One of the things that happen, one of the toxicities of modern civilization, is kids have lost contact with their parents. Because kids were meant to be on their parents, evolutionary point of view, till they grow up. In the United States, 25% of women have to go back to work within two weeks to giving birth. For economic reasons. Now that's a massive abandonment of children. Most children from an early age on spend most of their time around other kids.  So when you're under the kids all the time, your brain creates the peer relationships as your primary attachment. Which immediately alienates you from your parent. And now you give these kids this technology, that even when they go home, they can still be with their peers. On Facebook or whatever programs are available. Because kids need to attach to connect with somebody. And because the adult world no longer provides children with those healthy stable attachments in many cases. Kids look to each other. And the technology simply enables that to happen in a highly addictive and pernicious fashion. Not to mention that the technology itself is designed to make people addicted to itself. It's called neuro marketing. They know how to appeal to the most addiction-grown circuits of your brain. This is not conspiracy theory. This is conspiracy reality. It's been documented. So there's all kinds of reasons why the technology is amazing as it is. And it allows conversations like this one. And it used to be called the information highway. It was designed for mature adults to exchange scientific intellectual information. But it's what's really become is an instrument of mass hypnosis. Immature people connecting with each other because they've lost their relationship to mature adults. So it's pernicious. And along with that comes the attention that they get from their peers, right? If their parents are absent or the kin work has been offloaded onto strangers, childcare, babysitters. Then these children are going to crave that attention from somewhere and social media very quickly provides it. Absolutely. And if you look at, how shall I say this? I read one half year ago about some social media celebrity who farts into a bottle and then sells it. What the heck is that? I mean, it's about the humor of a two-year-old. You know, the people are actually paying money for this. So what do you get famous for? You get famous for farting into a bottle for God's sakes. You know, or there are kids on TikTok who, as far as I know, have billions of followers and made, you know, more money in a month than I might in a 10 lifetimes.  For advertising a certain toy. You know, right? So I'm not saying this resentfully. I'm just saying, is that the values we want to inculcate in our kids?


Coming up on this edition of Abledon Arnair. Senator Anne Watson, what is her position on the environment and people with special needs? This actually is part two because we've done part one before here on Abledon Arnair. All that and much more when Abledon Arnair starts right now. Major sponsors for Abledon Arnair include Washington County Metal Health, where hope and support come together. Media sponsors for Abledon Arnair include Park Chester Times, Muslim Community Report, WWW, this is the Bronx dot info, Associated Press Media Editors, New York Power Online Newspaper, U.S. Press Corps Domestic and International, Anchor FM, and Spotify. Partners for Abledon Arnair include Yachad of New York and New England, where everyone belongs, the Orthodox Union, the Division for the Blind and Visually Impaired of Vermont, the Vermont Association for the Blind and Visually Impaired, Center Vermont Habitat for Humanity, Montefiore Medical Center of the Bronx, Rose of Kennedy Center of Bronx, New York, Albert Einstein College of Medicine of the Bronx, Abledon Arnair has been seen in the following publications, Park Chester Times, WWW, this is the Bronx dot com, New York Power Online Newspaper, Muslim Community Report, WWW dot H dot com, and the Montpelier Bridge. Abledon Arnair is part of the following organizations, the National Academy of Television Arts and Sciences, Boston, New England Chapter, and the Society of Professional Journalists. Welcome to the tradition of Abledon Arnair, the one and only program that focuses on the needs, concerns, and achievements of the Divinity Abel. I've always been your host, Lawrence Seiler, Arlene is not here today, but let's talk about our guest. Anne Watson was born in Vermont, in Burlington, Vermont and grew up in Essex. She received her Bachelor's of Science degree in Physics with a minor in Mathematics from Penn State University. Her graduate degree is from the University of Vermont and is in Secondary Education and has been a science and math teacher since 2004. She's an ultimate Frisbee coach and has served on the Vermont Youth Ultimate League. She was appointed to the Montpelier City Council in 2012 and represented District 2 and has maintained that seat for three elections. She was elected Mayor of Montpelier in 2018 and again in 2020 and 2022 and enjoys ultimate Frisbee crocheting, spending time with her family in Montpelier. She lives in Montpelier with her husband and son and she's been a member of the Senate of 2023 to the President. Thank you Senator Anne Watson for joining me on this edition of Able Down On It. Well, thank you so much. Okay, so let's talk about the environment and how that plays into helping people with disabilities or special needs or, you know, what is your take on how the environment deals with people with disabilities? Oh, yeah, for sure. Well, thank you so much for asking that question. I think that's a topic that doesn't get a lot of airtime necessarily or enough airtime. So I'm delighted to be talking about it. So one of the things that I think is really important to note is that particularly around, you know, climate change or other environmental issues around like toxicity in our environment, for example, that can end up affecting more vulnerable people a lot more. The elderly and... Yes, yes, absolutely.  And so we expect to see more very hot days as the climate warms and that is going to be really important for people that are especially elderly or who, you know, may not have as great mobility to be able to have access to cool spaces. You mean like cool... Because New York... Excuse me, I know that New York and other big cities have cooling centers. Is that what you're talking about? Exactly. Now, in Vermont, we may be more familiar with the idea of warming shelters, you know, places for people to get out of the cold, especially at night. But cooling shelters are going to be increasingly important as the climate warms. And of course, we're going to do our best to reduce our carbon emissions and other greenhouse gases so that we can at least do our part in reducing the driving factors of climate change. But we know it's likely to get hotter in the trajectory that we're on. Yeah, I remember just to reiterate what you said, I remember when we first got to Vermont, when my wife and I first got to Vermont in 2015, it was 75-80 degrees on Christmas. Yeah, yeah. Right, like there's trends are changing. How does that play into... So the warmer the weather is, the worse the climate becomes? Well, I guess I would say it's the other way around. One of the effects of climate change is that patterns that were stable are becoming less stable and extremes become more extreme, right? So the the hots become hotter, the colds become colder. And I would actually, I would add that storms are likely to be more, they're likely to be stronger. So we might get more instances of extreme precipitation like we saw this past summer. And but we're also likely to see more droughts as well. So all of the extremes kind of become exaggerated. And again... Because that has to do with the, because in terms of what you mentioned climate and like rocks erode and like if someone lives, I'm just your example, someone lives in, say, Hawaii. And they live in a seaside community. The tide comes in, they can ruin their house. All of that, it can erode things, flooding, this big flood that we had. Absolutely. Well, and I mean, what was tough about that was the ground was already pretty saturated from prior rain and then adding an incredible volume of water on top of that and Barry experienced something like 200 relatively some small, some not so small landslides. What is a define?  