. Is this it? No, that's coffee, uh, okay, wait what's this, hold on, it's a gift box. I remember this from Dock O'Stream. Well there you go, get a complimentary entry pass, awesome. I'm actually gonna save again. Right, so now we can enter the Mega Pizza Plex, right? That's the entrance we just barely missed escaping before midnight and now, here we go, customer service. Okay, so I need to find that. I want to dodge these guys, but I also want to get this bag. Not me Chica, please go away. All right, so I got, oh wait, let's hide in here. Awesome, and let's check what we just got. Easy money, my cousin walked here. He said, magnet screw with the ticket machines. Just head up to Fazpad. You can get down to customer service through the back door and grab a stack of tickets. I'll be waiting for you outside if you hear any robots just hide until they leave, you'll be fine. Okay, I don't trust you Chica. So now we need to go, okay, so she's up here and we need to go to the Fazpad which is... Oh there. All right, there it is. Oh, there's also a gift box and another bag. I kind of want to go out that way. Wait, where's Chica? Okay, she's up there. Let's go this way actually. Or can I not? No, there's like nothing out this way. Okay, never mind. Let's go to the Fazpad. Oh God, she didn't see me. Did she? You didn't see me. How do I get up there? Vent? I can't use that. Oh God. Let's go up. How about that? Let's try going up. All right, more hiding spots. Right here, right? This is the Fazpad. Let's go. Awesome. There's another one. There's another staff bot and Chica's right down there, dude. Don't see me. Don't see me. All right, we got to sneak around this guy. Is he gonna go over here? No. All right, let's sneak around the counter. Oh God. And we need to get out.  I'm just gonna go. Oh, okay, this is good. This is good. Kitchen, I think. This is kind of like a kitchen. We'll hide. Okay, we can hide in there. Oh, a gift box. Let's get this. More collectibles. Always good. Ooh, a Chica plush. That's cool. So now, all right, here we go. Down to customer service. Oh, exotic beverage. Nice. Um, that's customer service. Uh, and I can't go to the Lost and Found just yet. Right here. All right, Freddy. Uh, different maze every hour. Interesting. Your sign here, Sodoroni. Another gift bag. Hi, Dave. Customer complaint. You should fire Dave.  Wait, we know of a Dave. Is that like Dave as in Silverized Dave? As in Purple Guy Dave? Interesting. So how do I get out? Do I need to go back up through the Fazpath? Oh, but you can't get to me though. Oh, never mind that opens. Okay. Okay, Chica. Okay. Oh, God. Okay, she's still coming. So let's get up here. Let's hide in here. And she, she shouldn't be able to find us. What? How did you see me get in there? Ooh, ooh, another box. Okay, Chica named shirt. Thanks, guys. I'm making sure to get all the collectibles again, so I don't miss them. I don't think there was one in here. All right, Glamrock gifts. Oh, there's a bag down here. All right, the Dave ones. All right, let's find where Chica is. And then hopefully, right, hi, Dave. We saw that. Easy money. We saw that. Chica's in the main lobby. She's going up the stairs. Right? Yes. All right, so I think we should have time to go across the hall to Glamrock gifts. I can't open this, but Chica can. That's, oh wait, here. Okay. Okay. Oh, how do I get in? No. No, I need to go up stairs, don't I? Where's Chica? All right, she's still up there.  Let's hide in here for now. There's the motion detector. Oh, look at that. That's helpful. And I should see her now come down these stairs. Oh God, that's so creepy. Go away. I need to get up there, I think. You can see her right down there. Is this how I get in? Superstar daycare pickup. Let's hope I go in there. All right, she's going out that way, which is not really where I want you to be going, but it could work. Yo, let's try. Oh, don't see me. Don't see me. Don't see me. Oh, oh, right here. Glamrock gifts. Okay. Okay. This might be a bit tough. Just as long as Chica doesn't come up here, I think I should be able to maneuver around this guy. Maybe. I don't know. Oh, I don't know where I'm going. I might hide in here. Oh, I don't know. I don't know where I'm going. I'm just running. There's a gift down here. No staff bot. What's this? Okay. I don't have that, I guess. What's this? Mr. Hippo. Mr. Hippo fridge magnet. Mr. Hippo. I love Mr. Hippo. Wait, no, we can use it. It's a magnet. Remember? That's what the email said. All right, let's open this door and let's actually save, god damn. So now we can use the magnet and oh, god. I didn't know she was right there. Okay. You jump scare. Oh, oh, god. Oh, god. Oh, god. Oh, god. I didn't know the staff bots could jump scare you. All right. All right. All right. Where can we go? Oh, god. How does she still know where I am? Are you kidding? I'm just going to run. This is crazy, dude. Where are you singing? What? What? How?  