Welcome to theCUBE's coverage of VMworld 2021. I'm Lisa Martin, another CUBE alum joining me on the program next, Sanjay Upal is here, the SVP and GM service provider and edge business at VMware. Sanjay, it's great to see you. Thanks for coming back on the program. Oh yeah, thank you. Thanks Lisa and thank you to theCUBE. It's great that we're covering VMworld. I can't wait till they're back in person. This is another event that is virtual for obvious reasons, but I wanted to dig into your role and have you really kind of unpacked that for us. Your role as the senior vice president and general manager of the service provider and edge business, talk to me about that. Yeah, it's a bit of a mouthful, but really what we're doing here is recognizing that the world is shifting and a lot of the workloads are moving to the edge. So that's the edge part of my responsibility. And the other part is the service provider. Service provider, of course, is the name for facilities-based telecom operators as they used to be called in the past but simply called service providers today. So putting those two things together because service provider, 5G and the edge all go together. So I'm running that as a business for VMware. Got it. Let's get VMware's definition of the edge. I always like to do that because some companies have slightly different spin on it. What is it to VMware? Yeah, so to VMware, the edge is distributed digital infrastructure. Digital infrastructure, of course, is the software stack that you need to run the applications on top. And it's for running workloads. Now the important part here that we're defining is that the workloads can be in what's known as the underlay, which you can think of as the infrastructure that is needed to run 5G and fiber. But the workloads can also be in the overlay, which is where you find software-defined WAN, secure access service edge. And the workloads can be at the edge application layer. These are the new class of applications that we'll talk about. So it's for running workloads. And the other important part of it is it's across a number of locations. This is not just about being in a few handful of data centers. This is about being in hundreds of thousands, sometimes millions of locations, which has its own quirks in terms of how that infrastructure should work. And the important point is that the edge is placed close to where the end points are either producing or consuming data. So that's what the edge is as we define it at VMware. Got it. Talk to me about the strategy and the vision that VMware has for edge. Now, we're at a very important inflection point in the industry as far as the edge is concerned. And I just always link it back into what's happening as an example in music. So one of my favorite songs from Aerosmith is living on the edge. And that's literally where we are right now. We're living on the edge. And what Aerosmith says is, we're looking at the world in a different way because things are changing all the way around. Of course, I'm paraphrasing a little bit, but our strategy at VMware is to take this living at the edge, which is happening across the board and to capture it into infrastructure that we're building, come up with a common software stack that will support workloads that are running in the underlay, in the overlay, or at the application layer and support this entirely new class of applications that are coming in. And these applications to contrast it with what has been happening before, these applications are being built for experiences. And I'll dig into this in a little bit, but really essentially VMware strategy is to come up with that common software stack that is going to be placed at all of these edge locations, sometimes millions of them for different types of workloads, but the commonality of the stack is important because that is what the service providers and the enterprises use to derive the benefits. Being designed for experiences is so interesting because that's what we expect in our personal lives, in our business lives. We want to have good experiences whether we're ordering something on Amazon or we're trying to collaborate via Slack or something like that. That is experience matters, it sounds silly to say, but it's absolutely true. Talk to me about some of the things, the edge being core to customer's future in any industry. Yeah, so from an industry standpoint, we always used to talk about what are the features of your product and what are the benefits for customers. And then we started seeing an evolution from benefits into what are the outcomes that the customers want. But now we're getting from outcomes to experiences. And you take just an example of a retail chain that we're working with. What they want to do is not just simply sell a product to a customer walks into the store. They want that person to have an excellent experience. And in order to get to that experience as an example, what would happen is this person walks into a store, they recognize who that person is, what they had purchased before, they look at what are the likelihood that they want to buy something today. Do I have that thing in my inventory? If I don't, can I manufacture it with my third generation printer that I have over here, the 3D printer that is sitting in the back room. And then once that is produced in the next few minutes, can they have an experience in playing a game with the sportsman of their choice on this massive screen that's in there? That's experience. That's not just walking into a store, buying a product and walking out. Another experience would be when you look at healthcare, what's going on right now, that when you have a symptom, you go to your doctor, you get checked out. But what if your body tells you that there's something that you need to get done? So this entire new class of applications are coming in with sensors that have artificial intelligence in them that are metricating what is happening. And these sensors with that intelligence then get fed into the edge infrastructure because this is voluminous amount of information. As you can imagine, the amount of metrics that your body needs to track, all this voluminous information needs to get correlated and then you need to make an inference about it. Again, that's an experience because you're completely changing the nature of health as this is going about. So in every vertical industry, we have these examples of experiences and what this requires is computation, networking and storage to be pushed all the way into the edge. It requires a network to get this done. It requires connectivity and it requires, as I've spoken about before, this common software stack that VMware is bringing. So talk to me about what's being announced and unveiled at VMworld. So what we are announcing very simply is the VMware edge. And what that VMware edge is, it comprises three common software stacks at different layers of the stack. So the first thing that we're saying is that we are announcing the VMware edge compute stack. So this is software that companies can use, ISVs can use to develop edge-native applications. These are applications that are born at the edge. They're not applications that are necessarily being refactored from somewhere else. And this is stack that is available in very small form factors all the way to large form factors and it's stack that's connected together. As I mentioned before, the numbers of locations are very important. So we are packaging this, we are making it available across the board next week. This is the first part of the announcement. The second part of the announcement is the expansion of our secure access service edge offering. And that expansion includes going from software-defined WAN, which was the first and highly successful service to include secure access, cloud web security, and then to follow that on in a multi-services approach and add more services as we go along. And the third piece is to take our telco cloud platform, we are announcing that that platform is being co-opted to now run at the edge. Now, one very important development in that part is that we've had our ESXi product which is very successful in running in the data center. We have an edge-ready version for this product. We've made a 10x improvement in the overhead and latency of ESXi. So now it can be deployed in edge locations in very small form factors and it is absolutely equivalent to bare metal overhead. So now when companies are looking at, is there overhead associated with the ESXi hypervisor? We're saying no. It's equivalent to bare metal and all the benefits that you get with deploying ESXi will now accrue to benefits that you would have at the edge. Talk to me about some, how the events of the past 18 months, we've seen massive acceleration and digital transformation. We've seen, you know, you mentioned the retailer, the retailer's having to be able to massively shift, curbside delivery, e-commerce. How have the events of the last 18 months influenced or catalyzed VMware Edge? Absolutely. So if you take a step back and think what has happened due to the pandemic, all of us are working from locations we're not going to some centralized location to our offices, we're actually working from our home edges. We were literally living at the edge when we were working from home. And also when you go to do curbside pickup, you're making a decision right there.  So really to me, what has happened with the pandemic is emphasize the need for moving computation all the way to the edge. Now you take one use case, work from home itself, work from home has gone up by in some cases and five X to eight X compared to what it was before. And we've seen the network come under tremendous strain because of work from home. We've seen that the user experience, if it's not good, then of course your productivity gets hampered. So work from home is one of those use cases that has been focused on because of the pandemic. And we've come up with the solution that will help people when they're sitting in their home environment, the kids can do homework, someone can be watching streaming movie, but the business user still continues to function with full productivity. So it's really emphasizing the need for moving computation all the way out to the edge. Yeah, the edge exploded in the last year and a half. I'm going to now rethink instead of working from home or living at work, living on the edge. So thank you for giving me that idea. That definitely changes how I feel about this room right here. Talk to me about some of the customers, customer examples, customers in terms of their feedback as VMware has been developing this. I know you're very much a customer centric organization. What were some of the directions and the influences from the field? I think, you know, as far as customers go, they're an integral part of our development process. It's not that we develop a product and then we go sell it to the customer. What we do is we get the customer to be a part of that process. We figure out what are the issues that the customers are facing in their own business. As an example, when the pandemic hit, we had, you know, in the healthcare space, we had one acute care hospital that came to us and said, well, you know, we can't get enough of the telemedicine done because the radiologists and all are not able to come into the office. Well, we came up with a solution so that radiologists sitting at home can still look at very high definition images as they're talking to their patients. Now, once we develop the first part of the