So can you define what a landslide is? Sure. Well, so I think you could say that normally roots of plants or trees are generally holding a lot of the dirt together. But if the ground is steep enough and saturated enough with water, it may actually become more than what the roots that are there can hold in place. And so because of the gravity and all the weight, because of the water in the soil, it comes loose and then slides down the slope. And a lot of things can play. Well, okay, we mentioned landslides and stuff.  When it gets overly cold. I remember one Christmas, we couldn't walk around Montpelier. There was a sheet of ice. Oh, yeah. Well, and that's more likely to happen as well. And I know also significantly affects people with disabilities. You know, again, in terms of like getting around. And one of the things that we saw last winter was... Was that last winter? I forget. Was that last winter or the winter before? You know, I don't recall the instance that we're referring to. But last... You weren't talking about this. I do, yeah. It might have been last winter actually now that I'm thinking about it. But, yeah, last winter we saw a lot of instances where there was a significant amount of very wet, heavy snow that caused a lot of outages, power outages around the state. But, I mean, one of the other effects of that is that you might get a lot of ice forming. And that is... It's just, it's really hard to move around when you've got a lot of ice. Especially for wheelchairs and other people that have kids. Now, the pandemic saw things in the environment that... When you're dealing with lack of hospital... I'm going to bring this up. Lack of hospital beds. Lack of medical care. I know we had to, we had... When Obama had Obamacare. But then when you... How does lack of medical care play into the environment when it comes to, you know, people got sick. People, you know, that kind of thing. Yeah, I do want to highlight that the Affordable Care Act still exists. Oh, it does. Okay, does it? Okay, go ahead. But it's a great question though about the interplay between climate change and the medical community. I hope we don't mind.  Oh, no, not at all. I think it's totally relevant and important. One of the things that, again, I think goes under the radar that people may not think about is the effect that climate change has particularly on folks with asthma. So, you know, particularly with, you know, increased particulate matter or increased pollen levels, that can... Because it goes back to physics also. When you ruin...  Yeah, and so, I mean, we anticipate, you know, that there is going to be more demand for medical services as a result of climate change. And that's something that we need to... Do we need to plan for? And it actually might be worth mentioning. So we have this legislative session coming up here starting in January. And one of the bills that I'm really excited to work on is I would call it a climate superfund. So there's this... Are you familiar with the idea of a superfund site? Not exactly, but... Okay, so the general premise of a superfund is that a company may have polluted an area and through that pollution caused damage to a community. And they have to give... They have to give restitution.  They have to pay for the... Fixing the damage that they caused, if that makes sense. Example... Well, oil... If oil spills into the ocean, a company has to...  So if there was a lot of oil or some other toxin that was dumped into a piece of land, it might become a superfund site. Speaking of which, I'm going to mention this. When we have the big flood... Yes. Correct me if I'm wrong. Okay. I understand that... Because sludge of sewage... Yes. That's a correct me if I'm wrong. Okay. Just excrement from people's toilets and sewage and sludge. Left an awful smell. And then I heard also... Correct me if I'm wrong. One of the gas stations petroleum... Was it a truck that was in... One of the bodies of water? I have not heard that, but that would not surprise me. Okay. I'm sorry if I... No, you're fine. But how does that when sewage back up? Yeah, that's a good question. I think the difference between what that is and what I'm talking about with a superfund site is that it has to be really clearly attributable to either one or a certain number of specific entities. It's got to be clearly linked to some business that happened, if that makes sense. Like the Exxon problem that was used... Sure. Yeah. So they would give money if Exxon or gas station or gas company was in play and oil spill, they would give money to fix that. Right. Yeah. As an example, right? And so the idea that... The bill that I'm going to be working on is creating what we would call like a climate superfund, which is to say that our community is experiencing damage because of carbon pollution in the atmosphere. And people may not think about what's in our air as being polluted, but really like we are out of balance because of the amount of carbon in our atmosphere right now, that is a pollution and it is genuinely causing damage through climate change. So the goal would be to say, we can measure how much worse storms are now as a result of climate change and that differential, and particularly the damage that caused, that differential caused is directly attributable to companies that sold us the petroleum or the fossil fuels in the first place. And so the goal is to say, you are responsible for this damage and therefore oil companies or fossil fuel companies you need to pay a certain percentage of the damage that we are experiencing. Is this millions of dollars? We're talking about hundreds of millions of dollars. Sure it is probably. So the goal of what we're talking about right now is 100 million dollars a year for the next 25 years. But how does that... So it's like 2.5 billion. 