Well, it looks like we got our quorum here, so I'm going to go ahead and get started. Today's topic is Diagnostic Errors in Medicine. And by way of background, a landmark study was published by the Institute of Medicine in 1999 entitled, To Errors Human, and it focused on preventable errors in medicine. The findings were gathered from two large studies of hospitalizations in the United States, and they determined that adverse events from a cohort in Utah and Colorado, and we're talking about hundreds of thousands of patients, what adverse events occurred at a frequency of 2.9% in that group and 3.7% in Utah, and of these patient deaths occurred in 6.6% of the Utah-Colorado group and 13.6% in the New York group. So this data was alarming, and when they extrapolated to the 33.6 million hospitalizations that occurred in 1997, they concluded that between 44,000 and 98,000 people die every year as a result of medical error, and you've probably heard these data in the lay press, but this was really a wake-up call, and the errors that they defined fell in these four categories. Diagnostic errors which were errors in or delay in diagnosis, failure to employ indicated tests, use of outmoded tests or therapy, and failure to act on the results of monitoring or testing. There were treatment errors, these are errors in the performance of an operation, procedure or test, error in administering the treatment, error in the dose, or method of using a drug, avoidable delay in treatment, or in responding to an abnormal test, and inappropriate or care or care that was not indicated. There were preventive errors, failure to provide prophylactic treatment, inadequate monitoring of follow-up, or inadequate monitoring or follow-up of treatment, and then other things like failure to communicate, failure to pass off patients well amongst colleagues, equipment failure, and other system failures. And at the Annenberg conference on patient safety leading up to the publishing of this study in 1998, the year prior, Nancy Dickey, the past president of the AMA, said the only acceptable error rate is zero, and then at the same conference in 2001, Gordon Springer, CEO of Alina Health, said, let's be absolutely clear on this. The goal of patient safety, of the patient safety movement must be to eliminate all errors. This is like climbing Mount Everest, but it must be our goal and it can be done. So that led to two questions in my mind. Number one, is it reasonable to have a zero-tolerance policy towards medical error? And number two, could the statement, the goal of the patient safety movement must be to eliminate all error?  So that really got me interested in this question of risks climbing Mount Everest. So here's an article entitled, effects of age and gender on success and death of mountaineers on Mount Everest. And what they found was the overall death rate, but what they found basically is climbing Everest is very risky. And so, by analogy, practicing medicine. Overall, the death rate by age is 5%, if you're over age 16, about 1.5% for younger climbers and there's no gender difference. But you're more likely to die on the way down, apparently, than you are climbing. And so for the death rate among some of the tiers actually is a whopping 25% for people greater than 60 years of age. And only climbs modestly to 2.2% amongst younger climbers. And again, there's no gender difference. So that actually got me interested in the question of whether the effect of age on death and complications during hospitalization. And here's a study published out of Great Britain. And they're looking at all of the hospitalizations and negative outcomes in England and Wales over a full decade. So you can imagine, again, we're talking about millions of people. And they found the following. Our study shows that older patients are more likely to experience a misadventure during surgical care and medical care and more likely to die as a result. That seems pretty obvious. One explanation for the frailty of older people, one explanation for this, is the frailty of older people, which alongside the presence of comorbidities is likely to affect their capacities to survive misadventures relative to younger patients. Again, kind of obvious. A fragile health status is also likely to account for the elevated mortality observed in children less than one year of age. So there's a graph of mortality by age. And we see that it claims markedly as we grow older. The higher rate of misadventures in older adults is likely to be a consequence of greater exposure to health care. So risk factors simply to be a part of the system with advancing age. Furthermore, our study suggests that older age groups have experienced a greater increase in the number of procedures performed than younger age groups. Despite being more vulnerable to misadventures, the data might suggest that older individuals are also being exposed to more procedures than in previous years. It is also possible that older people undergo a greater number of complex, risky, and invasive treatments to which they are more prone to error. Believing the obvious, but clearly showing that age is a risk factor for complications and for death as a result. So we conclude then that as population, general population ages, we can expect both a higher rate and a higher total number of misadventures or complications. And with respect to zero tolerance, the aging baby boomer cohort is a major driver towards an increase in reported medical errors. But today we're going to talk about this first category, diagnostic errors in medicine. And a couple of comments. It's important to note that most misdiagnoses result from our failure to consider the correct diagnosis as a possibility and not from a lack of knowledge of the correct diagnosis. In fact, a full 96% of errors are really just have to do with interpretation of the data and not knowing what the true diagnosis is. So and also to point out that the diagnostic errors occur most frequently in primary care settings such as family, internal and emergency medicine and they're less likely to occur in specialty settings. So back to the question of can we, you know, eliminate the risk or incidence of diagnostic errors. This is a review that considers the feasibility of reducing or eliminating the three major diagnostic, three major categories of diagnostic error in medicine. The first category are no fault errors and these occur when the disease is silent or presents atypically or mimics something that is more common. So it's relieving to hear that there are, that they give us credit that sometimes we simply can't make the diagnosis at all and these are no fault errors. These errors will inevitably decline as medical science advances, as new syndromes are identified and diseases can be more, can be detected more accurately or at earlier stages and they emphasize that these errors can never be eradicated. Unfortunately, because new, as new, because new diseases emerge, tests are never perfect, patients are sometimes non-compliant. What they mean here is patients sometimes just don't give you the information that you seek, don't describe their disease as well, well enough for you to make a diagnosis and physicians will inevitably at times choose the most likely diagnosis over the correct one illustrating the concept of necessary fallibility and the probabilistic nature of choosing a diagnosis. The second category are system errors that play a role when the diagnosis is delayed or missed because of latent imperfections in the healthcare system. Again, these errors can be reduced by system improvements but can never be eliminated because improvements lag behind or degrade over time and each new fix, every time we try to fix something in the medical system, it creates the opportunity for novel errors. There are always trade-offs between making decisions, trying to improve things because resources are limited and they simply are shifted from one area to another area so we'll never be able to completely resolve the issue of system errors. And finally, the main topic, cognitive errors which reflect misdiagnoses from faulty data collection or interpretation, flawed reasoning or incomplete knowledge. And the limitations of human processing and inherent biases and the inherent biases in using heuristics which are just rules of thumb to help you make quick decisions, guarantee that these errors will persist. Opportunities, however, exist for improving the cognitive aspect of diagnosis by adopting system level changes such as a painting second opinions, implementing computerized decisions support systems, enhanced access to specialists and by training to improve cognition or cognitive awareness. So in summary, diagnostic error can be substantially reduced but never completely eradicated. So how do we make decisions? That's really the topic of discussion here. And discussion making is really the most important thing that we do in our lives. I mean we decide where we're going to go to school, what we're going to major in, our careers, who we're going to marry, et cetera. So the question of how we make decisions is actually a very important one. And through the history of Western thought from the Greek philosophers up until the recent president, there's been a great emphasis on making decisions through a very logical and reasoned process. And it's been generally discouraged to use intuitive thought processes because they're thought to be too impulsive and emotionally based and really based in more kind of primal and evolutionary forces. So there's been an emphasis on using logical reasoning to all the great philosophers and it is generally accepted that we become better at logic through culture and education and intellect. So there's various schools of thought on decision making, big, you know, lifetime areas of research and they fall into two categories, the intuitive versus the analytical approach. The traditional thinking in medicine is that with training, logic in medicine, training in logic and mathematics, positions should and will use the analytical approach. They should obtain a complete history, perform a thorough exam, consider the differential diagnosis, then order tests and arrive at a diagnosis using principles of logic and application of conditional probability. I became interested in this topic after hearing Dr. Jerome Grootman on national public radio speak on how doctors really think in the heat of battle. He's the chair of medicine at Harvard Medical School. He's also the chief of experimental medicine at Beth Israel. And he's also a staff writer for The New Yorker Magazine. And he describes clinical decision making in these five categories. And I'll go through his thoughts quickly here. So intuition, the use of intuition, these are his comments. The more experience you have, the greater temptation to rely on intuition or consult when making medical decisions. But this is fraught with potential for error and you really have to remind yourself to remain systematic. Another approach is pattern recognition, which is based in heuristics, these rules of thumb and certain cognitive biases that are really built into us. And this is the flesh and blood decision making process. All cues to a patient's problem from history taking to examination radiology labs and ophthalmology visual field OCTs all come together at once to form a pattern in our mind. And this pattern occurs within seconds, largely without conscious analysis, and does not occur by a linear step by step combining of the cues. Rather, the mind acts as a magnet and pulls in the cues from all directions, and hence pattern recognition. Clinical algorithms, he says, can be useful for run-of-the-mill diagnoses and treatment, but they quickly fall apart when the doctor really needs to think outside the box. And he starts his discussion by, you know, he's a lab researcher primarily, but once a year he spends a month on the general medicine ward. And he became very concerned sometime in the 90s when he wrote this book because he noted that a lot of medical students and residents had been trained to use clinical algorithms, and he felt that they weren't thinking well and that they weren't able to think outside the box. So in such cases, he states, algorithms discourage physicians from thinking independently and creatively, and instead of expanding a doctor's thinking can actually constrain it. So his thoughts on evidence-based medicine, that it's rapidly becoming the canon in many hospitals and medical schools, and treatments outside the statistically proven are considered taboo until a sufficient body of knowledge can be generated from clinical trials, and this rarely mirrors the reality at the bedside. And then finally, Bayesian analysis is a method of decision-making that is favored by those who construct algorithms and strictly adhere to evidence-based practice, especially people who design medical records and design our clinical decision support systems. It relies on mathematics to model diagnosis and treatment, and most importantly, rarely do we have high-quality studies that are available from which decision analysis can drive a probability. You have to have very well-designed studies in order to apply these. So in reality, we live in a