You should not know I'm in here. I don't even know where I'm hiding, actually. I think she's gone, though. Oh, my god. That was nuts. Oh, oh, here she is. So she's leaving customer service, which is good. And there she is, main lobby, going upstairs, I think. Okay. Okay. Let's try this. Oh, let's go. Oh, no, help. Oh, no. Oh, is she coming? Oh, shoot. Second floor balcony. All right. Second floor balcony. We know where that is. It's right past Glamrock gifts. I'm just going to go. It's right here. Go. Oh, textures. Let's load. Thank you. Oh, my gosh. Can I go in here? Hey, guys. Hey, guys. You're hiding any secrets in here? Any secrets? No? All right. I'm just going to hope that Chica can't come in here just yet, but I'm going to get moving. Hey. Oh, a present for me and another one. Excuse me, dude. What's this? Freddy. Great. All right. Don't look at me, dude. That's weird. Night terrors. My son never had sleeping problems, but after spending an evening in the daycare, he refuses to sleep with the lights out anymore. He just cries and cries. And then when I do let him keep the lights on, he wets the bed. Night terrors. That is the name of a level in Help Wanted. So very interesting. Let me find where Chica is quick so I know I'm good to leave. Okay, she's actually so far away. All right, let's go. Wait, these are on the calendar. These were the freaking art renders models on the calendar. Wait, is Freddy here? Ooh, a bit of lag there. Probably loading in something. This is cool. Freddy, he's not here. Another save spot. That's good. Can I go out this way? No, out of order. All right. Well, let's go to the daycare, I guess. I don't know if I should be using other save slots. I'm not right now, but here we go into the daycare. Dude, this place is huge. Oh my God. So are you guys the same character? Also, are you clipping through the ceiling? No, you're not. All right, thank God. I was about to say steel wall. Come on. Oh, oh, slide. I was like, wait, I can't get in. There's a slide to fun. There we go. A bit of issues. We saw that in the trailer, though. Son, his name is just Son. Wait, so are you like friendly, my G? Having a slumber party? Where are all your friends? Kellen sounds so good.  There's only one rule. Keep the lights on. Okay. Oh, wait, wait, where did you? Oh, uh, Jesus, Jesus. I got it. I'm having so much fun. So much fun.  Press E to distract. Oh, I don't really know what I'm supposed to be doing. Let's go up here. Why not? Another slide. What? Oh, oh, God. Oh, God. Don't find me. Don't find me. Don't find me. Okay, uh, yo, so he, okay, so he just, okay, I get it. So I have to distract him because he wants to play with me, but I don't want that. So while he's picking those up, I have to find something to do. Gotcha. Let's save, actually. This area is off limits. Oh, take security badge. Security badges. Allow you to access, oh, okay. Player security level is tracked on the FAS watch. Okay. Oh, God. I didn't mean to. I don't even know how they turned off, actually. I don't like the sound of that. Oh, wait, he had a string on him. Did you guys see that? Oh, uh, press and hold E to recharge the flashlight. Okay, take some time to recharge. Gotcha. Okay. Um, so I need to find the generators. I don't know if I like the sound of that. Is this a gen? That's a gen. So how do I get there? Dude, I hear him. I see him. Dude, what the actual heck is even that? All right. How, how do I actually get to that? Oh, wait, what's this? Turned it on. And I did see another one somewhere around here. Oh, God. Uh, right here. That's two.  He's so creepy. All right. Well, he's going out that way. I'm going to recharge and also save. Oh, dude, you're kidding. You can't save. You're kidding me. Bro, Steer Wolf. Why do you do this to me? You actually didn't see me. What is wrong with you? I'm just going to go. I just got to go. Oh my God. Dude, this dude is terrifying. Dude, I hate this.  Dude, dude. Oh no. Oh, I'm so dead. Oh my God. Dude, I don't know where you are. I found him. Well, this should hopefully make my life a bit easier. Excuse me. Thank you. No, none of that. None of that actually. None of that. Thank you very much. Thank you very much. How are you right there? Oh no, no, no, no, no. Just leave me alone. Jesus. Oh my God. Oh my God. Dude, how are you everywhere? You know, it's kind of funny. If you hop into the play area, the Sun guy can't actually get you until you hop down. And then, yeah. Oh, he's fast. He is very fast. All right. And you can't leave once you activate the badge, obviously, because of the cut scene. Oh my God. Jesus. Pretty outside the daycare. We did it. Jesus. That was actually kind of scary. So where's the daycare attendant? I am so lost, but yay for us. All right. So I'm going to go meet Freddie and then I think we'll call it there. A little concerned because I don't know where, I don't know where daycare attendant went. I also don't know how I get out of here. Oh, the door probably. Let's try this. Yep. Oh my God, Freddie. Why are you near Chica?  Chica. Nothing to see here, ladies and gentlemen. Just your friendly neighborhood, Freddie Fairbair. Escape the daycare. Okay, but how? Roxanne, I am Freddie.  Oh, I sure do love pizza and being Freddie, because I'm Freddie. I'm Freddie. Oh, keep an eye on the time. At the end of each hour, get into the recharge station or you will be caught. Stations are marked on the FAS map. Whoa, every hour, the power is diverted to the recharge stations. Then that happens, the lights go out and when that happens, the daycare attendant is free to roam the building. What the freak is that? All right. Well, I think in next episode, we'll find out how to dodge the daycare attendant while escaping inside of Freddie Fasbair and it seems like we're only just getting to the first hour, which is crazy. So thank you guys so much for watching another episode of FNAF Security Breach. I'll make sure to get episode three out as fast as I can because I know a lot of people are already getting super far into the game. So I'll see you all in episode three. See you on the flip side. Goodbye.