solution, we actually brought the customer in, you know, gave them a prototype. And then I tell my team that when the customer gives feedback, it's like they're handing us a flashlight and that flashlight illuminates the path ahead for us. And so we follow that path that the customer has set based on the technology that we've produced. Our responsibility is to iterate on that technology in a very fast cycle so that as we get the flashlights, we illuminate the path and that gets to building the product. And then we get the product built and then we have a happy, successful customer with good outcomes and experiences. And in the end, VMware has done something positive, not just in terms of our business, but for the world at large. Right, I love that, handing the customer a flashlight. Another one I'm going to steal from you, Sanjay. Thank you, giving me two good ones today and also a different look at Aerosmith, which I probably now won't be able to get that song out of my head. Some of the trends that we've seen, trends over the last 18 months, what are some of the things that you think we've had a lot of acceleration, but there's a lot of positivity that's come from that, but I don't think it gets enough coverage. All of the capabilities that we now have, if you take even just the work from home use case that you mentioned, that's going to be persisting for quite some time, some amount of it's going to be permanent. But what are some of the trends that you're seeing now that you think are really going to help facilitate the edge and the compute and the network and customers being able to take advantage of that even faster? Yeah, I think that one of the really important changes that has come apart from, because of the pandemic is giving customers choice. And as a part of it, VMware is really focused on multi-cloud. So the cloud has come in, we had a movement of workloads from the private data center into the public cloud, but now what customers are saying is, we want choice, we want to make sure that this infrastructure is always available to us. So we are focusing from a VMware standpoint on multi-cloud. Now, what does that mean? It means that it gives customers choice. They can go to different cloud providers, including the private data center and run their applications on top. And this we think is here to stay. This is a trend that we think is as important as what's happening in the future of work. Because previously we used to think of work as a destination, it's not. It's a workspace right now. People could essentially be working from anywhere. And one of the things that we've learned in the pandemic is that that actually does happen. Human beings, we are flexible enough that we can accommodate to these changes that are coming in. So the future of work is going to be distributed. It's going to be work spaces and not workplaces. And then multi-cloud and marrying those two things together is what we are focusing on at VMware. What are some of the tracks or sessions at VMware where folks can go to learn more about that use case in particular, as well as VMware Edge and what you're announcing. Yeah, so we have some excellent tracks. I mean, we have a track about, of course, the distributed edge. We have a track about what's going on with cross-cloud services that we have come up with. We have tracks in terms of what's happening with networking and security, because security obviously goes hand in hand with everything. Zero trust is becoming fundamental in everything that we do. I was talking to one of my customers who owns gas stations and he was saying, Sanjay, you have gas stations in places that I would never visit. But there are people who would sit at these gas stations. I still need for them to come into the network, but I can't trust the devices that they're coming in on. So these would be a few of the tracks that I would recommend that people would go and watch. Excellent, yeah, speaking of zero trust and just the massive changes in the threat landscape in the last year and a half, the things that we've seen with massive rise and ransomware indeed also attacks and attacks like this becoming a when, not if kind of a scenario. So everybody needing to ensure that they have, they can trust the people and the devices on the network. Sanjay, thank you so much for joining me, talking to us about VMware Edge. You gave us some great analogies there that I'm going to take forward with me. And I look forward to seeing you hopefully next year at VMworld in person, fingers crossed. In person would be awesome. Thank you so much, Lisa, and thank you to theCUBE. Our pleasure. For Sanjay Upal, I'm Lisa Martin. You're watching theCUBE's coverage of VMworld 2021.


Our speaker today is Dr. Laney Ross, who will speak on the topic of pediatric transplantation, donors and recipients. Dr. Ross needs no introduction, but that doesn't mean I won't give you one. Dr. Ross is the Carolyn and Matthew Bucksbaum professor, the associate director of the McLean Center and a professor in pediatrics, medicine, surgery and in the college. Dr. Ross also serves as the co-director of the Institute of Translational Medicine here at the university. Her training was medical school at the University of Pennsylvania, residency at CHOP in Columbia, and then she wrote her PhD at Yale, PhD in philosophy. At the University of Chicago, many of you have worked with Dr. Ross and you know her extraordinary capabilities as a mentor and teacher. She serves on the secretary's advisory committee on human research protection and on the American Academy of Pediatrics section on bioethics executive committee as its chair. It's a great delight to invite and welcome Laney to give today's talk. Thank you. Thank you very much. I wanted to begin with two things, first to acknowledge the two students and Dr. Thistlethwaite who worked with me on this project. I don't know if Chris or Will were able to get out of their clinical responsibilities. And I wanted to start though with a question. So in kidney transplantation, are there more pediatric recipients or pediatric donors? So how many of you think that kids in a sense take more than they give or do they give more than they take? So how many think there are more pediatric recipients? And how many think there are more pediatric donors? So we're sort of evenly split and here's the answer. In 2011, there were 843 pediatric deceased donor kidneys making up 11% of all deceased donors. There were 454 pediatric deceased kidney recipients making up 4% of recipients. Hence the reason to discuss pediatric deceased donor allocation issues from both perspectives. Just for those interested, there were zero pediatric living kidney donors, that has not always been the case. And there were 302 children who received kidneys from living donors. So here are my four objectives to discuss the policy issues raised by giving minors special priority in deceased donor solid organ transplants. And then to discuss the ethical and policy issues related to elective deceased donor transplants in minors. And then with regards to pediatric solid organ donors, I'm going to really talk about allocation issues with pediatric deceased donor organs. I doubt we're going to have time for me to talk about the whole issue of whether children should ever serve as solid living organ donors. So I'm probably just going to focus on these three. So let me begin first with pediatric recipients. So the first question is should children be given priority for deceased donors and then priority for early allocation and priority for the best quality organs. And so a policy was written in October 2005 that UNOS implemented which basically said that all renal allografts from young deceased donors, less than 35 years of age, would be given preferentially to local pediatric patients less than 18 years. Although if a local suitable pediatric candidate couldn't be found the organ would be offered to a local adult candidate. And the policy was intended to reduce waiting times for pediatric candidates and allocating ideal deceased donor kidneys to them. Now I should begin with my real bias. I'm a pediatrician so I'm always wanting to get the best for kids. So clearly I was in favor of a policy that was going to do that and there are actually clinical reasons to justify my bias. One is that children don't grow and develop appropriately on dialysis so that if they're in chronic renal failure they really do need kidney transplant. But why 35? Why did they pick the age of any deceased donor under the age of 35? And here I have a graph which shows you that the quality of kidneys from donors over the age of 35 have a worse graph survival as time goes on and clearly kids are going to need kidneys that are going to last for decades. And so it makes sense to give them kidneys that are going to last as long as possible so that we don't have to start talking about retransplanting them in their 20s but maybe in their 30s or 40s. I also just wanted to point out the impact of SHARE35. So before we had this rule what you saw was that kids were getting kidneys from everywhere. And in fact if you just look under the bay so up to here they were getting what we now call ideal donors but they were actually getting a large number of kidneys from people 35 to 49 and even some of the older donors from 50 and up. And now under the new policy you notice two things. One is they got more kidneys in the same five year time period but also that virtually all of the kidneys they got were from donors under the age of 35. The yellow representing a small number of deceased donors from 35 to 49 year olds and these may be individuals for example who had high sensitization and therefore weren't able to match easily to a kidney. So the policy did what it wanted it gave the best kidneys and it gave more kidneys to children. And here in fact if you look is another way of seeing this data and what we did here was look at time from weight list registration and again if you look you're going to see two things. So 2002 was just a year we picked that was going to be pre-SHARE35 and 2007 post-SHARE35. And what you will see is that within six months after SHARE45 only 43% of the children who had been weight listed were still waiting and that it was down to only a quarter by one year versus there was still a third waiting for kidneys pre-SHARE35. So again they were getting them more quickly. You're also going to notice one other change though which is that here when you see where they got kidneys from the children in 2002 got 301 of their kidneys in the first six months from deceased donors and got 83 or about a quarter of them from living donors. And here in 2007 they got 278 transplants and 86 from living donors. But overall in the end for the living donors in 2007 they look like the same they're actually pretty equivalent in the number of numbers. So not too much of a fall in 2007 in the number of living donors. But I also wanted to show though some of the unintended consequences of SHARE35 and there is actually a relative drop in the number of parents who continue to donate to their children. And in part you might say why is this and the answer is if I'm promised a great deceased donor within one year I might as well save my kidney for when my child needs to be re-transplanted. This was not anticipated at the time of writing the deceased donor policy for SHARE35. And why this becomes a problem is this becomes a problem because there are two concerns. One if kids are taking more deceased donor kidneys and taking the best kidneys then as there's less kidneys for adults then adults are going to have to start looking for living donors. And in a sense if you ask me would I rather a 15 year old get a living donor or a 65 year old get a living donor the answer is clearly I want the 15 year old because again those are the ideal donors they're going to last even longer than the best deceased donor and so it will reduce the need to re-transplant. But from a parent's perspective you can see why they might go the opposite way and think to themselves when they need to re-transplant they're not going to have priority so let me save my kidney for that time. And that's what happened and this is important because as we're talking about new kidney allocation policies currently in the United States there's this move to give the best kidneys not just to kids under 18 but to really give some of the best kidneys to even young adults up to 30 or 35 and what that might do is decrease the number of living donors overall. 