medical world of pattern recognition using heuristics, and we definitely become more error-prone as we believe that we can use intuition to make decisions. And this is really a question now, given the background of complete information, whether we've even become more error-prone as we move in the more analytical direction. In the past few decades, there's been a confluence of data from a variety of fields, including cognitive psychology, neurology, neuroanatomy, neurophysiology, genetics, and philosophy that all support the central role of intuitive, non-analytical decision-making. And the recent data suggests that many decisions in everyday life are made quickly and reflexively using heuristics and useful biases, and this is due to built-in neural architecture that has evolved through Darwinian national selection. These are viewed as efficient mental strategies to deal with an uncertain and ambiguous world, and on most occasions they work, but occasionally they fall apart. So we really need to be aware of the conditions under which our fast thinking, our intuitive thinking falls apart. So two Nobel Prizes have been awarded in this area. One to Herbert Simon in 1978, and both were in economics. He got the Nobel Prize for decision-making in the organization. He developed these concepts of bounded rationality and satisfying. And he also won a Turing Award, which is amazing. He's the only person to do this. The Turing Award is really the Nobel Prize of computer science, and for basic contributions to artificial intelligence and the psychology of human cognition. Daniel Kahneman in 2002 won the Nobel Prize for the psychology of judgment and decision-making, and he discovered these cognitive biases for human error as a result of using heuristics. In psychology, heuristics and biases are viewed as efficient mental strategies with which to deal with an uncertain and ambiguous world. And they work, as I mentioned previously on most occasions, but they do occasionally fail, but they're not as biased considered to be intrinsically bad. A cognitive bias is the human tendency to make systematic decisions in certain circumstances based on cognitive factors rather than using the evidence. An example of this is the availability bias. And what this is, is if we see 13 patients in a row with a flu virus because it's traveling through the community, then the 14th patient that walks in with the constellation of sign and symptoms, it's the most available thought in our mind, so we may just diagnose them with that, and it may turn out to be something entirely different. But these cognitive biases are thought to be very valuable evolutionarily because if you see a threat in the savannah or the jungle, you learn it and you respond very quickly to it, and you don't stop to think, well, maybe could that be like a timeline? Respond. So heuristics are evidence-based techniques for problem-solving, learning, and discovery. And we use heuristics when an exhaustive search is impractical and thus heuristics are used to speed up the process of finding a satisfactory solution. And an example of using heuristics is what we discussed previously, the use of pattern recognition in medical diagnosis. I just, as an aside, found this little story about Daniel Kahneman interesting. This is where he describes why he ended up going into psychology. He was originally from Israel, and in late 41 or early 42, his family was living in Nazi-occupied Paris, and the Jews were required to wear the Star of David and to obey a 6 p.m. curfew, and he was a little boy, and he had gone to play with a Christian friend and stayed up too late, and he had to return home, so he turned his brown sweater inside out in order to walk a few blocks home. As I was walking home, I saw a German soldier approaching. He was wearing the black uniform that I had been told to fear more than others, the one worn by specially recruited SS soldiers. As I became closer to him, trying to walk fast, I noticed that he was looking at me intently. Then he beckoned me over, picked me up, and hugged me. I was terrified that he would notice the star inside my sweater. He was speaking to me with great emotion in German. When he put me down, he opened his wallet, showed me a picture of his boy, and gave me some money. I went home more certain than ever that my mother was right. People were endlessly complicated and interesting. I found that quite moving, and that is, again, what moved him to go into the field of psychology. The experimental data demonstrates that in busy clinical settings, physicians primarily use pattern recognition and diagnostic decision-making, because it's fast, efficient, and often correct. Conditions of stress, and it's most useful under conditions of stress, fatigue, and sleep deprivation. Because we lose in these conditions our ability to use analytical reasoning, and we move towards the use of heuristics and biases in order to get to the day. It's also the most efficient strategy under conditions of clinical uncertainty when the data is incomplete or ambiguous. This is a quote that I found quite interesting from David Eddy, his professor of health policy at Duke. Uncertainty creeps into medical practice for every poor, whether a physician is defining disease, making a diagnosis, selecting a procedure, observing outcomes, assessing probabilities, or putting it all together. He is walking on a very slippery terrain. It's difficult for non-physicians, and indeed for many physicians, to appreciate how complex these tasks are, how poorly we understand them, and how easy it is for honest people to come to different conclusions. So under conditions of time constraint, the data is just unclear, and when we're stressed and fatigued, we move away from logical thinking towards intuitive thinking processes, in particular using pattern recognition. The role of context here is very important. Context is the milieu in which a case presents and the decision is made. For example, contrast these two case presentations. If a complex diagnosis made in a busy, emergency room at 3 a.m. by an overworked, tired and stressed out resident who is using pattern recognition and other heuristics to get to the night. And then the same case discussed in grand rounds, taking a more logical and reasonable approach using, again, logical decision-making patterns. It's understandable that under these different circumstances we could come to completely different conclusions. So is the context misleading or adaptive? Well, the brain is hard-wired to interpret information via the context in which it is presented. And so here we have the letter B, you know, surrounded, we can interpret, versus the same shape now understood to be the number 13. We can arrive at very different conclusions depending upon the context in which information is presented to us. And the brain uses context to interpret meaning, which can be adaptive and also misleading. Here we have actually two different vertical black lines that are of identical size, but they appear. You'd swear that this line is much larger than this line because the brain interprets that we're in some architectural space, and this may have, again, you know, an adaptive advantage to us, but can also lead to wildly different conclusions based upon the context. So context influences intuitive decision-making, and is a significant potential for error, but has little effect on rational decision-making. So, as, again, under conditions of stress, time constraint, and fatigue, we move towards intuitive decision-making, which is highly influenced by context and very prone to error. And consider this example as well. This is an actual headline from the National Post in 2008. Man, fatal issues, wife, and chastain gets away with it. And this was, you know, on day one, this was the headline, and there was understandable outrage because the perpetrator had been released from prison. And the following day we learned that the accused was an elderly man diagnosed with terminal cancer who was the sole caregiver to his wife with NCH Alzheimer's, and he died two weeks later. That really just changes everything about how we interpret the case. And so, again, context has great impact on how we make quick decisions when we're just, you know, interpreting events as they're presented to us. So there's an article entitled, Context is Everything, and written by Pat Cross, who is a big thinker in the field, and he states that retrospective investigations, such as root cause analysis, critical incident review, morbidity and mortality rounds, and legal investigations all suffer from the limitations that they cannot faithfully reconstruct the context in which decisions were made and from which actions followed. In the past few decades, there's been a confluence of data, again the same concept, from a variety of different fields, and they've all come, everybody agrees, all people who study decision making agreed it on this model for dual process theory. And it basically states that there are two ways we think, which is what I've been presenting to you, an intuitive system one and a rational system two. And the properties of the system we've discussed, you know, fast heuristic level thinking versus deductive thinking. The awareness in system one or intuitive is very low versus high when we're in analytical, very aware when we're thinking analytically. It's a reflexive, system one is reflexive, automatic, it's fast, the effort is minimal, low energy, and, you know, works at 3 a.m. It's low psychological cost, it's very vulnerable to biases, it has low reliability, makes a lot of errors, has low predictive power, and it's probably hardwired into the brain. Low scientific rigor and it's highly dependent upon context. So this is dual process theory. Basically, if we're presented with a patient, it moves into kind of a pattern processing section of the brain and we interpret all the data very quickly. If we recognize the data, we move immediately into fast system one thinking. In contrast, if we don't recognize data, we should move along the system two path where we're again using intellectual ability or education training and skills that critical thinking through to try to arrive at a logical conclusion. Over time, as we learn a particular area, it becomes repetitive and it moves into more of a system one process. And at any time, we can use, if we find ourselves questioning our system one thinking, we can rationally override. And that's really a main concept in this field is that we should be aware of which system we're in when we're thinking about patients. And the concept is metacognition that we can be aware that we're really using rules of thumb and heuristics and rapid theological thinking patterns and override the system and move back and say, okay, wait a second, let me think logically, let me break this down and rationally override the processes. So dual process thinking is a really big model now in various fields and describe how we think and how we decide. But it is, as I've mentioned, very vulnerable to error. So how do we overcome these vulnerabilities to making errors when we're in this fast thinking mode that we're typically in as we're working in busy clinics? So back to Jerome Grootman in his book How Doctors Think, majority of errors in physician thinking occur because of a cascade of cognitive errors. And again, as I mentioned, rarely due to technical mistakes or lack of knowledge, 10, 15% of clinical diagnoses are inaccurate. In one study of 100 diagnostic errors, only four resulted from inadequate medical knowledge and the rest of these errors fell into cognitive traps. And the major risk factor is being rushed. So these are some of them. There's really at least 50 different cognitive errors. I'm going to go through about eight of them. But these are the most prominent in medicine. Anchoring is a shortcut in thinking where a person doesn't consider multiple possibilities for diagnosis, but quickly and firmly latches on the first one that comes to their mind. It's very common. Again, these are evolutionarily adaptive ways of thinking. But they don't always work in the complex world, real modern world that we find ourselves in. So this is prematurely closing the differential diagnosis. And one of the strongest safeguards against cognitive errors, such as anchoring, is to make a short differential on every patient. If you can train yourself to do this, you're going to avoid this major form of cognitive error. And one thing on your differential, you should always ask yourself, what's the worst thing that this could be? The availability error, which I discussed briefly earlier, describes the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. So what's available in your mind is strongly colors that you're thinking about a new case that has some similarities frame of reference. So he gives an example in the book where he was an intern at Highland Hospital in California, inner city hospital. And he had just seen a number of victims of violent crime come in who had been beaten up badly. And then there was a young man who came in, maybe the eighth or ninth patient that evening, also a victim of violent crime and unconscious. And he just assumed a victim. But, you know, actually, I'm telling the story entirely wrong. A number of drunks, he had a whole series of people who had come in under the influence. And then this eighth or ninth person came in under the influence and he just assumed another guy. It turned out he was a physics graduate student at Berkeley who had been a victim of violent crime and had been completely misdiagnosed as being a drunk. So the availability error is one where we, the most recent events are the ones that come to mind most easily and set our frame of reference. It may cause you to ignore the major differences in that particular case and come to incorrect diagnosis. So Grootman says that being quick and shooting from the hip are indications of anchoring and availability and that these are the two most frequent cognitive biases in the emergency department. And often there are all the doctor needs to hit the mark to make the correct diagnosis, but they can also deal widely off the mark.  