This is Think Tech Hawaii. Community matters here. Aloha. Welcome to Much More Medicine with Think Tech Hawaii. I'm your guest host today, Tom Forney. I'm an emergency physician with Hawaii Emergency Physicians Associated. And today we'll be discussing stroke care within Hawaii. I would like to introduce our guests, Dr. Kazuma Nakagawa, a neuro-intensivist and director of the Stroke Center with Queens Medical Center. As well as Jennifer Moran, APRN and stroke care coordinator. Welcome. Thank you both for being here. Thanks so much for having us. Yeah, thanks for inviting us. So there's been tremendous advances in stroke care over the past 10 to 15 years or so. But before we get into all the great advancements and everything that we've had, I'd love to hear some of the basics on what is stroke and how, what are some of the basis of it? Yeah, so stroke is a brain attack, it's a medical emergency. And it happens when there's a blockage, a sudden blockage of the blood vessels in the brain. And that part of the brain stops getting oxygen and blood flow and starts to cause this damage, permanent damage. And the thing is that damage can occur very quickly and starts to spread with time. And it's estimated that about 2 million brain cells are lost every minute during the stroke. So just to recap, if there's a blockage, the damage starts to form a very small area and then every minute it grows really fast. So if you can actually intervene and open up the blood vessel right away, that part of the brain can be restored and saved. But if you don't act quickly, there's a large area that could potentially be damaged permanently and cause a chronic disability. Yeah. And if we could load the first two images that we have, it shows a nice picture of... Okay. And it shows some nice pictures of how that goes. But that intervention, tell me more about it and kind of the need for acting quickly. Sure. So most of the blockage usually occurs from a blood clot or thrombus. And then since 1996, there has been an FDA-approved medication called a TPA. It's actually a tissue, a pleasant agent activator, but we call it TPA as abbreviation. And it's a clock-poster medication. It kind of works like a drain when your kitchen sink is clogged. You kind of give that medication and kind of dissolves and melt away the clot. That's how it works. And it works if you give it. The clot actually does sort of dissolve and melt away. But really it's not about whether the medication works or not, but whether we can actually give that medication fast enough. Because if you give it, but the brain tissue is already damaged, it's too late. You know, we can give that medication at most hospitals in the emergency department. And but we have to have a system in place. We have to have the right screening protocol and then the clinical pathway so that we can give the medication to the right people. Here, and I think we're actually bringing that first picture up, showing how many brain cells go. So describe this picture for me. So that is a picture of the brain. And in that bright spot you're seeing is probably the where the clot is located. And then that's the epicenter of the damage. So that's the part that starts the damage. And if you don't treat it, that area can grow with time. And then probably the next picture can show you that again here, immediately at time zero when the clot is formed, that dark area is a small little area that gets damaged. Again, if that's the only damage, then you can potentially walk away with no deficit. You can go back to your life of 100% recovery and move on. But if you don't intervene and give the treatment, that dead tissue grows, gets larger and larger.  And that leads to permanent weakness, speech problem, and disability. And in fact, stroke is considered a second leading cause of death globally worldwide. And in Hawaii, it's the third leading cause of death. And it's the non-grown cause of disability in the United States. And even if you survive stroke, it adds to both financial and emotional burden to the family and to society. And that's truly huge numbers of number three cause of death, number one cause of chronic disability. So it affects a lot of us. And the nice part is there's been tremendous advances over the past 15 years. Jen, I know you've been integral in the development of stroke centers throughout the state. Yeah, so we actually, the Queen's Medical Center in 2004 first became certified as a primary stroke center. We were