75% of all transplants in young adults under the age of 30 come from living donors and so either we're going to have less overall number of kidneys because the living donors are going to stop donating or we're going to be transferring those living donors to older people who might not otherwise get a deceased donor and that would be quite inefficient. But one question is, is it working in the sense are there graft surviving as long as we had hoped and I just want to point out this one piece of data which shows that the one year and five year allograft survival among recipients of kidney transplants from ideal donors and what you're going to see here is that the number of grafts functioning at five years really plummets in that adolescent to young adult group. So as we give them better kidneys they're not doing so well with it and the reason is because they are the least compliant with their immunosuppression and so in a sense are we really getting the efficiency that was hoped for and in fact in this article by Levine et al. this is the quote the allocation of ideal donors to adolescent recipients may not maximize graft utility reevaluation of pediatric allocation priority may offer opportunities to optimize ideal renal allograft survival so there's at least some people who are trying to push back on the grounds of poor compliance. Again my bias being a pediatrician is that clearly I support chair 35 but I think we have to acknowledge some of the issues and acknowledge the unintended consequences of reducing living donors and part of this is we have to remember that UNOS controls allocates deceased donors but in a sense as a living donor you get to choose who you're going to give to and so the more we give priority to young children but also young adults of living donors we may actually reduce the number of living donors overall or change it to be giving it to older people who really don't need a kidney that will last them for 25 or 30 years so I just as I said the point of this whole part was to really think about the unintended consequences that as we give all these donors we're going to decrease the number of living donors the next part of the talk then is to look at something that very few people think about is this notion of elective organ transplantation in children so what is an elective transplant? It's the practice of offering an organ transplant when an alternative procedure exists and there are two good examples in the literature one is hypoplastic left heart where children can undergo a three stage Norwood procedure and the other or they can get a heart transplant and the data mostly from Alex Kahn shows that people are offered usually one or the other depending on the site where their child happens to be born and diagnosed and yet their results in morbidity and mortality are actually quite similar another place where we have elective transplants and the one I want to talk about today is in liver transplant where some children with metabolic conditions for example maple syrup urine disease they can be treated by dietary means or liver transplant the problem with the dietary means is that if they have an event it can be quite catastrophic from which they may not recover particularly cognitively and so in some ways the liver transplant reduces the fear of a protein overload in these children and this is going to become a bigger and bigger issue as we continue to expand newborn screening because we're going to be picking up more children asymptomatically with some of these conditions who may be in a sense the ideal transplant candidate so the procedure is elective and we can debate whether we're talking about in hypoplastic left heart or maple syrup urine disease whether the alternative treatment or the transplant is better but the point of calling it elective is that there are some children who need a heart transplant or a liver transplant who don't have an alternative right so they're going to die on the wait list while we're going to give some priority to these children and we need to ask ourselves is this fair and as I pointed out though at this point nor would it be equivalent the data is still coming in about which is better from an individual child's perspective a liver transplant or dietary treatment from maple syrup urine disease so traditionally this is the way we treated children with maple syrup urine disease in order to preserve normal function of the CNS in an ill newborn ECMO may be necessary and then lifelong dietary restrictions to maintain blood metabolic concentrations close to normal and throughout life there's aggressive interventions every time they have an illness in order to rapidly reverse any metabolic derangement but the real concern then is that these kids can stroke out if not aggressive enough and so despite aggressive treatment despite knowing how to take care of these kids many kids with classic maple syrup urine disease have a poor intellectual outcome sometimes because of delay in diagnosis sometimes delay in starting treatment sometimes because of acute metabolic derangement and that their metabolic control tends to deteriorate with age so what are the outcomes with liver transplant and maple syrup urine disease it's interesting that the first report actually was done sort of accidentally so there was a seven and a half year old French gypsy girl with maple syrup urine disease and terminal liver failure caused by hepatitis A viral infection and she got a liver transplant and both did quite well from the hepatitis perspective but also in a sense cured her maple syrup urine disease and after that there was another decision then made to actually transplant a two-year-old Spanish boy who had frequent metabolic decompensations and in 1997 there was a two-year-old girl here in the United States who had a vitamin A intoxication her parents had given her overdose of vitamin A thinking this would help treat her liver problems and so again not only treat reversing the vitamin A problems but also curing her maple syrup urine disease and it was because of several of these case studies that Strauss et al. at the special clinic in the Amish community out in Pennsylvania worked with the Children's Hospital of Pittsburgh to actually put these children on the liver transplant wait list at the Children's Hospital of Pittsburgh and they were able to actually argue for high prioritization due to the neurologic burden of the disease particularly if there's decompensation and as one would imagine is that patients with hepatic-based metabolic disorders will do really well with a liver transplant it reduces their acute metabolic decompensation but it's also that they're very healthy in general when they go into having a liver transplant so at the clinic for special children as I mentioned they did it and they actually looked at it from a cost perspective because this is the Amish community which doesn't have health insurance but pays in cash for their health care and they came to realize that it was actually financial not only just from a medical perspective but they also thought that economically it was saving in order to have a liver transplant and part of their argument about that was they looked at the number of hospitalizations for acute metabolic decompensations for their children so what's the obstacle to performing liver transplants in all patients with maple syrup urine disease and part of the issue is going to be the scarcity and the fact is that they have an alternative treatment and we're going to have to ask ourselves whether it makes sense to be giving people transplants when they have another alternative I point this out because the year 2001 has two interesting facts that happen one is and this is for all living donor liver transplants for both adults and children and you'll see that in 2001 we have 524 living donors and the numbers in a sense decrease thereafter and still haven't recovered and probably never will and you'll also notice that in 2001 we peaked in the number of deaths and the number of deaths have been going down since 2001 and there are two facts that happened in the year 2001 the first was the death of a living donor Mike Hurwitz which really put a damper on the whole issue of doing adult to adult living donor the reason for the decrease in the weight list was also a change in the liver allocation policy and so something called meld and pelled and as you can see it's actually been quite effective even though the number of livers that are available really hasn't changed over the time the number dying on the weight list nevertheless people with metabolic disease would have very low pelled scores and so wouldn't be eligible and yet there are reasons that you can go to a region to ask for exceptions and metabolic diseases have been considered one of those exceptions so that they would be eligible for rather high priority in giving a liver transplant so looking at the UNOS data looking at who gets a deceased donor liver transplant what you can see is just to give you an idea from data from last month is that the total being weight listed for children under the age of one is only 38 children and actually a pretty small number overall for all children you can see that the number of children who received a deceased donor liver transplants in 2012 a pretty large number the number who received living donor transplants and again as I said actually it's smaller than I would have thought it's only 40 of the transplants of living donor pediatrics but you could also see the total number who died in 2012 while waiting on the liver transplant so it's this group in a sense that there are 12 dying on the transplants and if we're going to have a dozen or so children every year born with maple syrup urine disease around the country the question is should they get priority when other children are dying on the weight list but so you have this issue because from the particular child's perspective it's probably better to get a transplant than dietary management although as I said the data aren't fully in yet in our western bioethics approach we think of it as our obligation to the individual patient which would then suggest that we should be offering liver transplants to these individuals and that if offered it will probably be accepted but one could imagine a community deciding you know what there is an alternative and the alternative is dietary and basically saying that we're not going to be transplanting children with metabolic conditions unless in a sense they have a living donor I actually don't support that but I do think we need to