The confirmation bias is attention to data that supports the presumed diagnosis and minimizes data that's contradicted. It's driven by an expectation that the initial diagnosis is correct and involves selectively serving the data. So once you've arrived at the diagnosis you just pick out pieces of the data that support your diagnosis and unconsciously ignore pieces of data that might refute your or contradict your diagnosis. So to avoid the confirmation bias we need to pay attention to data that does not fit. Always look for pieces of data that just don't quite fit what you think is going on and then chase them down and figure out why they don't fit rather or what's going on, why they're appearing rather than simply dismissing them. Improper framing, this is an interesting one. This occurs with patients that are being referred to you. So if somebody says to me I'm sending a patient with primary opening with glaucoma I may just accept that frame and fail to recognize that this is indeed an angle closure patient or a pigment dispersion patient. And it often occurs with specialists once an authoritative senior physician is fixed a label on a patient it usually stays firmly attached. And self-aware physicians should know that accepting the frame can lead to serious area. So when you receive a patient who's been labeled start over and try not to fall victim to this framing effect which is quite common. The representative error thinking is guided by a prototype and we fail to consider properties that contradict the prototype. So for example if a healthy fit man appears with chest pain that doesn't fit the prototype of coronary artery disease so we might dismiss it or diagnose it as muscle pain or something else or perhaps a young person with cup disc. It must be physiologic cup and you can't possibly be glaucoma, they're too young. But you have to be prepared for the atypical and most importantly as I learn in practice don't reassure every patient just because they don't fit the prototype that they're okay because it may not be the case. An affective error is a tendency to prefer what we hope will happen rather than less appealing alternatives and this tends to occur with people that we like. This is why we don't take care of family members because we selectively survey the data. We want a positive outcome for this person and that we like them. And so the example might be in the patient that I like and this patient might have some suspicious disc but their visual field results are good so I overvalued that information. I report the great news. I don't bother to get an OCT that might have showed me the negative, the early glaucoma and I fail to follow up appropriately so I commit the affective cognitive error and I think this is the last one here. The attribution error is a tendency to overemphasize personality-based explanations for complaints or symptoms.  We may feel this way about this particular patient but they may have a true underlying diagnosis so you have to learn to recognize negative feelings towards patients and then plan a red flag in your mind that says, I'm thinking, I have personal feelings about this patient that may be coloring my ability to see what's really going on. So in summary, the publication to Erich Human from 1999 cast a real dark shadow on the American medical system. Approximately 50 to 100,000 deaths per year were attributed to medical mistakes and this resulted in a major call to action to reduce medical error. The challenges, however, are daunting. Like climbing Everest, medicine is inherently risky and unpredictable. Diagnosis and treatment are often obscured by uncertainty. Uncertain place a huge role in medicine that we often are unwilling to acknowledge. We have an aging population that is increasingly susceptible to bad outcomes, and as cohort ages we're going to see more and not less bad outcomes unless we make dramatic changes and it's important to remember that when we look at mistakes retrospective analysis entirely misses the context in which decisions were made and retrospective analysis is done, you know, like Grand Rounds, it's done using logical system to thinking and so you can't necessarily understand how mistakes occurred if you can't create an environment in which we understand the context in which the decisions were made. The expectation of perfection or zero tolerance for error simply is unreasonable. Error cannot be eliminated because there are no fault errors, there are system errors and cognitive errors which I went through earlier that simply are built into the system and there's no way around them. To reduce the risk for cognitive error we have to remember that being busy, stressed out is really the number one risk factor for error. We need to recognize when we're under these conditions basically whenever we're in clinic and we have to really structure our thinking make a conscious effort not to commit cognitive errors. We need to always create a differential diagnosis and consider whether we're just anchoring on the very first idea that comes to mind. We need to always ask ourselves what the worst thing this presentation could possibly be and am I dismissing or ignoring information in the presentation because I'm just focusing on what I think the answer should be and slowing down the same way to say what's this, why is this not fit and chase that down. We also need to ask ourselves whether we've uncritically accepted an improper frame when a patient is referred to us. Basically start over with your work up whenever you receive a patient. This is a hard one because it's really built into our brains in terms of how we think but ask ourselves if we're simply in an environment where we're being exposed to one type of case consistently whether we're just jumping to conclusions when we make that diagnosis in the next patient and it's my thinking erroneously guided by a prototype am I considering atypical presentations of common diseases or fitting everything into this common prototype. In conclusion then remember that the air is human and to forgive is divine so I thank you for your attention. The first thing I would advise is don't blame yourself mistakes. That's really the best way to learn. Unfortunately the medical culture the societal culture surrounding medicine is that we're supposed to be air free so I think that's where the tension was. We're there's a number of biological explanations as to why learning occurs best by focusing on mistakes and there is a time to go into that norma and expert in that but the prime example is great chess players for example the way they become great is they look at their games they go back and they focus on the mistakes eventually by through mistakes thought processes become intuitive so it's counter to what we're taught that we're never supposed to make mistakes and everything can be learned in a linear fashion step by step but it turns out it doesn't always work that way. The corollary, well thanks again for all the


Hello and welcome to WaterFlow. PERSA has developed this video as part of their water market literacy program and it's one of a number of resources available to help you make the most of your water trading options. This video will show you how to register with WaterFlow. Find information about trading zones. Research water to buy or sell and help you learn more to plan your season ahead. To get the ball rolling, you'll need a WaterFlow account. It's free to register, just click here at the top of your screen. Complete your details, your name and email address, then select your trading zone. Zone 12 is for the South Australian River Murray. Finally, type your password, then type it again to confirm. Click on submit and you'll shortly receive an email to confirm activation of your account. Click the activation link and now your account is created. To access WaterFlow's features, you'll need to log in. Click the log in button, enter your username which is the email address you signed up with, plus your password and then click log in. WaterFlow brings together water market information from various sources and delivers this essential independent up-to-date data directly to you. Once you've logged in, you can access this information by clicking Market Overview. Across the top of the page, you'll see various options to find what you're looking for. Starting with temporary water, you can view when water was last traded and the cost per megaliter. Scroll down to zone 12, SA Murray. To see the last five trades from our data providers, click here. If you'd like more detailed information, click see market details. At a glance, we'll show you the zone map, storage levels and market spread. To get back to water prices, simply click the back arrow. If it's permanent water you're after, choose the permanent price tab. It uses a similar format as before and also shows options for the different types of water reliability. Under see market details, you'll find current allocations, five-year average and carry-over allowances. To find out about storage and allocation levels, click on this tab and the percentages will appear for each zone. For up-to-date trade limits across the basin, click the connectivity tab. For example, you can see if the bar machoke is open or closed and its current limit. Buying water can be a big outlay. River Murray irrigators have more than just the standard choices available to them. Water flow will allow you to compare options across trading zones. If you're wanting to buy water into South Australia, click buy water. Choose either temporary or permanent and enter the amount of water you'd like to buy. Click search and the most suitable options, which take into account the current trade opportunities from across the southern Murray-Darling Basin, reflecting the current trade restrictions will be displayed. The results are based on your default water trading zone. If your default zone is 12 SA Murray, then it will look at water available for purchase across zones connected to South Australia. You can change your trading zone in settings. To do another search, click the back arrow and change your criteria. You can add extra search criteria by clicking advanced search. This enables you to add a minimum or maximum price per megaliter. Choose your source state or for permanent water, change your trading zone. If you're considering selling water, click on sell water. It looks much the same as the buy water screen, but you can choose the zone from which you are selling. Click on advanced search if you'd like to add more details such as forward water and then hit search to view the results. Our notifications tool is useful if you'd like to be alerted when water reaches a particular price or trade limits have changed. To set up a notification, click notifications. Choose rules and then click the add button. Click the type of alert you'd like to set up, either a price alert or a trade limit alert. Complete the information and make sure you click on save notification. To amend a notification, click on edit, update your notification requirements and click save notification again.  You may be interested to know that WaterFlow has content to help South Australian irrigators in its water university. The WaterMarkets 101 section has loads of information about water trading. You can learn trade rules and limits, different types of water market products, plus a water glossary that explains each water trading term from A to Z. The Reports and Outlooks section includes trade reports for temporary and permanent water in each zone. The standard time period is one year. But you can go back as far as five years. The Allocation Outlook report shows you projected allocation under various scenarios as the irrigation season progresses. You can select Zone 12 SA Murray from the drop-down menu and see the projected allocation from wet to extremely dry conditions. The Climate Outlook gives an overview of rainfall and temperature reports from the Bureau of Meteorology, providing you with a snapshot for the upcoming season. Now you've got the basics covered, you can use WaterFlow as part of your toolkit for navigating the water market. There are lots of great resources available to help you learn more, stay informed, plan ahead and make the most of the water market. Head to the PURSA website to find out more.