2.5 billion. But that's just from some preliminary estimates and we'll need to dig deeper into the amount of damage that Vermont has experienced. And... Is there any particular... I hate putting blame, it's not good to put blame on people. But are we all... If this was a trial, let's say, are we all at fault for messing up the climate? Well, I think we would say, particularly with the model from Superfund sites, it is whoever has sold the product into the state. Like as it turns out, Vermont doesn't have any naturally occurring fossil fuels here. So it is whoever has imported it. Now to be fair, we need to all be doing our part to curb the carbon emissions that we are personally responsible for, burning in our cars or houses or whatnot. And that's also really important. So we're getting into winter. And I know that... I'm going to mention Economic Services. They're a wonderful organization for people who need it. They have something called... This is a national thing, probably international at some point. It's called HEAP. Heating something... Is it LIHEAP, Low Income Home Energy Assistance Program? Yes. Yeah. That's a great program. Great program. Okay, so you mentioned... Okay, so when a person, let's say, needs pellets for their... Is that a natural fuel? That's a great question. Or anything of that nature? Yeah, so I would certainly say that generally speaking, from a climate perspective, pellets and wood products used for heating in your home is better than fossil fuels. I mean, it's not ideal because we're still burning something. But because it's a woody product, that means that it is a part of what we would call the short carbon cycle as opposed to the long carbon cycle. People may not think about this very much, but all the fossil fuels, like the gasoline we put in our cars or... By the way, for those that want to know, HEAP stands for Home Energy Assistance Program. Yes, yes. All of that material was once probably a plant. It was probably an algae that was growing in some lake or ocean somewhere, and all of that decayed and condensed into what we now know as fossil fuels. But it was a plant millions of years ago. So the long carbon cycle was millions of years, and the... So the carbon that is locked up in that material was in the atmosphere millions of years ago. The carbon that is in the woody biomass that we would burn as pellets or as cordwood, that was in the atmosphere on the scale of 40 to 100 years ago. So speaking of... Something that's natural for the environment is better to burn for fuel than something that's not natural. Coming to this, we're coming into the electric car age, or we're already there. There's not enough electric charging stations. We're working on that. We're working on that. They even have contacted some organizations. They even have a car that drives itself for the blind and visually impaired. Oh, yes, yeah. They're working on that cycle pilot program. But what is your take on... Well, bicycling is important. Yes. Exercising is important. But what is your take on the electric car industry versus gas? Are we going to stop gas? Example... New York. And I bring them up. They are stopping gas stoves in some places and going electric. Yeah. So induction heat, some people like cooking on gas because it's faster. But what is your take on first the electric car industry versus gas, and then changing from gas to electric when it comes to cooking and other... That is a great question. Oh my gosh, there's so much to say about both of those things. We can keep going. Well, so... I want to do... We'll do more segments on climate change. Okay. Fair enough. So one of the things I think is important for folks to know is that Vermont recently passed or I should say adopted the clean cars and trucks rule that start in California. It's California's rule. California kind of dominates the auto industry in the United States. So we had the option to adopt what California has done. We've done that. And what that means is that by 2035 all of the cars and light duty trucks in the United States... What does it mean by light duty trucks? I'm not sure that I have a technical definition for that. That's a great question. Oh, you mean smaller trucks? Yes. As opposed to dump trucks. No, I'm talking about moving trucks. Right, I don't think that is included. But I don't know that. But that's a great question. In any case, all of those vehicles will need to be electric by 2035 and an increasing percentage of them has to have to be electric as we get closer to 2035. The demand for electric vehicle charging stations is only going to go up. Is it going to be cheaper for people for electric charging stations versus gas? I think that is going to be the trend over time, yes. And to be fair, it is already cheaper to operate electric vehicles than to operate fossil fuel based vehicles because electricity... Gas has gone up too. Yeah, well, and it's likely to continue there. There you go. Well, electric vehicles are much cheaper to drive per mile than the fossil fuel equivalent. Some people call them ICE cars, internal combustion engine cars. And I think this change to electric vehicles is the right move for a lot of reasons. One of the reasons... That we're actually going into more electric before you continue. The more electric vehicles you might have, the less likely because there's been car fires on the road. Sure. People's cars blow up in the wrong places. So the less likely of that, I guess. Yes. I don't have statistics on that, but there is certainly a lot less maintenance that's needed for an electric car. And you don't have the tank of fuel that is at risk of catching on fire. That's not to say that there is a risk with batteries, for sure. Oh, since you said batteries and we're talking about people with disabilities too, sometimes if you charge... I know when I've gone into an airport and I bring my computer along, they check what kind of battery you have so it doesn't blow up or break or whatever. And sometimes you're not allowed to bring certain types of batteries. Has Vermont adopted a rule with batteries and recycling because I know that we recycle in Vermont. We do have rules about battery disposal. That's true. And I think there's an opportunity to recycle them, but I don't know as much about that as I would like to know. So I have some learning to do around that. But getting back to the electric vehicles, one of the significant advantages of electric vehicles is that in an ICE car, an internal combustion engine car for all of the energy that you put in the tank, 80% of that energy is lost through inefficiencies in the engine and in the... basically like heating it up. It's kind of like an internal combustion engine car is like a little heater that also generates a little bit of motion. So it's very inefficient as far as the use of that energy. And electric vehicles is almost the reverse. It's going to be more on the scale of 80% efficient. So 80% of the electricity that you put into the vehicle is going to be useful in terms of the motion of the car as opposed to heating it up. And so just as far as like the use of energy resources that we have, electric vehicles are already significantly better. And because of mass production the embodied energy of the batteries has gotten a lot better. And so on the whole it is a really good thing that we're switching. So would you say it's more lighter on the wallet having an electric car than having a car with gas? Yeah. And one of the barriers is that the upfront costs for electric vehicles can be a little bit more than the upfront costs for an internal combustion engine car. But that's getting better. It's coming down, it's getting cheaper.  