think about what our policies are going to look like as we increase the number of metabolic conditions that we're going to be identifying in early childhood through newborn screening that this issue is not going to get smaller but it's going to grow and it's going to require that you know come up with policies about thinking what type of priority if any that they want to give these children so those are two issues about children being organ recipients I now want to look at pediatric donors depending on the time I'm probably only going to focus on children as deceased donors but if there's time we can also talk about when if ever should children serve as living donors so starting with allocating pediatric deceased donor kidneys so currently as I showed it represents over 10% of the total supply of U.S. deceased donor kidneys 90% of pediatric donor kidneys actually go into adult recipients the majority are aged 35 to 49 and in fact a third of these kidneys are transplanted into adults over the age of 50 so pediatric deceased donor kidneys are actually quite important and so one question is this a good use of pediatric deceased donor kidneys does it make sense to be putting in these small kidneys into larger individuals so just to give you an idea giving you a graph from over 10 years data and I see Will Parker made it and he's the one who actually made this graph what you can see is then so these are all pediatric kidneys from different ages 0, 1 to 5 this means single kidney transplant these mean on block and we'll be talking about that so this is giving to an adult a single kidney from a 1 to 5 year old versus giving them both kidneys from the same donor 6 to 9 and 10 to 17 year old and as you can see there are a lot of kidneys being pediatric kidneys being transplanted into adults with the majority in the 35 to 49 year old range so fact 1, old pediatric kidneys are not the same and what I want to focus on for right now is the case of the very young donor so those less than or equal to 5 years of age and here is an important graph which shows looking just at 1, 2 and 3 year old kidneys and their graph survival over time versus the 0 year old kidneys so clearly the 1, 2 and 3 year old do pretty similarly and do much better than a kidney from a donor less than the age of 1 year the next fact is that very young donors as I mentioned can either be allocated as single kidneys or on block and as you can see here is donors up to the age of 5 and the green is the number of kidneys that are transplanted on block and the purple are the number that are transplanted as a single kidney and so as we get older and as their children's weight get higher you see that it becomes more common to do a single kidney transplant but does it make sense to be doing all of these kidneys as an on block procedure? and so here's our data looking at again with the 0 kidneys doing worse but what you can see here is that the 10 to 17 year old kidneys which are really considered ideal kidneys they look sort of like the 18 to 35 year old those ideal deceased donor kidneys what you see is the 1 to 5 year old on block kidneys have a little bit of a problem right at the start in working but once they start working their long term outcomes are as good as the 10 to 17 year old kidney and compare that though to the single kidney which does approximately 10 percentage points worse over 5 years but here's the problem so I acknowledge that given the choice everybody would want a 1 to 5 year old on block kidney but if we can save two lives with the first live having just a 10 percent lower 5 year survival does it make sense to be giving both kidneys to one individual or should we be splitting them always and we'll ignore the under one age kidneys because on block and single they do much poorer than all the others so historically we think that it's important not just to look at how do 1 to 5 year old kidneys do but to really look at the difference between on block versus single because those on block kidneys really do as well as the ideal donors and to actually split out the zeros because when transplants urgency the data from young children under the age of 5 it looks much worse because you're adding on those 0 year old donors who we know are actually quite different than all the other deceased donors under the age of 5 and so here it compares all the pediatric kidneys again to the ideal adult donors and what you see is here is the pediatric kidneys and here is why am I not seeing my 18 to 34 year old donors because the lines totally overlap so this is actually where you find the 18 to 34 year old donors and the 10 to 17 year old donors and again the 1 to 5 year old is slightly worse and as you can see here are some of the pediatric kidneys they actually do a lot better than the 50 to 59 year old and the 60 plus donors and the 35 to 49 year olds doing as well as all of the other pediatric kidneys including the 35 to 49 year old donors which is the red looking quite similar to the green line which are those single kidneys from 1 to 5 year olds so really questioning whether we can justify giving these kidneys out on block so by allocating kidneys from donors age 1 to 5 on block the total life years gained by the system goes down they have somewhere between as I said a 7 to 10% decrease 5 year survival overall so one question is well we will share 35 shouldn't we just give all pediatric recipients on block kidneys from donors less than the age of 5 years and one of the things you saw from the data is most pediatric donors do not go to pediatric recipients and so given that since we're giving lots of adult 35 to 49 year old kidneys and these single 1 to 5 year old kidneys look the same it might make sense for us to be dividing many more of them and at least increasing the number of transplants that can be done in fact of the 1122 on block kidneys done over the decade only 52 of them went to pediatric recipients now the 0 year old kidneys do much poorer and so I don't think the arguments about on block and single really hold for them currently the decision on how to procure kidneys so how you take it out of a deceased donor is left to the transplant team in Euro transplant it's required for example that procurement occurs on block for donors under the age of 2 for donors between the age of 2 and 5 it can be recommended that procurement occurs on block that doesn't say how it's allocated even if it's procured on block you can still allocate them singly but it may be better to determine allocation as single kidney transplants versus on block based on weight rather than age is one concern but also just the whole concern of whether it makes sense to be doing on blocks at all fact 3 about deceased donor kidneys is that these donors less than 1 year of virtually all transplants on block and yet they still do substantially worse and so part of their problem is really that they just have a high 100 day risk of graft failure but ultimately they start to perform as well as organs from candidates over the age of 50 which compares in the kidney world to those kidneys that are currently labeled extended criteria donors and in fact this is a comparative graph which looks at just the 100 day survival and as you can see the ideal donors which are 18 to 34 and that to 10 to 17 year olds look exactly the same both at 100 days and at 5 year survival those 1 to 5 on blocks 2% lower in the first 100 days so they have a slightly increased graft failure right at the beginning but look exactly the same at 5 years and so they might be almost too good to be giving out on block then when you look at the other children slightly poorer in their 5 year survival compared to the ideal kidneys the 1 to 5 single kidney again slightly poorer of first 100 days but looking just like a 35 to 49 year old kidney donor and most people would think that's a pretty good deal if they got a 35 to 49 year old healthy deceased donor with the zero year olds looking more like their older compatriots from the age of 50 and 60 plus so this is the interesting thing which is it depends what type of better you are because so the dotted gray line is the 50 to 59 year olds which clearly do better than either the zero year old donors for at least at the beginning and clearly do better than the 60 year old donors but the betting question is so they do really poorly in the first 100 days but after that they're actually better than many of our extended criteria donors so the question would be now knowing the data if offered and if offered and particularly the typical individual accepting an extended criteria donor is going to be someone over the age of 60 which do you take? do you bet on the short term issues or do you go for the long term and so I think it actually raises some interesting issues that haven't yet been addressed in the literature so just food for thought which would you prefer given the fact that you know that you'll have a bigger risk up front if you take the zero year old kidney but in the long term it may turn out to be better so to conclude for this part of the talk shared 35 refers to old kidneys from donors younger than 35 years of age but what the transplant surgeon needs to know and they already know that zero year old kidneys have a high risk of early failure and there are very few programs that probably accept a zero year old kidney and yet we may need to be rethinking that particularly for recipients who are older the one to five a block performed similarly to the best adult kidneys probably should be split to maximize the number of candidates who receive kidneys and then if split the surgeon should consider though whether they want to use it as a minor because all of a sudden those kidneys are no longer as good as the most ideal kidneys but more similar to the 35 to 49 year old and we might want to leave those kidneys to the adults I did tell you I had a pediatric bias and finally that allocation that assumes that kidney function improves literally over the pediatric age range are wrong there's a lot of assumptions that you know says they're trying to design these new allocation systems that pediatric kidneys are linearly improved and I think what we've shown first of all is that on block does a lot better than single kidneys number one but number two that the zeros are so much worse that they often weigh down if you can include them in the zero to five year old block so the minor is a transplant recipient clearly I think the minors get and should get priority in disease-dorgan transplants but we need to acknowledge the unintended consequences of this policy and we need to figure out how to improve compliance so that they really are useful and we also need to develop better guidelines and be realistic about these elective transplants as they are going to increase over time so we should all be willing to serve clearly the minor is a transplant deceased owner we also be willing to serve as deceased organ donors or a parent should be willing to give permission for us to serve if we're minors who should be living donors I threatened was going to be a separate talk but given that I'm a New Yorker and talk so quickly I'm actually going to be able to cover it and I'm glad so I'm going to skip over two slides my conclusions and keep going the data about the quality of pediatric donors though needs further evaluation and Dick, Will and Chris and I are working on some papers in this regard and it may change what we mean by share 35 it may require guidelines about what kidneys should be allocated on block but as I always