I'm Sophie Socoloff, I'm assistant professor at UCLA School of Nursing and a member of the UCLA Center for the Advancement of the Gerontological Nursing Science in the UCLA Brain Research Institute. In this abstract video I'm going to describe the paper that was recently published with my co-worker in cytometry in which we show that it was physically possible to isolate and purify nerve terminal from Alzheimer's disease cortex. We show that actually we were able to resolve nerve terminal that cannot be resolved by light microscopy and to actually purify them and increase the content of their pathological markers such as amyloid beta and p-tow. So we are here at the UCLA Flowport Facility and this is where we did our physical cells story. And the first step of our experiment was to first acquire synaptosome based on their size. So we decided we get it on size standard beads and only collected particles between 0.5 and 1.5 micro. With this method we were able to store 500 million synaptosomes and further investigate the purity of the synaptosome by electron microscopy and we showed that actually our collected sample were a uniform population of synaptosome. So the second step of our experiment was to collect synaptosome based on the amyloid beta immunostaining and to collect particles that were only positive for amyloid beta and they were also of course based on their size. And so after 13 hours of sorting we were able to collect 100 millions of particles and to further characterize the pathology of those purified nerve terminal we did some immunoblotting and we labeled those membrane with an antibody against amyloid beta and we showed that actually there was an enrichment in the amyloid beta aggregate in the purified sample as compared to the non-purified sample. And the next step was to look at the content of p-tel so phosphorylated tel and we also showed an increase in the aggregate of phosphorylated tel in the sorted sample as compared to the crude synaptosome sample. So in the past year with micro workers Karen Gillis we have developed a analytical flow cytometry method to quantify protein in Alzheimer's disease nerve terminal but with this technique with the high speed self-sorting we show that we can actually physically isolate nerve terminal from Alzheimer's cortex but also to purify them and increase their content in the Alzheimer's pathology markers. And as synapses loss are believed to be an early step and correlate with the cognitive decline in AD pathology this method provides a new promising technique to look inside the nerve terminal and to understand what's happening in intact terminal and to better understand the early stage of AD pathology. And this also provides a new method that can further be used for other neurological disorders such as Parkinson's disease to better understand the molecular pathways in Parkinson's disease brain.


This summer I made a lifelong dream come true when I rode my bicycle the length of Sweden 1,300 miles from top to bottom and guess what way up here the sun doesn't set during the peak summer months It's pretty wild to have daylight all night long and I took advantage of it often pedaling into the night. I Even saw Santa's reindeer, which was super cool But I also got attacked by millions of mosquitoes, which was not cool at all Mosquitoes are nuts. Don't they ever take a break almost every day on my journey I met kind-hearted Swedes who took me in and fed me. This is what I call trail magic My destination was a tiny village at the southern tip where I lived as an exchange student 25 years ago Yeah, I love this country and reuniting with my beloved host family was one of the best days of my life


What is up guys, and welcome back to the John and Q channel. Thanks so much for watching. You saw the title of this video. Let's get right into it. I'm going to the EOS R.I. Switch. I'm currently using the EOS R to film and now the 60 Mart 2. Does it look good? Hope it does. I think it's a little bit better. Oh, that's too bright. I think it's a little bit better. Hoping that it's better. It can't say yet, but in the screen here it looks really good. I will say it looks a little bit sharper and better than the 60 Mart 2. Maybe that's just because it's like a new camera that I haven't dealt with and everything looks good. So I think it'll look good. Let me preface this intro with, this is not like an in-depth review or like a really informative review about the specs of the Canon EOS R. This is me more informing you on why I chose the EOS R over other mirrorless cameras and other systems out in the market right now. So let me find a spot to purchase you guys and we'll have a talk. All right, perfect. Okay, for me as a videographer, photographer and a YouTube creator, my name, like the name of the game for me is Portability and Workflow, like fast workflow. And the Canon 60 Mart 2 did that for me. Okay, no complaints about the Canon 60 Mart 2. There's little things that I'm like, I wish they could change that, but that's fine, like I'm not complaining. I mean Portability and like Workflow as far as how fast can I create videos? How fast can I turn the camera on to video and photo and just go for it, right? Let's, this bridge, I have a cool moment with my family and I want to switch right to photo. Can I do that on the fly? Can I do that on the fly with video? So those are the kind of things I look for when I want to just switch. Now I did consider for some time switching over to Sony only because it had high, I mean, Sony specs are just massive, but there are a few key features like the color from the Canon picture that just the Sony didn't really grab my attention for. It wasn't that gray, it wasn't on par. And for those reasons, that's why I didn't switch over to Sony. And I looked into different cameras like the M5, the M50, the new 90D, looked into various Canon mirrorless cameras and I decided on going with the EOS R because not only because it's the camera that people are using the vlog with nowadays, like filmmakers now going from the 60 Mart 2 to the EOS R, but it has a lot of the features that the Canon 5D Mark IV has that I like. Whoa, spider, oh my gosh. The photo camera that I use right now is the Canon 5D Mark IV and that camera is a dream to work with as far as photos. It does video well, but photography, it's just, it's my bread and butter. I always use that thing. And I knew that the EOS R had some of the internal specs of the 5D Mark IV and that caught my attention now and was like, okay, that's actually really intriguing. Not only does it have a 30.3 megapixels that the Canon 60 Mart 2 doesn't have, but I know the 5D Mark IV is far stills. I know that land, it's my world. Now translate that into a mirrorless camera, that would be perfect, that is perfect. And so that's a big reason as to why I'm upgrading to the EOR or have upgraded to the EOS R. I mean, it's like Hannah Montana and best of both worlds. That was a really lame reference. Cool. And so that's, like I said, one of the big reasons why I chose the EOS R. A lot of people have like a lot of creators that I follow on YouTube have the EOS R and I've seen their videos and what they can produce. And I'm like, okay, I'm a believer of the camera. If they can do that, then I can do that. And a lot of really big things like that that really swayed me to get it to EOS R. Things like Canon Log. For me, that stuff is great. That stuff I'll use every single day and it's gonna be a workhorse. And I know that this camera is a workhorse and I know that I'm gonna use it every single day to the extreme. This is how I see it. It's like a better version of the 60 Mart 2, but it's just also lighter. And honestly, that's how I view it. That's how we see it. And like I said, for me specifically, it's about creating content super quick, super fast. If I can create all my content in a fly and I have to learn a new system, I'm like, I'm thankful and that's why the EOS R has all those checkbox marks for me. Not only can I create content on the fly and switch over to photo and video within seconds, go to 60 frames a second, I now have 4K. I have 120 frames a second. You know, and those kind of things are the features that really won me over and really made me think about, okay, I'm gonna switch to the EOS R. Okay, let's be honest. This camera did not get a lot of good reviews. A lot of people weren't really excited when this came out as far as specs, but these people got it. Like these YouTubers and creators got the R and they're like, oh, I'm so impressed. It's gonna be the new thing. Forging the new frontier as a creator. I know it's not specs heavy. You know, I strongly believe that. It's not the gear that makes you good.  And if you have a good story to tell, even better. It doesn't matter what kind of camera you have or what gear you choose to have. If anything, I'm excited to be creating more and making new stories come alive with this camera. So it's not like I'm thinking, oh, I got a new camera. I'm the next, you know, big name on YouTube. I'm gonna continue to do what I do best and that's creating. I love creating videos on YouTube. It makes me happy if it fills me. Those are some of the reasons or a few of the reasons why I chose to upgrade my 60 Mark II to the USR. Now, that's not to say I'm not gonna use a 60 Mark II. I'm going to use it. But for the most part, vlogging and everything else is gonna be on the USR. Please let me know down below in the comments if you have any questions I can answer. Any review that you wanna see on the USR maybe comparing it to the Canon 60 Mark II. Let me know. I will see if I can do some of those. All right, thanks so much for watching. I'll catch you next time on the John and Q channel. Peace.