That's what I'm saying. Which brings me to more energy questions. Sure. We have this heat program and people that are low income that are in their homes there's been problems with it's called a space heater. Sure. You know what I mean? It's a small heater boat big. It does not have rules when it comes to that as far as what kind of heater a person can have in their homes. That's a good question. I don't know what rules people have around space heaters particularly, but it may be good to know that heating your home with a space heater is a very expensive way. And dangerous sometimes. I think it is probably dangerous to heat with space heaters. If you're going to use electricity in the efforts to heat your home an electric air source heat pump or ground source heat pump is again significantly more efficient. Not just more efficient than an electric space heater, but it's also more efficient than heating with fuel oil. And cheaper per it's also cheaper per unit of heat to heat with the heat pump. People have to pay the electric bill. I'm assuming, especially in Vermont power bills go up more in the wintertime because people are home more than Sure, well it depends on what we're talking about in terms of power. I mean a lot of times people will use air conditioners in the summertime and that can be a big draw on their electric bill. If people are heating with oil then their electric bill may not be so much in the winter, but it may be more in terms of paying their heating bill for fuel oil or propane for example. But if they're using space heaters or just like electric baseboard then yes, that would be huge. What's a baseboard? Yeah, so it's just like a distribution method for heat in your house where there might be a device at the floor level that gets hot when it's on and you might not see it, but there's infrastructure behind there's like a metal front to it that radiates heat into the room. So let's go back in the beginning we mentioned about the cooling centers. Sure, well to be fair we didn't actually talk about I'm sorry, I'm sorry. No it's okay, we didn't actually get to talk about cooking. Yes, go ahead. Yeah, no fair enough. So we don't have any laws that I know of anyway about cooking with fossil fuels but you know honestly I think if we have a method that is just as good for cooking then I think we should move away from fossil fuel based cooking. Regular electric ranges or induction stoves are great and people love their induction stoves I've heard. I mean to be fair I know that for commercial kitchens it's really useful to have propane or gas stoves and you know maybe there's maybe that needs to continue in some way but I would love to see us in general as a society move away from using fossil fuels for cooking. Just cook over an open fire. That's like the least efficient way. Why? Why is it the least efficient? Oh gosh because the heat just goes out in all directions and a very low percentage of that actually makes it into the food that you're hoping to heat up but anyways that's yeah. No but so let's go into you said cooling centers and then also in the winter for example the homeless population of Vermont you know they use churches as warming centers is that do you know if that's going to continue do you know because there's been I don't know if there's been problems in the past with getting churches on board but what's you know keeping people from temperatures can be environmental problems when you're done with frostbite and other cold issues. Oh for sure so I don't know whether I know there has been a church in Montpelier that has had a warming shelter in the basement in the past I don't know if that is continuing for this next season. The flood some churches have just continued so I don't know but I do know that there is a state program to help keep people housed during the cold months. Economic services yeah what they do is they give people vouchers for like 30 days for 28 days normal but well everybody's normal but 28 days on a normal circumstance but then if you're challenged or disabled in some way they'll give you an extra month to do what you don't give you an extra month in a voucher to get what you need as far as housing. No for sure environmental in terms of has the homeless population increased in Vermont and is there is there I know there's more housing going to happen but is there still a lack of housing in Vermont and I know that plays into environment. Oh for sure well so I don't have statistics about I'm sorry no no you're fine I don't have specific statistics about the amount of homelessness but my understanding is that it has increased and it is certainly not helped by the significant lack of housing that we have in Vermont right now we are lacking housing available at basically all income levels and that is it's been really hard to help move people from the hotel motel program out into during the pandemic that well they stopped they had a federal funds in during the pandemic go ahead. Yeah well so just to finish that thought right like so Vermont was paying motels for rooms for folks experiencing homelessness to stay there and they even actually bought some motels to convert permanently into temporary housing for folks and I think the hope is that we may do some more of that but that that is not going to be the probably the best long-term solution and one of the things that I anticipate we will work a lot on this coming session is issues of homelessness and of housing both. How so if we go over it's okay because we can split it up. Sure well my understanding is that advocates for homeless folks have a have had proposals and plans for what we could do to help reduce the rate of homelessness in Vermont and so I haven't seen those plans but my hope is that the session will be taking those plans seriously and seeing if we can put some money and energy towards doing those things and then I think the other the other piece about housing in general is that like so we have something called Act 250 in Vermont What exactly is that again? So it is a law that gets triggered by developments of a certain size or type and so it's if you have a certain size or type of development you have to basically prove that you are not I'm speaking generally here but it basically means that you're not adversely affecting the environment and so it's a lot of checks and that has put I mean on the one hand it has done I think some really good things in terms of protecting our environment but it has also simultaneously reduced the amount of housing that might have been built in Vermont and so this is it's a tough line to walk right like we want to do right by our environment but we also need to do right by people and have sufficient housing and so I think we are going to be looking at a bill this session that is going to tune some of those requirements for Act 250 that hopefully will allow us to both continue to protect the environment and prevent forest fragmentation but ideally and this is what I'm hoping for allows easier construction in areas that are already impacted like in our you know village centers or downtowns or in that general periphery quick well of course you know we might go over what in terms of now I know food insecurity or lack of food or ways to get food can be part of the environment can you talk a little bit about that yeah well we certainly saw especially during the pandemic when there was a lot of food drop off points there was a significant demand there is a significant demand food pantries were kind of low yeah right so we know food insecurity is a real factor in Vermont and we I think it's something that we need to be paying more attention to in general and you know I mean on the one hand so the we are certainly dependent on food from out of state and support from out of state you know we have this the federal farm bill that ultimately provides food through services like WIC what is WIC again I should know that better than I do but it's one of the services that ends up providing food for particularly like women and children WIC is a special supplemental nutrition program for women and WIC is the USDA special supplemental nutrition program for women and infants and children WIC provides food benefits nutrition education breastfeeding support yes so hugely important for Vermont and with the potential at the time that we're taping this there may be a federal shutdown but