say as I'm trying to conclude I'd be remiss if I did not mention that prevention of kidney disease actually must begin in childhood our obesity epidemic is just waiting to happen as these adults go into kidney failure so we need to reduce obesity we need to do better control of our children and diabetes and high blood pressure so I'm going to skip that I claimed that I was going to end and I'm going to go to the fourth point which is do children serve as living donors and should they so the fact is in the last 15 years at least 60 children have served as living donors in 2005 the Amsterdam Consensus Panel said no they never should a statement in the U.S. in 2000 actually said yes under certain conditions and the UNOS policies under developments in 2000 they said that age less than 18 is a relative contraindication but did not exclude it totally now the data I showed showed zero donors from this past year if you look actually in 2012 there's at least one minor who donated a kidney as a living donor and so I was asked by the American Academy of Pediatrics to write a statement on giving guidelines of when if ever should minor serve as living donors and this statement was written by the AAP Committee on Bioethics with both Dick Thistle Thway and myself as the lead authors so it's important because we actually based most of our recommendations on the U.S. Live Organ Donor Consensus Group from 2000 and they had four recommendations that the donor recipient are both highly likely to benefit that it didn't make sense to be taking it letting a child serve as a living donor unless you thought that the recipient had a high likelihood of doing well they also wanted to make sure that the surgical risk for the donor is extremely low so I think what we're really talking about is children serving as kidney donors although again if you look internationally at the data children have served not only as kidney donors but they have served as living liver donors they have served as intestinal donors the third point was that all other deceased and living donor options have been exhausted so we shouldn't be looking at children to serve as kidney donors if they have healthy enough parents or healthy enough other first-degree type relatives and there was an importance to at least give the child some degree of assent to donate without coercion and here it was recommended at the time to have an independent advocate living donor advocates have become commonplace now for both pediatric and adult but at that time in 2000 this was not a very common practice for the AAP we added a fifth criteria which were not only to focus on that the surgical risks below but that the emotional and psychological risks to the donor not only be low but also be minimized the data that we were looking at to think about this point really came from the bone marrow transplant literature and that literature where minors frequently serve as stem cell donors to siblings in part because they have the greatest likelihood of being 100 percent histocompatible the data there are somewhat or sometimes distressing particularly when a recipient does poorly that many children blame themselves rather than understand that it was their sibling's illness for which the recipient died so the interesting thing is one question is should we allow living donor transplant between identical twins right because genetically the same and the big benefit there is you don't need immunosuppression and so people ask questions about the emotional closeness and the data go in both directions sometimes identical twins are the best of friends and sometimes they actually hate each other right but this is the big significant benefit is the immunological benefit and so one question though isn't to just look at the benefit given that all the guidelines are focusing on minimizing surgical risk minimizing psychological and emotional risk the question is to the extent that we believe that being a living donor as a child may put you at long term health risks should we allow greater risk taking between identical twins and as I say some just do it as a cost benefit analysis say well the benefit is greater so the risk can be greater and some say no because the risk to the donor remain the same and so the question was should this allow for donors at a younger rate and Dick and I were very much against it but I should tell you that the American Academy of Pediatrics Board of Directors wanted us to treat identical twins differently they felt that there was such a big immunological benefit that we should be allowing transplants between identical twins so one of the ways of dealing with the Board was to get a student involved and do a study so this was a study done with Josh Joseph who is now an emergency medicine doctor at Mass General and what we did was we looked at 400 members in the American Society of Transplant and the 116 members in the American Academy of Pediatrics just because of the small sizes of these groups there were 80 members in the section on bioethics and 80 members in the section on nephrology and we gave them a survey where we asked them about 15-year-old twins one of whom has recently developed acute glomerular nephritis has begun dialysis and needs a kidney transplant the physicians were told that the patient had been placed on a C stone or weight list and would likely receive a kidney within the year due to her age the physicians were also told that her parents had inquired about serving as living donors but were ruled ineligible and that in response, her healthy twin asked whether she could serve as a living donor and so we gave a couple of scenarios with donation by the twin sibling appropriate in this scenario with donation by the twin sibling be appropriate if the weight for deceased owner was six years rather than one year with donation by the twin sibling be appropriate if the twins were 10 rather than 15 did it matter whether the twins were fraternal or identical and what if these were your own children so those are the questions that the docs were going to be asked 560 surveys were distributed 49 physicians were excluded because they couldn't be located another 75 excluded themselves saying that they either weren't practicing or these questions were outside of their area of expertise so the remaining 436 recipients we had a 39% response rate and what you see actually is that there was a 37% response rate by the American Society of Transplant a 43% response rate by the members of the American Academy of Pediatrics and here were our data and in part we're not going to get a lot of statistical significance due to the small size but what you can see is that overall looking at fraternal twins to looking at identical twins the numbers go up approximately 8 to 10% for every question whether it's about a one year weight a one year weight in a fraternal versus a one year weight in identical whether there's a six year weight and it continues to go up and noticeably that more were willing to have their own child serve as a living donor in each scenario more than they thought it was appropriate for the AAP to have such a policy so here's my question to all of you we have three groups the AAP bioethics the anthropology and the American Society of Transplant and my question is who are the least likely to want to allow a child to donate and who are the most likely so we're going to start with the most likely who thinks that these are the these are the bioethicists who thinks that these are the nephrologists who thinks these are the surgeons yeah well you're all wrong it's the ethicists who wanted to allow it so now I got data that made absolutely no sense to me right I'm sitting there saying I don't want to allow children to serve as living donors what's going on and we never actually because it was a small study we really don't know what's going on I came up with a story at least which is that the pediatric bioethicists think about things from a family perspective and so they were thinking about all the harms that would happen if they were allowed to donate and that the other child did poorly on dialysis but I'm making that up I have no reason to suspect that I want to point out that the surgeons are the least likely and when you think about it it makes the most sense they're the ones who are worried about the risk if anything goes bad when you're taking out a kidney from a pediatric donor I mean it's on your conscience and so it makes total sense that they were the most conservative I want you to know that when I'm in a pediatric audience the pediatric bioethicists so it was fascinating in this room that all of you gave the pediatric bioethicists that they were more concerned about risk than they really were so are twins different right so the overall data showed about a 10% difference between all respondents but anyway it was this data actually that helped us convince the AP board of directors that we were not going to make an exception for the identical twins so the policy came out saying that pediatric living donors should always be the exception regardless of histocompatibility and so now looking back at the study the donation by a minor is contrary to the recommendations from the U.S. live organ donor consensus group as well as from our AAP statement and you know even though I'm showing how many said yes and showing it between 30 and 45% that does mean that over half thought that children should never serve as living donors so to just conclude I've actually made many of these conclusions so I'm just going to skip to my final slide which is just to say I want to thank my colleagues who worked with me on all of these projects some of them are going to be presented the pediatric donor information is going to be presented at the AST in May and thanks again to Chris, Will and Dick this whole fight and Dr. Ross's paper is open for questions far in the very first section when you talked about the unintended consequences of being the less living donors it seemed like late there is a question of whether although we traditionally think of donation, living donation as super-arrogant or not not something that I was talking about on the obligation whether it would make sense for parents that we would think of them as having some obligation if they're compatible Donate I think all the parents would agree with you and what they're thinking to themselves is I'm going to be the retransplant that kidney is not going to last my child's life and while they can get priority for the best deceased donor I should take advantage of that so that my kidney is ready when my kid needs it so I don't think that they're in a sense reneging on their obligation I think they're deferring their obligation to a time when their kid really needs it Yes but not as long as what a ten-year-old needs Well no, I think the real reason I think it's an interesting ethical problem is because the new policy that they're trying to implement is this 2080 rule where the top 20% of kidneys defined by a kidney donor profile index would go to the top 20% of candidates mostly defined by age and so what we're going to see and I don't have a slide but if I did I would show you that approximately three-quarters of all kidney transplants in 18 to 30-year-olds come from living donors and as we start giving them priority for these deceased donors we're going to see a real drop in their receipt of a living donor transplant and then we're going to get real numbers remember kids make up a small percentage right, they make up 5% of all the deceased donor recipients 4% of