Hi friends, welcome back to my channel and welcome back to another collab video This is an awesome idea and this collab is hosted by Miranda at Running Away with Life. This is a summer festivity barbecue Camping collab that we are going to show you WW friendly adult beverages now I decided to give you two beverages just because I wanted to do something on the rocks and I wanted to do Something blended so if you want to see what adult beverages that you can enjoy this upcoming summer Especially with Memorial weekend right around the corner that are WW friendly then all you have to do is keep watching So the first summer adult beverage that we're going to make is a strawberry lime vodka spritzer now This is an extremely low smart point drink all that you have to count smart points for is the shot of vodka So let me show you what you're going to need in this recipe So first you're going to need some strawberries fresh or frozen I'm going to go ahead and do frozen just because I have them on hand You'll also need a fresh lime of course some ice cubes some vodka of your choice And then some seltzer water go ahead and grab your favorite glass and let's put together our strawberry lime Vodka spritzer so to get started on our lime strawberry vodka spritzer Go ahead and grab out whatever glass that you want to use This is the perfect size glass for this recipe you can see here that I've cut up my limes So I'm going to go ahead and take two lime wedges Give them a good squeeze and throw them into the bottom of my glass and then I also have some strawberries You can do fresh you can do frozen so I'm going to go ahead and toss those in as well This is where the vodka comes in go ahead and give yourself one shot of vodka And again, this is the only thing in this recipe that has points So this is a very low point recipe very summery and delicious So we've got our strawberries our lime and our vodka from there We're going to go ahead and add in some ice cubes So I like to put quite a few in my drink and then last but certainly not least is some seltzer water So go ahead and add some of that to your drink and we're going to give this a good stir And our drink is finished so I will show you the completed drink here and give you the smart points So here is our completed drink. This looks so Delicious look at that fresh fruit. It is fresh It is crisp and this is an alcoholic beverage an adult beverage for only three smart points So the only thing you have to count in this drink is the shot of vodka So this looks like a perfect summer treat So the second summary adult beverage I want to share with you is a summer peach drink This is actually a blended drink and again, this is extremely low points you guys So let me show you what is in this drink So of course again, you're going to need some vodka some water Whatever sweetener that you want to use. I'm going to go ahead and use trivia some ice cubes fresh peaches a lemon and Some mint. So let's get started on our summer peach drink All right So what we need to do for our summer peach drink is first you're going to need a blender to your blender We are literally going to add in our peaches our fresh squeezed lemon juice Five tablespoons of trivia two shots of vodka some ice and some water So let's get everything put into our blender And then we're just going to go ahead and get it all blended up and we should have a delicious blended peachy summery delicious drink Yum look at that. So we're going to go ahead and pop on our lid and We're going to get this blended we can always add in more ice as needed But let's get this all blended up and ready to go. Here's our summer peach drink nice and blended Look at how good that looks. This is only two servings. So this is a lot Per serving. So I'm going to get this into a beautiful glass We're going to garnish it and I will show you our completed summer peach Alcoholic beverage and here's our completed summer peach drink. Look at how good that looks. It's an adult slushie There's fresh peaches there is mint and look at this is a full-sized glass And again, we are only counting points for the vodka. So this is a total of three smart points for a slushie delicious peachy summer drink Thank you for joining me on this collab hosted again by Miranda at running away with life her YouTube channel and all of the other participants in this Fantastic collab idea are all listed down in the description box So make sure that you check out all of the other channels if you visit one of their channels Make sure you let them know that I sent you and if you came over to my channel from one of these amazing ladies Make sure you comment down below in the description or in the comment box and let me know who sent you over I hope you enjoyed seeing the two recipes for WW friendly adult beverages These are perfect you guys for Memorial weekend and for all of those fun weekend festivities that are coming down The pipe for over the summer. Thank you so much for watching Make sure you check out everyone else down in the description box below Subscribe hit the notification bell go ahead and give this video a thumbs up Definitely leave me a comment. Let me know if you're gonna try one of these delicious recipes They were both so good and refreshing and I'll see you guys all in my next video Bye guys


Man, I get a deliciously indulgent pleasure from watching these calligraphy videos. The sumptuous spread of the ink, the slow motions of the pen, talk about epic curlicues. If you've paid any attention to previous episodes, you probably know that I'm a fan of Star Trek, specifically the TNG flavor. I love the bright, shiny, optimistic vision of humanity moving beyond our peddier squabbles out into the wider universe. The future primarily dominated by values of scientific inquiry, exploration, and eliminating suffering and want. Of course, it can be difficult to write a TV series about a post-scarcity society, in a future where technological advances mean that humans don't really need anything anymore. Where's the conflict? Where's the drama? Will Picard get his tea? This leaves an interesting question. What would Star Trek look like without the militaristic backdrop of Starfleet? What if the crew of the Enterprise wasn't subject to a chain of command or orders from higher-ups, but were all just kind of traveling around the galaxy together, doing their own thing? Also, what if the ship's computer was a near-unipotent superintelligence with an attitude? E&M Bank's culture novels paint just such a picture of an alternate vision of space-faring, techno-utopian future. Rather than a united crew of duty-bound officers serving in a rigid military hierarchy, the stories focus on ordinary people living very cosmopolitan lives in an anarchic, post-scarcity intergalactic society of radical freedom, more or less run by extraordinarily powerful superintelligent AIs, with awesomely silly names. The eponymous culture is many things, democratic, meddling, diverse, but philosophically it's decidedly hedonistic. That term has some negative connotations in normal usage, denoting some sort of disgusting, immoral, overindulgence, and carnal desires. Many members of the culture love to party and indulge in baser instincts, but in philosophy hedonism merely describes a set of beliefs granting some privileged consideration for the phenomena of pleasure and pain. Pleasure can be derived from numerous sources, including less salacious ones than sex, drugs, and rock and roll. The Epicurean School, one of the earliest historical records of hedonistic philosophy, taught that the greatest pleasure in life was derived from simple living and modest appetites, as intense desire was simply another source of pain. You probably wouldn't find an Epicurean hedonist doing body shots at Coachella, the pleasure of giving back to a community or pushing yourself to succeed, the pain of seeing your kids suffer or of not living up to your potential. Most philosophers would agree that all of these things count for the purposes of hedonism, and that there's nothing inherently special about more salacious pleasures we normally associate with the word. Many value systems, which spurn earthly pleasures, have little nuggets of hedonism at their core, like the promise of eternal bliss in the afterlife, or a guarantee of freedom from suffering. There are several related principles that are lumped under the general heading of hedonism. For example, psychological hedonism is the position that everything that we do is ultimately to feel good or to avoid feeling bad. Now, if you dragged yourself out of bed early this morning to go to work, rather than sleeping for another half hour or so, you might have plausible grounds to doubt that position. But psychological hedonists usually make an important distinction between basic and non-basic motives. Basic motives drive us to action without any detours through thoughts about likely causal results, being desirable ends in and of themselves, while non-basic motives require a chain of reasoning and prediction to prompt someone to act in a certain way. You don't get out of bed in the morning just because you want to. You do it in the service of some other end goal, which a psychological hedonist would argue is a chain that always ends in either gaining pleasure or avoiding pain. I want to get out of bed because I want to shower before I go to work, because I want to be at work on time because if I'm not at work on time, I'll get fired, and if I get fired, it will feel really bad. Psychological hedonism seems to fit in nicely with our current understanding of neuroscience and behavior. The molecular systems that drive animals and humans to act in certain ways are called reward pathways for a reason.  It's certainly not unreasonable to say that those feelings are ultimately why we choose to do anything. Despite its explanatory power, there are decent grounds to be uncomfortable about jumping onto the psychological hedonist train. A common objection to all hedonistic claims, which we'll encounter later, is one of specificity in the definition of pleasure. Although it's compelling to suggest that human behavior is all motivated by some broad interpretation of the words pleasure and pain, it's difficult to draw boundaries around what those words mean without reducing the statement to a tautology or making it blatantly untrue. Maybe it's a stretch to call it pleasure-seeking behavior when someone volunteers to be tortured in the place of a loved one, even if they feel some amount of relief in doing so. Also, although it agrees broadly with some of our scientific knowledge about psychology and behavior, it's difficult to say that it's justified by those findings. We certainly haven't mapped out all the nuances of human motivation and trying to pick apart the supposed basic and non-basic motives seems like a thing that would be difficult to do robustly in experiments. In short, it's an easy claim to make and it agrees with some of our observations, but it's hard to prove in a way that would convince anyone who doesn't already believe it. Next, let's take a look at value and prudential hedonism. Value hedonists assert that the only metric for intrinsic worth is whether something causes pleasure or pain, that the beginning and end of an object or action's value is whether it makes someone feel good or bad. Similar to basic and non-basic motives, value hedonists differentiate between instrumental and intrinsic importance. Prudential