the temporary extension with the farm bill did pass and so basically the WIC program was extended so it's not changing to my understanding if it's a federal if it's a government shutdown let's say things like WIC things like social security people get SSDI SSI they stay and you get your government check they don't cut your government checks or you know that kind of yeah so I think it's also important that we are able increase talking about the support we get from out of state I do think it is important that we have WIC is a federal thing right? yes yes but so I think it's important that we are also supporting our in-state producers of food we had a lot of crop loss in the well in the flood but also in the freeze that happened in May of this year and so you know as much as we can be supporting our local farmers and producers of food as much as we can we need to be supporting them as well so both of those especially like our local food is more resilient food it's easier to it's less in terms of transportation access to it in that sense and so we need to be continuing to support our agriculture in Vermont okay so three or four more main questions before we end drugs okay recently there was a situation in Burlington I don't know if you saw on WCAX but a Burlington church had to stop homeless people from sleeping on their church grounds because they were finding they were finding needles and drug paraphernalia on the church steps I know Vermont has a clean needle program they have methadone clinics what is your take on what acts in the Senate have you been participating in when it comes to drug enforcement drug help I know that they have clean needle programs in the past if you want to speak a little bit on that sure well I think one of the most important things that we can do is it's part of the environment when you leave a needle sure yeah no absolutely with green up day you have to give special instructions to people in case they find needles because you're not supposed to be picking them up I know back in the 80s crack vials were on the streets yeah yeah well so I think the biggest thing that we can do to help with the drug epidemic is actually have better support services for people for themselves falling into these these traps where drugs are what they're turning to in terms of having better mental health support as well as yeah I think mental health in general is underappreciated and still has stigma around it since you said that mental health played into the environment mental health certainly with mental health we've got people that are that end up turning to drugs there can be a lot of pressures around that as well including relationship trouble as well including financial trouble can all be factors in those things so many other pieces as well I actually happen to know that particularly with the stress around the environment with climate change that can be a stressor for people as well and that can also play into people's mental well well-being I'll better go too much on the tangent no it's fine so really I think one we need to be treating people that have drug addictions as it's a drug use disorder we need to be treating them as people who need care and support even though we have Washington County I hope there's so many other services you find that there's still a lack of mental health services in Vermont for sure there definitely needs to be more funding and staffing as well that's a huge need so my hope especially in terms of addressing drug addiction is really to have better support in general it's so scary it's terrible and I think if anyone is struggling with drug addiction they ought to reach out to somebody that they trust and get the help because help is out there okay is there anything that we didn't touch on that's important well there's a lot of things we didn't talk about that I think are important but I'm glad that we got to talk about homelessness and housing and the environment those are all going to be issues that I think we're going to come up during this next legislative session okay well we would like to thank Senator Anne Watson for joining us on this edition of Ableton on Air and we will definitely have her back for other shows with climate change but really quick where can people reach you if they need to and what is the contact through your office yeah that's a great question the absolute best way to get in touch with me is by email and that my email address is available on the states website in case that's in case you forget anything else like you can find it through the states website but it is a Watson at allege.state.vt.us okay and with that so what particular issue would you like to we can go over a little bit oh gosh go ahead oh sure so we've been talking a lot about energy and the environment just to extend that a little bit one of the other pieces of legislation that I think we're going to be working on that I've been working on here in the off session is around where we get electricity from on the one hand it's great to have electric vehicles they are more efficient that alone is a positive that is a good thing but where our electricity comes from also matters in that conversation and so one of the things that I've been working on in the off session is to is really about making our electric grid cleaner what is an electric grid for those that don't know oh that's a great question so like the electric power lines that you see outside your house that is a part of it those I would call those distribution lines they're getting electricity to your house but you might also see like big power lines that are cutting over mountains along the highway like that kind of thing I would think of those more as like transmission lines that are trans that is how we get electricity from power plants to the more local distribution lines that are shorter and you might see in your neighborhood so I would refer to all of that as the electric grid it's the way we connect electric producing places to electric using places okay well so we might as well go over solar power is a big big issue what how does it well people with special needs might not know what solar power is I know when I was a kid I had a solar powered calculator oh nice but what is solar power and how is it cheaper in terms of your house and how does it work and how is it working in Vermont that is a great question so I mean I could go into like some really nerdy places on that go ahead because of my background in physics but yeah well okay we might as well we might as well talk about it we can go to the second part yeah right so we've got some materials including silicon that when a photon, a little chunk of light hits it the response of that material is to release an electron and so what a solar panel is is that it's got a lot of this material and as light hits it it's producing all these electrons and you put a little bit of a voltage across that and that little bit of voltage directs the electrons in general to all move in the same direction in that in a way and so they because of that small electric voltage they all travel together and so that creates a current and so that is what generates the electricity from like a solar panel and so that ends up like if people have solar panels on their homes it's got to go through an inverter to have it be able to connect to no it's fine it converts DC electricity I should say an inverter it connects DC electricity to or direct current to alternating current since you said that we're talking about AC DC current when Thomas when Edison we're talking about science when