the living donor recipients so it's a small number but as we start including the young adults I think it may become a bigger problem and it's one reason to actually oppose the 2080 it's not my main reason, I have lots of reasons for hating the new policy but it is an unintended consequence that no one's acknowledging and it's a really important one because you know can't control the living donors and they have to realize that we're talking about almost half of all kidneys are coming from living donors and if you do that Landy, isn't it the case that people who don't have the bad fortune of not having friends are going to be, they're going to miss out and otherwise get a lot of utility out of it? It is and that's why it's not a simple question but I think at least we have to acknowledge the data which UNOS has failed to do and then if they decide to go ahead with that policy that's fine but realize the consequences that may result which is less transplants overall and since their goal is to maximize their craft survival it probably is going against their own goal So Landy, throughout your talk I was trying to sort out your perspective on what to favor in some ways the perspective of the individual versus the community perspective and at times I had trouble sort of seeing if it was consistency or not for example in the maple syrup you talked about even though you might be able to serve more people in the community having maple syrup folks use dietary therapy you said you were inclined to say well they should be able to have transplant if they want yet when you were talking about the unblocked example and mentioned that well do you divide the kidneys or not you said well, so the opposite well probably we should divide the kidneys so that even those like a 7% less chance of survival benefit to people so this seems to be some contradictory So I'm going to start with my bias I'm a pediatrician and I really care about kids, right? So you notice I'm giving priority to the maple syrup I'm not, remember I'm also saying when I think we should be splitting the 1-5 year old kidneys because children get maximal choice of kidneys under share 35 what I'd really say to them is all 1-5 year old should be done a single kidney transplant and surgeon should be thinking about the 6-35 year old kidneys that they want to be putting into their kids So I'm consistent in that I am totally biased in favor of children I totally acknowledge that and again I'll argue that there's a real need for it in that children don't develop and don't grow and do really quite poorly when they don't have a transplant and they need it. With the maple syrup urine disease I'm a little more stressed with that because they can do well with dietary although if they have a decompensation you know it's irreversible and so that's really serious and it's really hard to maintain these strict diets and when kids get sick it's harder to really get to avoid a metabolic decompensation so again this is my pediatric side talking, nevertheless so since I'm a pediatrician so as a pediatrician I would definitely tell a parent with a child with maple syrup urine disease go on the liver transplant list so it's going to require that we have policies that are going to say yes or no or whether they get highest priority or not get highest priority because as a clinician the policy we need to decide if we decide we're not going to give deceased donor transplants to anyone who could be treated with dietary therapy then I'm going to even suggest to the parents to go for a living donor transplant so I don't think I'm totally inconsistent one I'm totally biased in favor of kids I acknowledge that at the beginning it's a full disclosure but second of all I do think that as a clinician we have to focus on our patients and yet we'll have to accept whatever policies we all agree on so I'm just going to start by reflecting out some of the intended and unintended consequences of the current policies that exist so Lanie my memory of our data is among the people electing to have their kids get a deceased donor transparent selecting for kids to have a deceased donor transplant first that's a much stronger more frequent opinion in the African-American community so I'm not sure that the answer you give answers completely that people are thinking this through because that should have no racial or ethnic bias maybe so Dick's point is a totally valid one which is when we look at which parents have become less likely to donate a living donor transplant it tends to be more of the African-Americans and that the Hispanic and whites were slightly lower but really minimally so and the reason it may be is again when we look at the health issues within the African-American family where by the time somebody is 45 the likelihood that they're going to have hypertension or diabetes is higher than in the other communities and so from their own health perspective it may be that they're thinking let's see if I can get the 45 and 15 be healthy enough to give a kidney that existed before also though second thing is that I want to emphasize the potential unintended consequence of the new system where you identify by who are the best 20% of recipients and give them the best 20% of kidneys because there are four things that decide who's in the best 20% of recipients and not having a prior kidney transplant is one of those so someone who gets a living donor kidney transplant as an infant needs another one when they're 20 years old isn't going to get one of those really good kidneys so they're going to be excluded so I think that's another reason for parents to defer in a sense to let their kid get the deceased donor kidney when they do have priority so the third thing I wanted to ask you as a pediatrician is that we know lesser degrees of renal failure not requiring dialysis when you're not eligible because of a low GFR even for a preemptive transplant do cause growth retardation cause delay and cognitive function are these should we actually preemptively be transplanting kids who have diseases we know are going to cause chronic renal failure early in the course of their disease wow tough question I guess I would let the parents make that decision right and I would bet that would lead to a lot more living donors for those children who have those kidney conditions which are going to be a slow decline and yet eventually lead to kidney failure I would bet they would go preemptive Alaney you showed us those curves on survival of organs by different age groups of the donors do you know if there are parallel curves in for example liver transplant or with the liver transplant situation show different kinds of results you're going to have to wait till the end of this summer since we'll have a student doing some of those projects this summer I don't know I'm sure there are but I don't work I specialize Mark I'm just curious in the calculations about maple sugar urine disease with and without transplantation how far out did the consideration of benefit go so for example did it consider the non-compliance of adolescence with immunosuppression and the long-term consequences of immunosuppression and the possibility of having to be re-transplanted at some time so since we've only started doing it in the last 5 to 7 years we don't have any long-term data but clearly those are issues the group that who have been in the sense that the forefront of this is the Amish community in Lancaster, Pennsylvania where the special the clinic for special something is and those parents that is a very tight knit community so that might not even help us in long-term data about compliance or anything else but it's a very totally reasonable point to be determined you have the same non-compliance with dietary control and again with the dietary lack of control leading to a metabolic decompensation that's irreversible Lainey what's the interaction of recipient age if the donor kidneys are very young do they they do well they do well if they get through the early period exactly that was all but we actually did divide it by age and people do well so it really is there's probably some cut off the one study that I pointed out looked and said it was something around 9 or 10 kilos worth of kidney is what you need we'll actually do an analysis of variants looking at recipient age okay well thank you very much


Aloha and welcome to Holistic Wellness Reveals. I'm Latisha Sharpe and I'm your host today as we discuss the difference between conversation, conscious conversation and talking. My guest today is Marisha Murnowska. She's an herbalist, a medicine woman and the director of the School of the Sacred Wilds. So grateful to have you on today, Marisha. How are you? I'm doing great. I'm so happy to be here. Thank you and Aloha. Aloha to you. You're in California, right? I am indeed. Beautiful. It must be a beautiful time of year there with everything blossoming and growing and... Yeah, we had a really good rain this winter which has been a blessing. So the mountains are happier and we're getting into that dry time which can be a time of nervousness as fire season approaches but we're feeling super blessed to have had a good rain. So hopefully we'll be safe and the land will continue to feel nourished and green. Right, so you have that baseline, right? Of, oh, the earth has been saturated. So that's really nice. And I guess that really kind of takes us into the topic today is being able to have that conscious conversation with the earth, with each other, with the planet, even with ourselves. What does the difference between talking and conversation mean to you? It's such a rich and a great question. I'm so glad that we'll be diving into this. I feel like talking often is unconscious to a certain degree. There's often kind of either some reactivity that can be at play more. Sometimes when we're talking, we're having our old wounds being triggered and we might be also kind of regurgitating ways of speaking and communicating that our parents used to talk or authority or teachers. Sometimes when we're talking, there can be power dynamics that are also really kind of unhealthy and funky. And it's really incredible to look at communication as a spiritual practice because what we say becomes matter and sound vibration never ceases to exist. I mean, it's completely incredible, but the big bang and also every prayer that has ever been spoken is literally still in the air around us. Sound doesn't dissipate, that vibration lives on forever. And so when we bring a little bit more awareness, when we use tools to calm our nervous system and ground and connect to the consciousness of the earth and to our own higher consciousness, then we can communicate in a way that creates magic and medicine and beautiful relationship. We can communicate in a way that is empowering and that is reflective of our own deepest truth. I love that.  As you were speaking towards how sound and prayers, they live forever, right?  