hedonists have similar beliefs, but take them one step further, suggesting that hedonism is prudent, that is, that it's the best way for someone to lead a good life. The most well-known framework of value hedonism is utilitarianism, which we've discussed before in the context of consequentialist ethics, often associated with philosopher Jeremy Bentham and his student John Stuart Mill. Utilitarianism holds that the only thing that matters for morality is maximizing total pleasure and minimizing total pain. Any other perceived sources of moral goodness, stuff like justice, rights, equality, and so on, are only instrumentally worthwhile. Worthwhile only insofar as they facilitate those fuzzy feel-goods. Bentham and Mill agreed that maximizing pleasure and minimizing pain were the only things that really mattered, but the difficulty of nailing down what that really means caused some disagreement. Bentham was a quantitative hedonist, holding that the only thing of consequence was the total amount of pleasure produced, regardless of its source. However, Mill was dubious of this assertion, agreeing with critics who characterized it as the happiness of a mollusk. After all, if a philosopher's pleasure of grappling with heady problems was just as valuable as the simpler and more accessible pleasure of, say, eating cheesecake, what was the motivation to spend time learning how to do philosophy instead of eating cheesecake? He was more moved by a form of qualitative hedonism, asserting that there were certain pleasures that were of higher quality than others, and that the total value of a phenomenon could only be judged by both the quality and quantity of pleasure it produced. He proposed that relative quality could be judged by asking those who had experienced two options which they'd prefer to do. It's not like a baby can offer any insight as to the relative pleasures produced by philosophy or cheesecake, but if you ask some philosophers, you might get a better idea. This gives us some helpful grounds for preferring a few high-quality pleasures, even at the expense of numerous lower-quality ones, but you might understandably object to Mill's handling of the cheesecake problem. There does seem to be an element of bait-and-switch to it, as though he's rolling some new set of evaluative criteria under the heading of pleasure and hoping that we'll let it slide. Is this new quality thing really about pleasure alone, or might it be about things like beauty, commitment, authenticity, any number of things? There are other serious difficulties that value hedonism must contend with to be an acceptable rubric for worth. In general, if it can be demonstrated that two situations have this same hedonic value, but one of them is intuitively preferable to the other, we have a strong indication that there's something else that we're recognizing as being valuable besides pleasure and pain, which would disprove the hedonistic thesis. One such argument raised by philosopher Robert Nozick involves a matrix-like simulation engine, a VR machine that's totally indistinguishable from reality. In this machine, you can have any experience you like. You can win a triathlon. You can solve the P equals NP problem. You can fall in love or eat cheesecake. By definition, the hedonic content of both the real and virtual versions of these experiences is identical. You feel just as satisfied or elated in each scenario as you would if they had actually happened. But they didn't. Not really. Are they just as valuable? Is it better to feel like you've done these things or to have actually done them? There are also empirical grounds to doubt the claims of prudential hedonism, most notably the infamous paradox of hedonism. Although it's well and good to claim that happiness is the thing that makes life worth living, people who pursue it directly often find less success than those who dedicate themselves to other goals. That doesn't necessarily invalidate the prudential hedonist position, but it might be a decent cause for some skepticism. The problems with the various claims of hedonism, both definitional and practical, have dissuaded many contemporary philosophers from accepting it as a sufficient explanation for human motivation and value. But it does have some intuitively compelling corollaries for improving the human condition, and maybe some clues as to what we should strive for in the future. For myself, I'm not totally sure if pleasure and pain are the only things that really matter, or if they're the only reason we ever do anything. All I know is that I really want to read some more culture books, and it sure feels good to read them. Is seeking pleasure the end all of human motivation? Is it the only thing that has any intrinsic value? Please leave a comment below, and let me know what you think. Thank you very much for watching. Don't forget to blah blah subscribe, blah share, and don't stop thunking.


and Mabuhay. My name is Amy Ortega Anderson, your host for Pinoy Power Hawaii. I want to welcome you to another special edition of Pinoy Power Hawaii here on Think Tech Hawaii. We come to you live every Tuesday at 12 noon. Much mahal again to Think Tech Hawaii for giving us the opportunity to come to your home where we aim to enrich, enlighten, educate, entertain, and we hope to empower. Today is a very very special day and along in line with the month for lovers of February we have these two special people in my life that serves as an inspiration and also they are my idols because they simply are two loving people and without further ado I'd like to introduce to you our guest John and Nancy Ortiz. John is our master retired US Navy master chief so he is the chief and of course the Queen of the household from the Alma Latina show Queen Nancy Ortiz. Welcome to Pinoy Power Hawaii. Welcome. Thank you very much. Love is in the air, right? It is. We are all dressed up for the occasion. Sir John, Master John, thank you so much for appearing on Think Tech Hawaii. It's my pleasure. Thank you. Awesome. Very talented people who does so much to contribute and also uplift and empower our community in so many ways. Hermana, sister Nancy, tell us about you and the chief. All right, what do you want to know about everything that you can share? Well, you know ironically enough the chief and I got married on Valentine's Day. Isn't that awesome? Actually a Saturday when we got married and so it was you know us with Latinos big blowout, right? Yes. Yes, but prior to that we met I think we were only what about a year going together just about a year going together and we both actually I was ready to to take that step again. He was not, but within what we met in January and in October he asked to marry me. He tells a story better. Go ahead. Yes, let's hear your version. Well actually I met Nancy first time I saw her was 1977 on a Mother's Day. We were playing music in his club and here's this beautiful woman walks by and I'm looking and one of my players knows her very, very well. So later on you know I asked him who's that girl? I think oh she's a really nice lady and so he kind of introduced us and from there on he just why not just marry away. Was it love at first sight? Not at first, but she kind of grew on me but yeah. Okay. And it's one of the best decisions I ever made was asking her to marry me. Wow. Publicly or unofficially? Officially, yes. Yes. In the best place where they want to kill part. We've come to the intersection and the cost stopped. I figured I better do something so the lights were red. I said would you marry me? She looked at me and she said she didn't know what to say and the lights turned green. I said well are you gonna marry me or not? I'm not moving till you answer me. Stop trying. And the car in the back was less than a half. She said okay, okay, I'm married. Move. She had no choice. That's perfect timing as we say. Wow. And how many years is? 38 years. 38 years. Yes. I was inspired to call you because I knew that you have, you have a great love story to share and judging from what I see I have served where you lovely come to drop off my sister to her show and I see you do that all the time and yet you never stick around for the show. No, I listen to it on the outside. Yes, but you are the backbone because you do everything in preparation for her big show, whether it's putting on her radio show in Alma Latina or the big productions that she does when she puts on a pageant or the community for Latinos. Sis, tell us about that. Yes, he's with me all the time. I do a lot of you out there know besides my Alma Latina show I do a lot of festivals. Yes. And he's right there and you know that is one of the ways of keeping a marriage or you know a partnership is do the things together. And so everything I do I always ask him first and I said hey you know I'm gonna do this this this will you help me he says go for it. Wow. And I go for it. The biggest supporter. And as you know he's a musician as well and that's the only hobby he has besides me and so he I'm there I'm there with him I support him all the way 100% as well. Well it's a great hobby to have because in line with what we do in the community we always need music. Yes to complete it right. Sir John so rather than hiring because musicians can be very very expensive. Yes. Yes. Yes. But I've been very fortunate because the band I play with they all support me and they support Nancy. Yes. So when she needs something to say yes let's go. So it's like a double cause. Yeah. All right. I want to send a shout out to Latin Amigos. Yes. Oh Latin Amigos. That's the name of this. Yes. Awesome. I've seen you on social media having a great time and all to the wee hours. Yes. Tell us more about your love of music. Well I actually my love of music goes back to a time I was five years old. Five. Yeah. And my neighbor noticed I used to like they were two brothers always playing music. I wasn't listening. So he asked my dad one day said you know I got his old ukulele. I want to string it up for your son and teach him a few keys. So that's what happened. And that's how it began. Yeah. With the ukulele play that for a little while and then it advanced to the guitar. And I found that I really enjoyed that. And you know for some reason I just could pick it up and went from there. Yes. And that's the wonderful thing about being naturally being given the talent. I didn't know I had that until I started. Yeah. And after that you know you listen to a song and you play it. And I don't read music. Wow. And I've actually had this guy tell me. He said I've been watching you. He said you play all these different keys but you don't you don't read music. I said no I don't. He just listened and played. That's a total gift. It is. It is to me. I really enjoyed it. And you know he's left handed. Lefties are very talented. Yes. He plays bass upside down. Yeah. String it up for right handed but I play it left handed. And that also got this guy excited. That is so awesome. Yeah. The reason for that was we had a party one time. One of our first dates. And we were just waiting at the HIC.  He said hey John. I said my dad wants to talk to you. So I looked and said okay so I know his father real well. He's a leader of this other band. So I come up and I said what's up? He told me my bass player just left. He got into a confrontation and took off. So he was stuck with other bass. I said I don't play the bass.  