certified as a primary stroke center for about 10 years and then became a comprehensive stroke center in December of 2016. Some of the differences between stroke centers and the importance of certification are with certification, it really holds you to a higher standard. So every patient every time is going to get that high standard of care. Adhering to clinical practice guidelines that are developed by the American Heart Association and American Stroke Association. And that's one reason it's important to maintain that certification to make sure that we're getting all the patients into the system so that they can get that quality care. Yeah, and so there's the, you said the comprehensive stroke center which you guys have obtained as well as multiple primary stroke centers. Congratulations, my understanding is that it's not easy to obtain. Right, so that's the highest certification that one can obtain and what it really means is that we can not only provide the IVTPA, the clot busting medicine, but also we can provide other forms of treatment. They've really come out with some new forms of treatment and the guidelines are really increasing on which patients we can choose and which patients we can treat. Helping us to determine which patients we can treat and make our patient selection very carefully has really decreased the risk that we're historically associated with TPA. Yeah, and with that, I think that's a nice transition into what is our treatment. And historically, I know you alluded to the thrombolytics being available in the 1990s, sometime in the 90s. And it's really gained more prominence over the past number of years. Tell me more about thrombolytics and its utility as well as some of the risks involved with stroke patients. Sure. So if a patient arrives at the hospital within four and a half hours of time last known well, they are typically able, the correct patients, to get the clot busting medication, the IVTPA that Dr. Nakagawa was speaking about.  So we try to do it very, very quickly. And we are able to give the IVTPA up until four and a half hours of time last known well, hopefully breaking up that blood clot and restoring blood flow to the brain, therefore kind of preventing the disability and death typically associated with stroke. So for our viewers watching this, what science should they watch for? If they're sitting at home watching this, what should they look for and say, OK, now I need to activate EMS and go into the same? Right. So we use an acronym. We use the acronym FAST to help people remember what to look for. So the F stands for facial droop. So you're looking for any asymmetry of the face. Ask someone to smile and see if one side is drooping or not. The A stands for arm. So you ask someone to hold both arms up. If one arm is weak, that could be a symptom of stroke. And S stands for speech. This could be the inability to speak. This could be slurred speech. Or this could be someone that's not understanding what you're saying to them. And the T is one of the most important ones. T is for time. Time to call 911. And we really want to emphasize that. That calling 911 is one of the most important things you can do to get the patient into the medical system, into the system of care. Excellent. Thank you. And so once they get into the medical system and visit an emergency room and see somebody like myself, we have to work together as a team to decide, does this patient need to have the TPA that you were mentioning? Fortunately, we have experts like Dr. Angawa to help us out. Tell me more about, we've talked about all the benefits. Are there any risks involved with the medication? So TPA does have some risk. Since it's a clot-busting medication, it can have the potential to cause bleeding. Like I said, because we are actually much better with our patient selection, then we're having much less risk of bleeding than historically we're done in the initial studies. So that's very good. We've taken away a lot of the limitations of the medication by correctly choosing those patients. And that's the point I'd like to elaborate on. This medicine has been available for 20 years now, but really only the last 10 years or so has it really gained much more momentum. And there was a lot of concern, at least within the emergency medicine world, of are we harming our patients and how much benefit is there? And as we've gotten better at selecting those patients, the risk involved has really plummeted. And so the true benefits to all of our patients has been increasing pretty rapidly. Yes. Yeah, we have seen some amazing results. Right after the medication, the patient starts walking and moving and talking.  