Like I can't unsay that. And then I've had some, you know, deep remorse for some of the ways that I've spoken in this life so far. And so it is bringing awareness to that and allowing yourself to actually be in conversation with people, which to me also, I mean, talking almost feels one-sided too, right? Whereas conversation is this reciprocal kind of dance that you do with each other, with other things, other living things, which everything is alive, right? Yeah, what you were speaking to about that remorse that maybe we experienced when we say something, it reminds me of a saying that we often say which is words create worlds and words can destroy worlds. So again, just emphasizing the power of speaking, you know, even spell casting, right? It has the word spelling in it. You know, words, even in the Bible it says, and then there was the word, right? So there's a lot of ancient myth, mythos, spirituality, a lot of history that kind of can ground us in an awareness of how powerful our words are. And to your point, communication doesn't have to be verbal. Communication is this exchange. When I think of communication, I think of deep listening as an integral component. And so, you know, when we are in conscious communication or in deep communication with a human, there's this almost like a third presence, which is the spaciousness. And typically these kinds of communications can move slower so that we don't go into kind of automatic or reactive or scripted response. We want to down-regulate our nervous system and stay in the body and connect to our heart and connect to our solar plexus and our truth and our breath and allow there to be this, this kind of exalted seat for deep listening. What am I saying? What are you saying? And what is not being spoken verbally but is present in the space? Right, and one way to be able to continue that reciprocity is questions, right? What I heard was this. Is that what you meant, right? And just having that, that's so friendly. That's so friendly to be able to say something like that and non-judgmental. It's like, wow, this is what I heard. Most times I would say maybe eight to nine out of 10 times what people are hearing is not what people are intending to be heard. Absolutely. I think what you just offered is such a great technique especially for couples and in relationships or especially when we're having those harder conversations or feeling more tender and vulnerable. It's so helpful to reflect back, this is what I heard, is that correct? Is that what you meant? And yeah, it's amazing. And that's a skill, right? I mean, what we're talking about conversation as opposed to scripted talking or trauma dumping, talking or any of those things, it's a skill and it's something that most skills need to be practiced. And so in practicing, we can mess up, right? And we got to love ourselves through that. Got to love ourselves through yelling at our five-year-olds because we're late and they're late and they're just looking in the mirror and dancing and they don't care about time, right? And so like I've had to forgive myself and love myself through certain moments of things like that. So, practicing that skill, right? Yeah, and to that, in that example, I think it's powerful when our kids witness us taking ownership and taking responsibility and apologizing. And I think again, this conversation of language talking, it's probably one of the more impactful ways that we can change culture, that we can change how we relate to our children, to one another, that we can change our whole society. And so, I know in my appearance generation, apologizing to the kids, especially coming from Poland and Europe, it's just not done. There's some kind of authority thing where it's not done. And so for me, I have this opportunity to create a different kind of culture in my family where we can all mess up and we can all take accountability and we can all forgive. And I'm modeling that to my daughter so that she can really be responsible for when she messes up. Thank you for talking about that because it wasn't until my daughter was 12 that I was really able, that she really taught me how important that was. And then, you know what? It's just not okay. It's not okay for you to dictate. That's not where we're at anymore. That's not the kind of human that I want to steward and support into growing to be one of the adult humans that carry on on this planet after we're gonna be gone and having more children. So it is, it's a cycle breaker. And I feel like there's a lot of things that we can learn from our kids, whether we have kids or not, it could be our nephews, our nieces, or maybe your teacher and you have kids. So yeah, it's a huge component of the growth and the healing of humanity. I agree. Yeah, so what are some of the places where we feel where talking originates in our body and where conversation originates in our body? And how does that feel in your body?  I know where that feels like to me, I'm interested to hear where does that, where do you feel that come up in your body and how does it feel? Yeah, I think there are some things that we can look out for when we're having, especially a difficult conversation, to kind of help us see where we're at. If we start to talk faster or louder, that's usually a sign that we're moving away from deep compassion and in body to truth. If we start to think about what we're gonna say next when the other person is still talking, which is very common, that's another great sign that we really need to slow things down if we wanna be in a conversation. And if we want that conversation to be deeply medicinal and productive and revealing of the greater truth. And I think, when I'm in a conversation that's really vulnerable or difficult and I'm practicing some of the skills of conscious communication, I do certain things before the conversation to prepare myself. I often will burn a little bit of a blessing herb, light a little sage or just something, some kind of an incense, something to help clear the space. And these, there are so many ancient herbs like white sage or copal, palo santo. These are some of the more kind of popular ones right now but even the local herbs around us, dried rosemary, dried mugwort, burning or pine resin, burning a sacred smoke has been used for thousands of years to clear the space, to clear negative energy. But what it does for us and in our body is it grounds us. It helps us take a deep breath and really get into our body and it clears the mind. And so that in itself is such a powerful tool for entering a conversation that might be difficult or vulnerable. It helps create a safer container. Something else can be lighting a candle, drinking a tea that's relaxing to the nervous system, chamomile tea. You can drink a tea with your partner or the person that you're gonna be having this conversation with, holy basil, just having a moment to really get into the body and calm the nervous system and connect to your intention for the conversation. And then to answer your question, for myself, when I am having a vulnerable, difficult conversation, I notice energy rising in my chest and in my breath. And sometimes if I have to say something that's difficult or really vulnerable, I notice my voice shaking or quivering. Sometimes my belly feels a little nervous. And so, again, taking deep breaths and taking pause or even putting our hands on our bodies or on the earth or asking, can I have a moment and sharing? Like I'm feeling this is really vulnerable or this is really hard to say. I'm just gonna take a few breaths here. Being able to communicate that, it allows for more intimacy. Yeah, I think that that brings up such a great point too is what I keep hearing you say is slow down. Slow down. So many times we feel like we have to just get it out or we feel like we just need to get this conversation rolling or get a point across or things. And that's not necessarily how communication or conversation, true conscious conversation works. So that's slowing down. And you also brought a beautiful point of that these techniques and tools were all brought to us from ancient times. They were gifted to us from our earth, right? And perhaps even from, I'm gonna go there, galactic beings who may have brought them to earth for us as tools when we were ready to wake up and use them. So, yeah, that's here. And it seems what we've done is we veered so far away from what the actual communication is. I mean, I believe that we can also have nonverbal communication, right? So in that kind of communication, there are no words. And I feel like we're moving back to some of that, a lot of that in our culture, in our modern culture. So I know you have things to talk about with that because I am in your school. So I'd love to hear. I love that you're bringing this in, nonverbal communication and communication with the nonhuman, right? So as far as nonverbal communication goes, we're all doing it all the time. And we're all very capable of doing it. I think everyone can relate to a moment of like walking into a room and no one's talking, but you get this feeling of like, ooh, something just went down, right? So we can sense energy. So often someone is saying something and you might be feeling something really different. They might be saying something with a smile and you're feeling hostility or resentment. So we're all actually very aware and I think very tuned in. And it's good for us to trust ourselves. And then I think it's good for us to check in if it's a safe enough relationship and just say, I'm really feeling just some tension here. Is there something that you wish to communicate? So again, just bringing things to light, bringing things to light is always good medicine even when it's hard. But I think the really rich thing that we can dive into is communicating with the non-human. And yes, you are one of my beautiful apprentices to the sacred wild. And what we do is we learn how to communicate with the earth and we develop an ability to learn and understand the language of plants and specifically healing herbs and plant medicines. And so when we embark on that journey of wanting to create relationship, intimate relationship with the earth, with the land that we live on, maybe with a tree that we're always noticing and just feeling some kind of affection towards or stones, you know, some people are really drawn to the minerals and the crystals, animals, you know, there's just a whole world of beautiful deep relationship that's possible there. And in the case of the plants, the plants have a way that they communicate what their medicinal properties are. And they communicate that through the way that they taste.  