Edison and Tesla were having that battle AC and DC current and the light bulb was created energy efficiency I'm getting somewhere energy efficiency is there rules around Vermont when it comes to lighting your home with certain light bulbs well so Vermont is actually phasing out a certain kind of compact fluorescent bulb and the reason is because fluorescent bulb is what what exactly is that well so you can so a fluorescent bulb in general has a tube that has a gas inside of it and I'm not sure I could tell you exactly what that gas is but by putting a voltage across that gas it excites the atoms of that gas and then unexcites them when the voltage goes away and so in unexciting it releases a photon so we see that as light fluorescent bulbs they're actually turning on and off so quickly that our eyes can't perceive it and so a compact fluorescent bulb just takes that tube and winds it up so that it is the size of a regular like the light bulb shape that we sort of think of as being normal for light bulbs but it turns out that those tubes have a little bit of mercury in them and if you were to break one that would be really bad so as speaking about mercury we mentioned it years ago photographers the chemical that was used in dark rooms they kind of phased out bad chemicals with certain types of jobs environmental stuff mercury was one of them you know you can get extremely sick by exposure to mercury and other types of chemicals when it comes to heavy metals heavy metals and what so what is Vermont doing with that well so my understanding is that those not mercury itself but I'm talking about like those bulbs so I think I saw recently about a certain kind of bulb is just no longer going to be allowed to be sold in Vermont and I think that's probably a really good thing anything else that we didn't touch on of course there are so many things Larry we can save them for another time no problem I hope this wasn't oh no great okay well again we would like to thank you for joining us on this edition of able then on air and for more information what is your email again it's awatson at ledge.state.vt.us okay and we would like to thank Senator Anne Watson for joining us on this edition of able then on air I'm Lauren Seiler see you next time on the next climate change edition of able then on air major sponsors for able then on air include washington county metal health where hope and support come together media sponsors for able then on air include park chester times muslim community report www this is the bronx.info associated press media editors new york parrot newspaper us press corps domestic and international anchor fm and spotify partners for able then on air include new york and new england where everyone belongs the orthodox union the division for the blind and visually impaired of vermont the vermont association for the blind and visually impaired central vermont habitat for humanity montefere medical 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So, today it's a double on neuro-ophthalmology.  But I'm going to first start with the typical case of a 28-year-old woman who has headaches. They're increasing. They're daily, and they're disabling. And she also has transient visual obscurations. She hears noises or whooshing noises in her head, and she has pain between her shoulder blades. She has good acuity, no afferent defect, her neurologic examination is normal, and her general examination is notable for her obesity. Her visual fields show enlarged blind spots and also some nasal loss. And when you look in the back of her eye, she has bilateral papillodema. So you're thinking she's got some kind of intracranial hypertension. And the first point I want to make is that whenever we see one of these patients, well, you know, she's obese and she looks like she fits the stereotype, we want to be thinking about secondary causes of intracranial hypertension as well as primary causes. Today we're going to talk about primary causes, but it's really important to rule out venous sinus obstruction, look at medical conditions, and consider medications that she could be on like the tetracycline, minocycline, norplant, and so forth. But she had a normal MRI scan, except that there are a few findings, and I tell the residents to always look for dilated optic nurseries on the MRI scan. You may even see the papilla bulging into the globe. You also want to look at a sagittal view because an empty cell is frequently seen. And with many of these cases, we're getting venograms, MR-venograms, which can be done exactly at the same time as the MRI. And one of the findings that is seen sometimes in the venogram is some irregularity of the transverse sinuses, and some people feel like that narrowing of the transverse sinus can actually be a sign of increased intracranial pressure. You can't stop just with the scan.  And her opening pressure was 350, and she had normal protein glucose in cells. So this woman meets the criteria for idiopathic intracranial hypertension. Her symptoms are only those of increased intracranial pressure. Her signs are only those of increased intracranial pressure. You can sometimes see a six-nerve palsy, rarely a seventh-nerve palsy, and sometimes you can see some trigeminal abnormalities. You have to have a documented elevated intracranial pressure, and this is really important. You have to ask how was that pressure obtained? Was the person lying on their side with their legs outstretched or could have been falsely elevated? And that's going to be important when we talk about idiopathic intracranial hypertension without papillodema. The CSF must be normal. If it's not normal, then you've got some other process going on, and you really have to look carefully for other causes on imaging for intracranial hypertension. So what is IIH? As you know, this disorder has undergone a metamorphosis of terms that used to be called meningitis serosa, then it was pseudotumorcerabri, and then it was benign intracranial hypertension, and we're settling on, at the moment, idiopathic intracranial hypertension or primary intracranial hypertension. It really is a disorder of women, six to one. No question about it. About 90% of the people who have this have headaches, about 50% have some kind of visual disturbance or auditory disturbance, and if you ask about wishing, and if you really ask the question, that percentage will go up. Papillodema is almost universal, although there are some cases that don't have papillodema, and it's usually associated with obesity. Now you have to ask yourself, what's at stake here, and why do you even care about it? Well the first point is that there's visual loss, and while acuity is not lost, and blindness is not common, visual field loss is actually present in at least a third of the patients. And about a quarter, when Dr. Corbett went through all of his cases, over 20 years had permanent, severe visual field loss, and despite all of our treatments, even modern day treatments, 14 to 35% of people will have visual function or visual field loss. The second thing is, it's a chronic condition. At Iowa, they reviewed 410 patients, they had 20 people followed for more than 10 years, and about half of them worsened after being stable. So people can be toodling along and be doing really, really well, and then all of a sudden they start having headaches and visual loss, and then they're having the condition back again. And their quality of life is definitely diminished. Julia published in Neurology about 10 years ago, a wonderful article about, and was the first article to show that