So there's that hesitancy to give something that may be potentially harmful. But over the last 10 years, we've gotten so much more comfortable and confident with that medication. We know exactly who's at risk for bleeding. So really realistically, our bleeding rate here in the state is much lower than what's been quoted. And we feel very comfortable. And I also just want to emphasize what Jen had said that it's important to call 911 because a lot of people make a decision to start driving in themselves or drive their loved one in because they feel like, well, each one is wide open. We can start driving and it's only 20 minutes from my house. And then calling the ambulance is going to cause more delays. It's actually not the case. When the EMS shows up, they activate the system. They notify the emergency department physician and they call the stroke team. So when the patient shows up to the ER, there's going to be open. CT scanner's going to be open. The whole team's going to be there waiting for that patient. Whereas if they drive themselves in, they may be placed in the waiting area, be asked to wait in the triage area and so on. And that adds time. That could be five minutes, 10 minutes. And that could be the deal breaker. So I really want to emphasize to the audience here that it's extremely important to call 911. Absolutely. And you touched on a good point of you and your team have helped a number of the hospitals across the state really break down the barriers to that quick treatment of having EMS take the patient directly to the CT scanner to make sure there's nothing else going on to make sure that the patient is a good candidate for stroke, the quicker registration. Everything is happening so much more quickly now than even a couple of years ago that each extra minute that we save is tremendous. And, but all patients that look like they might be having a stroke aren't necessarily. Tell me a little bit more about some of the stroke mimics. Stroke mimics, sure. So sometimes a non-stroke neurological condition such as seizure, migraine or other condition can mimic stroke like symptoms. So that's why it's extremely important for an expert to assess the stroke patients before giving that medication. Like they have stroke mimics and give that medication, we could potentially harm them. That's why we have a clinical exam and also imaging technology to roll these things out. Absolutely. So it's not necessarily always so easy to determine, but using, being involved with experts like yourself to determine, yes, this patient actually has a stroke we need to give the medications versus not. How many patients are going through your department now and kind of how many stroke patients are seeing it on average at this point? So we actually see at Queen's Medical Center, we're seeing about 1,000 stroke patients a year. So quite a few. And I know just throughout the state there's typically about 3,000 stroke patients per year. So Hawaii does have a lot of stroke. Yeah, that's a significant number. And do you know how often you guys are, they get transferred to the Queen's Medical Center versus staying in their local hospitals if they're transferred into you? So we're actually trying to empower the local hospitals if they have the ability to treat, to go ahead and treat those patients and then keep them at their hospitals. We do want to transfer the patients transferred that need the higher level of care, the more advanced technology and services that we can offer. So really like making the proper patient selection is important for those patients. Yeah, and what are some of the criteria for that? When do you determine, say yes, this patient needs to be at the Comprehensive Stroke Care Center versus no, they could stay in their local community, say whether it's in Waimea on the Big Island or Molokai or whatever. Sure, so if the TPL, the clobbusting medications is all they need, they could potentially stay at that local hospital. Some hospitals can, but if they need further treatment, which I'm going to describe now, then they'll be transferred to a higher level of care such as Comprehensive Stroke Center. And just going back about the treatment, the TPA is a great drug, but in reality, only about a 30% of the patients benefit from TPA. So what happens to the other two third of the patients, they don't get better. They don't get worse, but they don't get better. And the question is why? In reality, if the clot is so big, if it's so big, the medication's not enough to dissolve the clot. Back to the plumbing example, if the blockage is so bad, the drain is not going to cut it, you're going to get a rotator to take it out. That's what we need to do. So over the last 10 years, we've developed this technology where we can actually do a minimally invasive, really like a neurosurgical procedure where we can thread a catheter, a wire from the groin, all the way through the body, through the heart, through the neck, to the brain, find the clot, and really grab the clot and yank it out, and we can do that. But that requires an expert who's well trained, long years of training to do that procedure, and only a Comprehensive Stroke Center can provide that 24-7. And so anyone with a severe stroke with a big clot that's seen on the CAT scan gets potentially transferred to a place like ours and provide that service. That's fascinating. I think let's show some images about how that's done after the break and discuss more about that new technology. Sounds great. Thank you all for watching, much more about medicine with Think Tech Hawaii. We'll see you in a minute. This is Think Tech Hawaii, raising public awareness. Children, adults, and veterans