And so even if you have never thought about communicating with the plants, you can start to kind of notice like, oh yeah, actually because I am made of the earth and air and water and fire and the plants are made of the same elements. I can actually learn directly from them and I can notice how they feel in my body and I can heal myself and follow my own intuition around which plants are asking me to deepen relationship with. Yeah. And okay, so one of the reasons why I chose to study with you is because all of the plants, like every, they have like a guide, okay, this plant is good for this and that herb is great for that. And this will help your blood pressure. This will help your eczema or whatever, right? What you're talking about though, in the conversation with the plant is that it can be reciprocal, right? So not only are you smelling it, you're feeling it on the outside, you can see it. So you see different behaviors, you see the way that it is, you see how it grows, you see where it grows and that's a part of listening. And then you feel where it goes in your body and then you have this personal relationship, right? And so even though Burdock may be really good for grounding, say Burdock to you, not only is it good for grounding, but it makes you feel so secure and wanting to just express yourself love and all these things that maybe it's a real great heart opener for you because that's your personal relationship. And once you develop and have that conversation with a plant ally, with an essence of this earth that is made of the same essence as I love how you put that as we are, then you can't lose it, it doesn't go away, right? That is now a relationship, it's just like my mailman, it's just like my teacher from third grade, it doesn't matter that that's been eons ago, I have a relationship with that person and I have a feeling and a knowing of who they are and how we share in this life together and it's the same with plants. Absolutely, I love how you spoke to that. And I love how you're really emphasizing an opportunity for all of us to develop deeper trust of our own capacity to trust what we are feeling drawn to, to trust how something feels in our body. And if there's ever one of the symptoms of kind of patriarchal capitalism and the modern world is it's constantly taking us out of our body and telling us to trust the ads, to trust whatever, the news or our feed and we should be buying this, you need this. Oh, you have formal issues, then take this. Our sense of trust and empowerment is constantly being taken away from us and displaced. And so I just love how you really spoke to the plants and their ability to have us learn and listen and hear these subtle and yet profoundly transformative effects and messages that they have just for us because each of us are completely unique and different and to be able to open to that deep conversation with the natural world and realize that every plant has a message that's just for us, it's completely life changing. It really is and even in like planting things. I mean, I've realized that and it's, you know I'll plant something and maybe it didn't work there and I'm like, okay, well, I guess I have some more work to do in listening, right? Because maybe if I was not rushing or just saying, oh, it'll look pretty there but I really did actually ask the plant and sit with the plant or the seeds of the plant or the earth where the plant's going to go then perhaps it would have had more longevity, you know or maybe it would have thrived or nourished. They had more nourishment there. So, and it is a practice and that's what I really want to bring to light is that people can, but you've got to start it, right? You have to start the practice in order to be able to gain the skill and you have to stick with it. And it is so natural and it is so accessible, you know? Yes. And it feels like a coming home. It feels like a coming home. It brings back also a sense of wonder and magic that brings us joy and energy the way that, you know, when we were kids the world all just felt a little bit more sparkly and that sparkle actually never really went away. It's just that, you know we began getting conditioned and told that we should be productive that we wish that this is what's important, you know that, you know, whatever it might have been and so to actually come back into relationship and reciprocity and love with the earth and with the natural world it brings back a deep sense of wonder and joy and then health and vitality because we are more whole. We are meant to be nourishing all parts of ourselves and we are meant to be in these relationships with the earth that is part of us and that we are a part of. Yep. Yes. Great. So I just want to for a second bring to light your school because the apprenticeship to the School of the Sacred Wilds has it's really helped me to find my way home to my inner knowing and I just love the practice every month. This last year was the first year in my entire life that I can remember where I actually embraced the slowness of winter and the hibernation of winter and the darkness and I was so surprised that I actually got a lot done. Everything got done only there was less like worry and strife and stress around it all and what a beautiful way to be able to honor the rhythm of the earth and so that's one of the many things that I learned from this school and your enrollment for it's a 10 month class of course that's ongoing for the rest of your life. The 10 month log apprenticeship we began September 9th and so registrations open and yes each month students receive a package of herbs or they can get them themselves and we drink these herbs together and the herbs connect you to the energy of what is happening in the earth. So like you said in the winter there's more of an energy of hibernation and the plants have released their leaves and they're nourishing their roots. The winter is a good time for us to build deep immunity and deep chi so that in the spring we actually have this effortless vitality and so we go through the wheel of the year connecting to the seasons connecting to all of the kind of ever renewing cycles of nature and throughout the 10 months students are drinking healing herbs that target each of the chakras each of the systems of the body and we have these beautiful online tea ceremonies where you are learning how to understand and hear the message directly for you from this plant. So it's a very magical and beautiful experience and just such a sweet community the people that gather are just incredible and I warmly invite anybody to join us. Not only second that invitation I also I just can't say enough about how nourishing it is to be able to have that community to be able to come back to and even mentorship, right? So there's mentors, it's not just you and it's you can reach out to people around you in your area it's all over the world say you travel to France there's somebody in France who is a part of this apprenticeship I just know it. That's cool, yeah, it's wonderful. It's really great and you don't have to go to in-person things although that's magical you're able to be able to do it from your home in your community and be able to still find that connection to the collective and be able to regroup and ground with the parts of us that have always been available and maybe we just forgot, so. Yeah. Thank you so much. And so just to recap I wanna say some of the tools that we could use for communicating with conversation is to really listen to our bodies if you have a difficult conversation that you're gonna have prepare beforehand allow yourself to be vulnerable and transparent ask questions and give yourself a break and know that we're all in this together we're all learning we're all finding a way to be able to reconnect to our inner essence so that we can be made human by each other in this heaven on earth. Thank you so much Marisha for coming on today and I look forward to seeing you on the 9th and even before I think. So, thank you Mahalo. Thank you, blessings to all of you and the lands you live on. Oh, I love that. And thank you to Think Tech, Hawaii and all of our sponsors and donors that continue to make this platform available so that we can have these amazing conversations. Aloha. Thank you so much for watching Think Tech, Hawaii. If you like what we do, please click the like and subscribe button on YouTube. You can also follow us on Facebook, Instagram and LinkedIn. Check out our website, ThinkTechHawaii.com. Mahalo.


Google announced today that it's adding earthquake early warning alert technology to its Android operating system for mobile devices. With this announcement, advanced earthquake warnings can now be sent in three ways, giving Californians life-saving seconds to drop, cover, and hold on when an earthquake is about to hit. It was a sobering experience. Last October 17th coinciding with the 30th anniversary of the devastating 1989 Loma Prieta earthquake. California launched its own earthquake early warning system, the successful result of Cal OES leadership, and the investment of more than 58 million dollars. And after years of research and development that included the placement of thousands of early detection ground motion sensors throughout the state, and innovative advancements in technology, Cal OES, in collaboration with the California integrated seismic network partners from the University of California at Berkeley, the United States Geologic Survey, Cal Tech, and the California Geologic Survey are more than excited to launch the nation's first state earthquake early warning system. Scientists, developers, along with local, state, and federal emergency planners, beta tested the new system first in Oakland, then in San Diego. The launch culminated with VIPs and media, gathering at the foot of the old Oakland Bay Bridge, backed by an arch of firewater, marking the exact location of the span's collapse during the 6.9 magnitude quake. We're announcing the ability for millions and millions of Californians to download an app, My Shake. Download the app, My Shake. Millions of people do that. We will have points of contact, the ability to crowdsource information, the likes of which no country in the world has advanced. Cell phones can already receive My Shake and WIA alerts, and now millions more will receive alerts through the Android operating system. Cal OES encourages iOS device owners to download the My Shake app from the iTunes store and check your personal phone settings to make sure your alerts are enabled. For more information, go to earthquake.ca.gov.


Hi, I'm David Cantor with the Law Offices of David Michael Cantor and today I'm going to talk about the Peoria City Court. Sometimes they call this a Peoria Municipal Court. If you hear city or municipal, it's the same thing. Now if you receive the ticket and we're told to go to a justice court, that's in a different building. If you're told that you were charged with a felony, that'll be at Superior Court. So I'm talking specifically about the Peoria City or Municipal Court. Now the address for this court is 10000 North 83rd Avenue and the directions are pretty simple. If you're going along the 10 to the 101 North and then this is if you're going out to LA and then you take the 101 North up to Olive Avenue, then you go right and you're going to go about 7 miles of Olive Avenue and then you're going to be left at 83rd Avenue and go up another mile. On the left side of the road will be parking for the court and there's going to be a traffic circle. And there they're going to have a parking garage. You're going to want to go in the parking garage and you're going to park at the top of that garage, okay? Now when you get there, make sure you dress appropriately. Don't wear a baseball hat, sunglasses, t-shirt or shorts. Dress as if you're going to a job interview. Now why do you want to use a lawyer?   They will not tell you, oh you have a great case, you should fight me on this, set it to trial and go to trial. I think you're going to win. They just won't do that. Now if you have an attorney, we go for you so you don't have to go. That's why you hire us. So you're not going to miss work or school. Average case lasts 4 to 6 months and every 30 days there's a court date yet you won't have to go, we go for you. Other reasons why you want to hire us, well, are results. If you go to our webpage at dmcanter.com, you can see we have over 2,000 wins on criminal cases of all type. You can also go to the page regarding the Peoria City Court and you can click on the button and it will show you some different wins, sample wins in that particular jurisdiction. Now the consultation is free. If you call us or fill out a contact us form on our website, we will get back to you and we will set you to come in for a 30 minute free initial consultation. It will cost you a dime, but it will take 30 minutes of your time. So I look forward to hearing from you soon. If you do have a ticket and you have to go to that court, please give us a call.