the quality of life in this condition is very low. And recently, three years ago, the Penn Group published this study, which was actually exactly what we found, they just used some different methods, but showed that the physical quality of life, emotional, so depression, anxiety are higher in this group, and their visual quality of life is also lower. So this is an important condition because it affects people's vision, but it also affects their quality of life. Now I did want to mention a couple new things along the way, one of these is men. Men do get IIH, it's not as common, and this recent paper by Beau Bruce showed that many of the men may have testosterone deficiency, and I think this is a really big one, obstructive sleep apnea is more common in men. So if you see a man with IIH, you should be thinking obstructive sleep apnea. They used two questionnaires to determine that people with IIH and men had a greater incidence of obstructive sleep apnea, and also a higher ratio of androgen abnormalities on a questionnaire. Now there are many controversies, I mean we could spend an hour just talking about the nomenclature of this disorder, we could talk about imaging controversies, but I'm going to highlight basically three. One, I'm going to ask the question, can there be idiopathic intracranial hypertension without papillodema? And I know that there have been more than one patient coming from triage with this question. Then I want to talk a little bit about obesity and the treatment of obesity and a study that we're going to be doing while we are doing. And then talk a little bit about endovascular treatment, which is a pretty hot topic. So let's take that same person that I introduced you to at the beginning of this talk.  Only you look in and you see this, she doesn't have any papillodema, okay, neither I. But her lumbar puncture shows an opening pressure properly done of 300 millimeters of CSF. So does this woman have IIH? So the first question you have to ask yourself is, can you have high intracranial pressure without papillodema? And there's some lines of evidence here that I think are pretty clear. First, if you take all people with brain tumors and ask the question, how many of those people get papillodema, they've got space occupying lesions, they've got high intracranial pressure, not all of them get papillodema, probably less than half, okay. Trauma, Jack Selhorst in 1985 sat in an intensive care unit in a busy city hospital looking at everybody's fundus who had had a bad head trauma. And he followed them through their stay in the ICU monitoring their intracranial pressure with bolt monitoring and went to look to see if they developed papillodema. And he followed them for days out. And he found that about half or less developed papillodema, even though he was looking every single day. And these people had documented high intracranial pressure. And then I think another really good line of evidence is we often see people with asymmetric papillodema. So here's the same person and on one side maybe you could make out grade one papillodema, but on the other side you've got grade four with obscuration of all the vessels, 360 degrees. You've got two different grades of papillodema in the same individual with the same high pressure. So this has led people to believe that the pressure is transduced along the optic nerve in the dural space. And that some people's anatomy may not allow for people to have pressure developing behind the globe and giving axoplasmic stasis, which is what papillodema is, axoplasmic stasis. So the answer to this question is yes, there can be high pressure without papillodema. Now the waters became muddied when the headache folks got involved here. And over the last 15 years or so they've been doing lumbar punctures on people with chronic refractory headaches. And in one center they found 15% of people with chronic daily headaches, they just all comers did lumbar punctures and they had pressures up to 450. Now this study was always criticized because they said, oh, you'd never had a neuroophthalmologist looking. You were just looking at an undilated pupil. Maybe all these people were rebound. And so a second study was recently published of 60 people with chronic migraine. And 10% of these people had increased intracranial pressure. And all of them had BMIs greater than 25. And their conclusion was that in patients with BMIs over 30, you should at least consider idiopathic intracranial hypertension if people have a high, have a lot of chronic migraine. So we did a study that we published last year. We took all of our patients with IIH and we chose, we found 20 people who met the criteria of IIH without papillodema. And we matched them to 20 people with papillodema. And all of these people were examined by a neuroophthalmologist. All of them had opening pressures done by Judith or by a neurologist that we trusted. And here's what we found. When we compared, I mean, most of these people were women, obviously. Most of them were obese. The BMI in this group was a mean of 35. They were almost identical. The two differences were the people without papillodema had a slightly lower intracranial pressure mean of 309 versus 373. We didn't pick anybody that wasn't, it had to be higher than 250 millimeters of CSF. The other thing was that these people had more lumbar punctures. Many of them, because nobody believed that that's really what they had, was that they had intracranial hypertension. They both had migraines. They both had depression. And we couldn't find any differences in their symptoms. They all had headaches, visual obscurations. Maybe the IIH with papillodema had a few more visual obscurations. They had the same pulsatile tinnitus, even a few with diplopia. And their headaches were very similar. We really couldn't tell much difference between them. The ones without papillodema maybe had more auras, but otherwise they were very, very comparable. Their acuities were by and large very good. The ones without papillodema did a little bit better. The ones with papillodema had a little fewer. Some of them had decreased acuity. And the visual fields were interesting. So the ones without papillodema, as you would expect, had a normal visual field without an enlarged blind spot and the ones with papillodema had enlarged blind spot. But here's what we didn't expect. We didn't expect this large number of the ones without papillodema to have functional visual loss. So these were people who came in with constricted fields, no papillodema. And at the tangent screen, the one meter, the visual field did not expand from one meter to three meters. So they had functional visual loss. And this has actually been shown also in a large study of IIH, where they found about a 6%, at least a 6% rate of functional visual fields in a large series of people with IIH. So one take home message for us is always to be careful that the visual field is not functionally constricted in this group of individuals. So we know that this is a chronic disorder. Dr. Corbett went and retapped patients 20 years later and found that people tended to have high endocrineal pressure despite no papillodema years after the diagnosis was made. Annette Kessler in Israel has targeted the recurrence rate to be at least 38%. The problem with recurrence is you don't know when it ends. Many of the patients I follow have it for years and years.  