of all abilities escape gravity right here on Earth. Search diveheart.org and imagine the possibilities in your life. I just walked by and I said, what's happening, guys? They told me they were making music. Aloha, my name is Mark Shklav. I am the host of Think Tech Hawaii's Law Across the Sea. Law Across the Sea comes on every other Monday at 11 a.m. Please join us. I like to bring in guests that talk about all types of things that come across the sea to Hawaii, not just law, love, people, ideas, history. Please join us for Law Across the Sea, ala. Aloha, welcome back to Much More Medicine with Think Tech Hawaii. I'm your guest host today, Tom Forney. We're having a discussion today regarding stroke care within Hawaii. And I'd like to reintroduce our guests. We have Dr. Kazuma Nakagawa, a neuro-intensivist with the Queen Stroke Center, as well as Jennifer Moran, APRN, who is the stroke care coordinator. Thank you both for being here. As we left to go to the break, we started having a discussion about some of the new treatments for large clots. If we could go ahead and upload the image in Induction Gala, if you could please discuss more, please. Sure. So if there is a large clot that goes into the brain, the medication, the clot buster medication, usually doesn't work. Actually it works about 10% of the time, but most of the time it doesn't. So we can actually go up to the brain through a small guide wire and micro catheter, which we can access from the growing site and basically thread that wire all the way from the growing, through the body, through the heart, through the neck and all the way to the brain and find that clot. And we can deploy a stent retrieval device. It actually acts like a stent and then basically grabs the clot and then we can yank it out. And then this is what the device looks like. And then this is what the actual clot looks like after we pull out the clot in the brain. And if you go to the next picture, you can probably see this CAT scan. Here we go. Before the treatment, so this is the CAT scan in the brain. It's a mirror image. One side is the left. One side is the right. But that yellow arrow points the occlusion, the blockage of the blood flow to that part of the brain.  Now it's symmetric. So now that side of the brain is getting adequate blood flow. And that patient did well, I think was a woman who walked out of the hospital with a minimal deficit, if not 100%. Yeah, that's truly amazing. And there's been some, obviously the new technology of being able to do the thrombectomy. I think the focus on large vessel occlusions has really changed our management of stroke here tremendously. Tell me more about the, both how do we select our patients who potentially are having a large vessel occlusion? How do we find them? And then also some of the time frames for treating them that are different than the typical stroke patient. So until recently, oh, this device existed for, or the older generation exists for about a decade, but we have failed to show efficacy because we weren't very good about choosing the good candidate, the people who'd actually benefit from the procedure. So we often did procedure when the case was too late perhaps. And then over the last five years, we've gotten much better at that. But until very recently, until actually last year, we were offering this treatment up to six dollars from the symptom onset. So, which is actually longer than TPA, so which is great. So if the symptom onset occurred anywhere from four and a half hours, which is a TPA cut off to six hours, we could still provide that treatment. And also some people with a blood thinning medication or recent surgery, which are both contraindication for clot buster medication, we could still do that procedure. So people who had a stroke right after big surgery can still get that procedure, which is great. Unfortunately, there are a lot of people who wake up with a stroke. So they went to sleep around 9 p.m. and woke up around 6 a.m. with a big stroke deficit. So the way we calculate or count the time is from the last time that person was seen normal. So if that person went to sleep at 9 p.m., the symptom onset was counted as 9 p.m. So that person would have been excluded from the procedure. And a lot of people woke up with a stroke and was left out. But now over the last year, we've gotten much better at identifying even people who woke up with a stroke, people who had a deficit 24 hours ago could potentially benefit. And that's through the advancement in the neuroimaging technology. So advanced CAT scan or MRI, where we can truly find out people who still have brain tissue that are alive and salvaged. And by taking out the clot, they can still benefit. So not everyone's gonna get the treatment beyond six hours, but we've learned that even after six hours, there are many, many patients who can still benefit. So now the new guideline came out. Actually, then two trials came out last year that have shown that up to 24 hours people benefit. And then with a 2018 ischemic stroke guideline, they highly recommend considering this procedure to 24 hours from symptom onset. So I mean, that's a tremendous change going from three hours only a few years ago to four and a half hours. And now we're getting it stretched out to 24 hours in the appropriate patient. And no medicine, there's some anatomical differences with the patients for up to 24 hours where there's good collateral blood flow. Is that correct?  