He could play the bass. I said okay I'm left handed. He said I see you play upside down so you can.  I said to the bass at home. He told me here this is yours. Wow. And we went from there. And how has it been for a long time? We made an album. And you know it's I really enjoyed it for some reason even now till today. That is so awesome to hear us stories from the heart and how everything unfolds because of your passion. Passions in life. The love of music. And couple that with the love of the love of your life. My one and only Valentine. Yeah I see you folks all together all the time. I think you know at that age when John and I met I was a very independent woman you know. I can tell. Single mother very independent and what I really admired of this young man. I'm still gonna call him a young man even though next month is his birthday. He'll be 85. Wow. Next month. Sir John. Yes. Looking good. What really got me you know a young man from Kaua'i born and raised in Kaua'i. His mannerism. You know everywhere we would go he would open the door and close the door in a car or wherever it was. Gentleman. Yes very gentleman and he was very gentle. And I really admired that because you know us rough you know doing things out there. But he was the complete opposite and I think that that's what really attracted us you know. And until this day we still do things together. I mean believe me it's nobody can say they have a perfect marriage but we know how to work it out. If we're angry with each other we know how to work it out why we are angry with each other. We don't go to bed angry at each other or anything like that or the next morning we'll get up and look at each other and say gee what happened why were we angry. We don't even know we started laughing you know. Yes. But that's that's just how it is and communication. Our communication is always open.  It's like okay sit down talk to me you know what am I doing wrong. Or sit you know just things of that sort. Communication is very very important. You hit in some key points that you have mentioned of course communication is the big C. The big word if you don't communicate how do how do we come across our feelings and be able to resolve things really really important. And that's one of the key key points. Yes. In keeping a relationship as you had mentioned number two is a lot of us whole grudges. Some of us whole grudges for life. And we go to our final resting place without being able to resolve things. And then we have regrets. Yeah. Absolutely. So in your case to give the tips to never go to bed angry and have hold that hatred that is also another great tip in keeping a loving relationship. Wow. And you know us Amy we're aquariums so you know us we're going to say what we want to we don't you know it's like it is we say it like it is but it's okay at the next day we're fine. Yes. You know but if we have to say something we're going to say it. That is that is so awesome to hear because like you had mentioned and nobody has the perfect marriage. We all have our own challenges. Yes. Yeah. Now that my husband is older I have to repeat myself over and over because he is developing signs of aging cannot hear sometimes but I hate to repeat myself. How many times I've told you I already said that to you you know but but you still love him. I love him and I feel like the repetitious sometimes is needed to reiterate you know to retell not necessarily a bad thing but sometimes we like to hear it over and over especially the special words Sir John yeah which and which is appropriate. I love you very much. Tell that to Sister Nancy. She knows that. He's not afraid to. I am actually I'm actually shocked because you may not know it but John is a very private person very shy and when you asked us to do the show today I asked him and I thought he would say oh no I don't want to do it. He turned on he said sure. Wow. I can go on there and talk about us and our love and all of that because he knows I can count on him brother John yeah whenever you say you're coming you are coming and you deliver yeah and that's really really important to sis. I found out that if I say something and I don't act on it and I don't fulfill that promise it seems like I had broken the promise that I made so you can agree with me that it's important to keep our word which is our bond and brother Chief John is shaking his head agreeing that definitely that's our word is our bond we need to take that extra step to not just say it sis like talk is cheap right that's right yeah that's true but putting it into action is very very important especially in our line of business where people depend on us we have timelines that we have to develop and in order for us to go on with the show we got to keep it going absolutely keep our word yeah absolutely yes these are golden tips that we're hearing from Master John and of course my hermana sis Nancy my sister from another another mother we want to thank them for sharing their special love story especially for this valentine my one and only valentine we want to wish you all happy heart's day and keep that romance alive we will be right back here on Pinai Power Hawaii on Think Tech Hawaii hey loha my name is Andrew Lanning I'm the host of Security Matters Hawaii airing every Wednesday here on Think Tech Hawaii live from the studios I'll bring you guests I'll bring you information about the things in security that matter to keeping you safe your co-workers safe your family safe to keep our community safe we want to teach you about those things in our industry that you know may be a little outside of your experience so please join me because security matters aloha aloha I'm Yukari Kunisue the host of Konnichiwa Hawaii Japanese talk show on Think Tech Hawaii Konnichiwa Hawaii is all Japanese broadcast show and it's streamed live on Think Tech at 2 p.m. every other Monday thank you so much for watching our show we look forward to seeing you then I'm Yukari Kunisue mahalo welcome back to Pinai Power Hawaii here on Think Tech Hawaii we have the pleasure of coming to your home live every Tuesday at 12 noon I am your host Emi Ortega Anderson that's my Latin connection my dad is from Toledo Spain so I have I have a Spanish blood in me that's why I am so part so proud to feature my armada my sister Alma Latina producer that's Nancy Ortiz and of course us and master chief sir John Ortiz thank you again for the opportunity that you have given us thank you for saying yes sir it'll just like the bank that says yes all the time since we're on that topic are you a yes man is that one of the a secret also yes yes it is he's a yes man yeah he is to a certain extent okay yes the certain extent yeah but most of the time yeah it's Nancy's way but he got you first with that with that yes that green light or you wouldn't go yes that's right that's true that is so awesome it is so heartwarming to hear uh these love story that never need to be spoken at times sometimes just the locking of the eyes will tell you or the holding of the hands you know in secrecy like when you're in church perhaps or anywhere else do you know that he holds my hand all the time I think you've seen us walking together everywhere we go I mean he's always holding my hand so that's awesome now is that interdependency sis or it's just being comfortable yeah comfortable comfortable and in love in love also yeah okay so what are some of the things that you do that is not costly to share your special love give some pointers well always listen to what I tell you mm-hmm when she gotta say something you pay attention okay if you can help you do it if you cannot that's okay now in her case she don't drive okay so I made it about to myself I would take her any place you gotta go thank you for driving her here today that's anytime uh huh and this is has been like that for the whole time we've been together mm-hmm yeah and as far as opening and closing the door mm-hmm I learned it from my father mm-hmm he always did that for my mom so you saw it growing up yeah being a gentleman yeah yeah I thought you would say that you because you're a master chief in the military yeah part of your military training but it goes beyond that beyond that yeah and that's from your upbringing yeah uh happy for you to mention that it was seeing your idol your father uh doing that to your mama and therefore it's stuck yeah it stayed with me it's a way of being a gentleman and he's always told me and my brother mm-hmm you always respect a woman no matter how I am beyond her mm-hmm you keep your feelings inside mm-hmm and don't don't get verbal mm-hmm so I try to do that a lot sometimes you're gonna get carried away but for human every human but you know and I can see him looking down at hey bro you know but I've been very fortunate because I've had a very understanding parents both of them mm-hmm you know like when we were kids you know you smoke right so one day one of these young kids has met in my brother mm-hmm so he told my dad you know Benny smokes my dad said yeah what Benny smoked uh-huh so he told him he said good don't ask nobody for cigarettes anymore I'll buy you cigarettes for you oh so the kid didn't know what to do yeah that's awesome but it was it was wonderful because when he met me he was not smoking already mm-hmm and I never smoked so that was wonderful that is good yeah when you're willing to give up something for your loved ones uh that's the show of real intent and uh honest and of course genuine love which we're talking uh about today um you know one of the things I really want to his other many traits that I really like is that you know I have three children yes and of course their dad died when they were young but when he came into our lives they were teenagers and what a challenge yes a big challenge and he took that challenge and I mean it was like hey you know you're going to marry me then you're going to marry my kids too that's just the deal you know they're part of the pack exactly and you know they he talked with them and in fact that he asked them for besides asking me you know to get married to me he sat down he set them all down and said hey I'm going to marry your mom but I'm never going to be your dad you know yet your dad has gone you know has passed but I'm here to be your friend yes and it was like wow you know they couldn't believe it in fact my daughter had a little bit was a little bit apprehensive because she said this guy she was already 18 so she says this guy's a little bit too mannerly you know and he's and she's never I guess met someone like that so uh but now they all love him yes all three of them awesome our grandchildren you know they just it's great kids are good one of my grandchildren one of my grandsons who's on the main and now he says papa walks on water I said no he doesn't he doesn't do anything wrong and if I say something and I say oh I'm so angry today or whatever he's what did you do not what papa did never his fault it's mine you know John Moses who walks on water wow rather than John it sounds so awesome because in today's world uh fast-paced and sounds like seems like we're losing uh those family values exactly you know the things that you talked about that you learn from your mother and dad growing up we seem to be losing it because society uh doesn't really uh enforces the value of uh respect yeah which is really really important mutual respect which is needed in a relationship and uh you're agreeing sis and uh these key points or key elements are important to keep