Everyone's different. And the more overlapping branch vessels we have, more likely you're gonna tolerate the lack of blood flow. So the example I gave is sort of like, if you have a beautiful backyard, you set up a sprinkler system where there's not much overlap. You have one over here, one over there, and then each sprinkler system's barely touching each other. If one goes down, that area dies really fast. But if you put a lot of sprinkler system, a lot of overlap, if one goes down, that grasp will stay clean for a long time. And that's the concept. Our brain has so many blood vessels. Some people have a lot of overlapping branches, some don't, and we can now identify those with a lot of overlapping branches and we provide that treatment to those people. So how do you guys decide? So say somebody shows up within that four and a half hour window. Are there criteria that you use to decide, hey, yes, this person is a thrombectomy candidate versus no, we'll give the traditional TPA? So our patients actually, you can get both treatments. It's not really an either or or. So if a patient shows up and they meet the criteria for getting the IV TPA, they go ahead and get that IV TPA. If they show signs of a large vessel occlusion, like the big bad stroke, both by imaging and also by clinical exam, those are the patients we then take to mechanical thrombectomy. So some patients will actually get both treatments. Some patients may only get one or the other. Excellent. And I think that transitions into some of the telestroke work that your organization has been doing as far as providing services to the rest of the state. Tell me more about the origination and how everything started with that. Sure. So maybe 10, 15 years ago in Hawaii, we really weren't giving a lot of TPAs just throughout the state. And there may be multiple reasons for that. Also, I think with a lack of comfort with that medication back then, but also other factors that are just limited number of neurologists and stroke experts in various hospitals. And without expertise, it was difficult to give that medication or make that decision to give that high risk procedure and whatnot. But with the technology, we can actually connect these hospitals to a tertiary center like Queens and we can access these patients remotely through telemedicine. So currently, we are covering approximately eight hospitals outside of Queens. So if they have a stroke on the big island or North Shore or anywhere, they can go to the closest hospital and if they bring that telemedicine camera, you'll see the stroke neurologist from Queens. So they don't have to drive 30 minutes to get to Queens to see us. That's how it works. And then really the trick is really making that really expert decision to see do the treatment or no treatment. Do we supplement the TPA with a procedure? Those are very advanced decision-making that we need to make and we really need to see the patient. So technology really overcome that barrier. And it honestly has been practice changing for myself working at some of the rural facilities throughout the state of, as you mentioned earlier, there are some risks involved with the thrombolytics. Making that decision to potentially save a patient but also potentially harm them is not an easy one to make. And so having your involvement with helping to make that decision has been very helpful. And I think it's also has reduced the overall variation. No longer is it each hospital, each emergency physician making a decision by themselves, it's making an end coordination with you and your colleagues to give the thrombolytics or not. And it's been an overwhelming success at least for my practice and helping to improve the patients. And if you wanna jump to the next picture, it essentially shows the way that works is there's a camera looking at the patient with you on the other end. And as you're able to actually see and evaluate the patient, it's almost the same as that you're being there in person. And if we go to the next slide, it shows the overall increase and actual telestroke, both the consultations and how often the thrombolytics are given. And the nice part is the overall utilization is increasing and on the rise so that whether you show up at a facility on the big island or Maui or the North Shore of Oahu, you're able to get the same stroke care as you would if you arrived at the Queens Medical Center and actually at the comprehensive stroke care. So it's has made a big impact over the past number of years. Unfortunately, we're running out of time. I would like to thank both of you for being here today. The care that you guys are providing through the stroke center, both at Queens and across the Strait has been truly amazing. Thank you both. I'd also like to thank much more on medicine as well as Think Tech Hawaii and our producers who produce this show. Thank you all. Aloha and Mahalo.