the relationship going yeah well I've always learned that respect is a two-way street I give you respect you give me respect yes and I've done that with our kids and I didn't tell today I'm not sorry I did because you know they can talk to me no matter what the subject and I listen and then if they want an opinion I will give it to them I will not force it on them say well this you got to do this no yes we're like the Brady Bunch because I have three children that are all here and he has three children that live in Texas and he has many grandchildren as well of parents but that's all we are we're you know we're the Brady Bunch we're together the perfect blended family we try and I like it when he said I want to be your friend and not impose or put on that uh military order like I'm going to be your dad from now on you give me the respect because what I see is what you do what I say is what you do yeah I think I'm more disciplined with my kids than he was uh because I have two boys and a girl and especially the boys he would say let them go they're boys uh what's their men now but I mean at that time you know he's just let him go you know I was more a little bit I tried to be a little bit more strict but it just didn't work you know sometimes I get one thing I want to see those children her kids it's never ever disrespecting me that's because you gave them respect right they don't call me dad they call me John and which I love that because that's their relationship and you know we can talk about anything I know the older son he's kind of hold back a little bit but we still can talk Wesley he's cool he's our youngest one and then well Gina well you know daughter's always special yeah mm-hmm yes and I thought I thought that you were the dad all this time just watching you folks from afar you know and that goes to show the true uh eternal love yes that you have for uh Nancy's children yeah and they know that I mean you know I never hold back they know that I don't have to tell them that I love they know that I love and that's the way it should be that's awesome uh I'm going to talk about a challenge in everybody's relationship which is do you ever fight over money because every now and then that gets in the way oh yeah you know I think it's more not fighting but more of a discussion discussion yeah because you know me Amy I'm I'm involved with a lot of projects yes that handle a lot of exactly and we have to sometimes use our own money to make those projects go forward and I've done that many many many times and um he does sometimes get upset about it but it's just for a little while you know he'll say something I told you not to do this not to do that and I don't say anything because I'm wrong and then later on he'll come and he'll say you know what babe it's okay I'll help you but let's try to make better decisions that is so awesome yes I get the same because he has to carry the difference and the load you know how it works is we don't have to go over the figures but he tells me oh just watch out a little bit on the extra spending this month because we need to make it we want to make sure that we're able to continue doing our mission without having to break the bank and and that is good that's good yeah yeah it's a healthy discussion because the reason I ask is that sometimes money matters cannot break the marriage because the two are not working together as a team if I may say because the marriage is a team you know you got to be considerate of each other's feeling and make sure that you don't make decision based on your own just because you want that Louis Vuitton bag you know I don't go buying that $5,000 bag I know sir John was gonna say okay honey you can buy it next month because we have a little bit more fun to do that to splurge but they just don't go out and and do it yeah yeah I still I still have to run the big purchases through my husband well I do too I you know and in due respect you know you have to run it yeah yeah uh huh so uh with the remaining minutes is uh what would you again advise to young couple or your children that's wanting to make it a marriage work uh commune like I said communication is one of the most main things and um always be loving do little things even if it's the littlest thing it means a lot um when John and I uh well when we first were married for several years every Friday he would bring me home a rose every Friday for a little bit until I told him you know what those roses get expensive you know but he still does for every occasion whatever it is you know he always does even if it's just a card um I know I used to always go and just little things you know um buy cards and leave it on his dresser drawer or something just you know I we always we always every single day we say to each other I love you and when he doesn't you know we're busy or doing something I'll say you know what you forgot to do he says no I didn't forget I love you awesome okay that brings our uh very special Valentine's Day edition my one and only love yes don't forget to express that genuine love not only in Valentine's but each and every day uh like uh Sister Nancy and Brother John said every little bit count but say it with love and uh with that I say mahalo mabuhay maraming salamat and we love you all thank you again mabuhay


Good morning everybody. Happy Monday. It is July 10th and hopefully everybody had a good weekend Wanted to give a quick market update. And so this is the SMP over a three-month daily chart and You can see that the there's a general weakness that has come in right after this high and you can see the money flow also coming down and Today has been a very sort of a flat-ish start But it remains to be seen. This was a little bit of a support area This was a strong support point. So I think the level to watch out would definitely be the 24 100 level on the ES which is the SMP futures the SPX will be about just a couple of points more three points more at this time and it is Probably going to I feel like because even the moving average is showing it's a five-day and a 15-day The five day is below obviously the 15 day and so General sentiment remains a little bearish. I think the The one to watch out for is the oil last week Of course, it was all about the G20 and you can see there was quite a bit of volatility Even the weeks was up and down quite a bit last week Now today the mix is starting out at about eleven point three but oil was down in the forty three handle this morning and Perhaps that's going to drive the markets There's some chatter around What oil is going to be doing and therefore the overall markets might also follow that now the what I want to do also show is Tesla seems like it's breaking down It's down to 304 309 or 3010 or 310 was a minor support level, but it's being but it's breaking down Price line made a very very good move up last week. You can see it's crossed the 1900 of course, generally today all stocks are a little bit weak and Google and Amazon also can watch Google has been in the bearish territory because of the EU lawsuit, you know big big number they had to they have to pay like three billion dollars almost so anyway So the thing to watch out for or our oil watch out for Tesla might break down and the next support level is I believe around 290 we can take a look Tesla is interesting can see it's like really really taking up cracking here and Everything is looking pretty pretty bearish. So this was very bearish move right from here Even this it didn't look like very much of buying there obviously a little bit of support came in but That is not going to hold. I think mostly it's selling because you can see today. It's taking a real beating So Tesla is in a bearish mode. It will At the 290 level it does have some support here. Yes There was there's a little bit of support at 300 not a whole lot You can see it's not a big support point, but this one definitely is at this time at least It's looking bearish. So all these market updates now are going to be put under the hashtag inside options. So Inside options is our hashtag that we are Adopting at option tiger. So on Twitter Facebook YouTube, you'll see inside options everywhere hashtag inside options You can search for it and you'll find market update videos as well as other commentary under inside options Look forward to catching up again. Can take a look at the options insider page and also July 4th Sale especially on Udemy is going on right now. So please feel free to take advantage If you have any questions, you can send us an email at info at option tiger. Thank you


T. F. N. N. Headline news update. Good afternoon, folks. Steve Rhodes coming to you live from the shores of still sunny Delray Beach, Florida. This year, 2 p.m. update and currently have all the U.S. indices, all the sectors with inside the S&P 500 trading to the upside. The Dow is up about seven tenths were set 228 points, one and a quarter percent for the S&P 54 points, one and nine tenths for the Nasdaq 100, a 282 point move. They're one and a half percent for the Russell, 26 points, two and seven tenths for the semis. That's a 94 point move, one percent for the Trannys, 151. Gold is up 18 bucks, nearly one percent, a little over two percent for Silver. That's 51 pennies, lights recruit, trading out at 81.20, up $1.10, one and three tenths percent. Natural gas pack, three pennies and a 30-year treasury, a one full point and seven ticks, trading out at 1.2105. Let's take a look at what all that means by looking at that nine panel market update chart. We begin with the ES mini, upper left-hand side. What do we know? Well, we know that one of the resistance levels is where price is likely headed to. That first resistance level is going to be the top of its daily profile. 45.06 is what I would call it. If you see a close above that, odds favorite, a move back to its high, its Rhodes-Micton indicator top at the 46, 21.75 level. Now, Spot Ballotinix is below its 50-day exponential moving average. Close below it yesterday, below it today. Odds would favor that this is going to go target a slower Bollinger band. That's at the 13.40 area. If it does that, Spot Ballotinix, we will see the ES mini take out that resistance level. The NQ right now is trading above the top of its daily profile. It doesn't matter what it's doing at 2.01. It matters what it's doing at five o'clock this evening. Does price close above the top of that profile at 15.359? If it does, that suggests move to 16.062. U.S. dollar index is attempting to form a new daily profile. That new daily profile is bearish in structure. Now, I won't have a confirmation on this profile until later on this evening. The U.S. dollar index has tried forming new daily profiles for the last several days out there. Right now, support is at 10307. If this profile goes away, the number you're watching, because I'll be gone for the next couple of weeks, the number to be watching the U.S. dollar index will be 10298. A counter trend move. So if this new profile doesn't form, then it's the old profile. And so a counter trend move to the downside in the U.S. dollar would find support at that 10298 level. So it's either 10298 or 10307. Gold trading above resistance at the top of its profile at 1953. Silver looks like wants to get back to its highs from back in the July time frame. Folks, stay tuned for the Trader Zed Show. But if you have to start your day, have a terrific one. We'll look forward to speaking with you again soon.