And this was corroborated also by others who have looked at this as well. And you have to ask yourself, how many of these patients continue to have increased intercranial pressure without papillodema? And the answer has not really been determined yet. So I think the IIH without papillodema exists. It's probably not common. I don't think it's as common as 10% of every chronic daily headache patient. I see headaches all the time, and it's not 10% of my practice in a headache clinic. But I think it's difficult to diagnose, and I think there's some caveats. We have to be sure that they have truly elevated intercranial pressure, that the pressure was measured properly, that the person wasn't fell selving. They weren't hypoventilating. I think you do have to look, you can look at the MRI scan to help you with these cases. I especially like to look for empty cellar, narrowing of the transfer of sinuses. And then I think we have to watch for constricted fields because they can have functional visual loss. And then I think this point really hasn't been made enough that this really is a chronic condition, and that people can have this condition for years. And while some people can have a self-limited one time event, there's a whole group of these people that have it for a long period of time. So going from IIH without papillodema to why does this occur, there's some work being done about the genetics of this disorder. Judith has given a very nice grand rounds about vitamin E in this disorder. I'm just going to touch on obesity. So I just want you to watch the browning of America, the fattening of America. This is in 2000, 2001, 2002, 2003, 2004, 5, 6, 7, 8.  This is really an epidemic. So does obesity have anything to do with IIH? Well, first of all, the first line of evidence is that 90% of the people who have it are obese. Case control studies show that that's one of the factors that separates out people with this disorder. And if you can lose weight, you can go into remission. And of course, obesity has numerous complications. We've already brought up sleep apnea, but there's insulin resistance and other comorbidities with obesity like polycystic ovarian disease that can make this diagnosis and this condition very difficult for these individuals. It is really clear that the incidence and prevalence increases as you look at obesity. So if you take a normal weight population, the incidence is about 3.5 per 100,000. As soon as you get overweight individuals, it goes up. And when you have obese individuals, it's 20 per 100,000. That's the same incidence as multiple sclerosis. So it's very common, you know, and we, it's pretty common in obesity. Moderate weight gain seems to precipitate this. And Annette Kessler has pointed out, this was I think an ophthalmology just this year, that the patients who have IIH tend to have the pear-shaped body or the lower fat body as opposed to the apple or mid-shape, the one you see often with metabolic syndrome. And there's some rationale for people having obesity causing or being related to increased intracranial pressure. One is some people believe that the abdominal adiposity affects the central venous pressure. And it is true that some individuals do have increased central venous pressure. And we do know that venous hypertension will lead to increased intracranial pressure. And then there's a group that thinks that the inflammatory markers that come with obesity are associated with setting up IIH. Now the first question you have to ask is, does IIH increase the pressure in the brain by itself? And James Corbett did a study where he showed that there was maybe a little bit of elevation of pressure, and so that's when we started adopting pressures have to be greater than 250 in obese people. So this study, which was done in Australia and England, showed kind of a normal distribution of CSF pressures. But these were normal people without papillodema, and even in normal people, you can see that there can be people normals with increased pressure. Then they stratified those people from underweight and normal. And while there was a trend for the overweight and obese people to have a slightly increased incidence of higher pressures, it was not statistically significant. So the normal pressure is in this large study between 10 and 25. Now I don't know if you saw this study, but this came out of Penn just in the New England Journal this year, where they looked at children and asked what's a normal pressure in children. And it was done at a children's hospital, people who were coming in for various reasons for lumbar punctures, and they excluded people with known high entercranial pressure. And look at the normal range in pressures. These were kids with no papillodema going from 80 millimeters to 450 millimeters. And one thing that they found that is, I think, important is that there were some things that caused pressures to be elevated. And one was sedation. So when kids are sedated, they hypoventilate a little bit, and their pressures can be elevated. And so you really can't accept that high pressure in children if they've been sedated. You really have to be careful about that or monitor it carefully. They also found a slight correlation with BMI. As the BMI went up, the opening pressures got a little bit higher, but it wasn't a one-to-one. And the pressure really was all over the place for all ages. So I think this is kind of cool that finally we have a study that actually shows what normal pressure is in children. So how about obesity? Should we say that obesity is the cause of IIH? Well, I think, first of all, we have to explain the non-obese cases. Not everybody's obese. You know, 10 to 20 percent of people are not obese. And in children, 70 percent are not obese. And in many centers across the world, very few people are obese with this condition. So there's a lot of things that we really don't understand. Beau Bruce did a study this year that showed if you take all the non-obese patients, more of them are likely to have medication-related IIH. So in your non-obese patient, you better look a little bit more carefully for a secondary cause. I think the link is there. It's not fully understood. And as we see more obesity in our country, we're more likely to see IIH. And we probably really need to repeat some of the incidents and prevalence studies. Certainly, this is well proven that obesity is linked with headache chronification, meaning that people who have episodic headaches can develop chronic headaches without high pressure due just to having obesity. Now, what about treatments? I'm going to spend a couple minutes now talking about treatment. There really are no double-blind masked controlled trials in this disorder. Data is really case series. And our goals of treatment really should be to resolve the condition, prevent visual loss, treat the headache, improve quality of life, and then get people back to work, because a lot of these people end up not being able to live their lives. Some people would argue you wouldn't even treat somebody who doesn't have symptoms or signs. There can be people who come into the clinic who have papillodema, diagnosed IIH, but have really no headaches, no visual loss, no nothing. You really could argue, do you really need to treat those people? Because you may not. For sure, you should at least think about depression because that's a higher incidence. Ask about sleep apnea using the Berlin questionnaire. And if they're overweight, you have to counsel them about weight loss. Because there have been many studies, Len Johnson and Mark Coopersmith have shown that just losing a modest amount of weight can actually bring about a remission. And the evidence for this really has been known for a long time. Back in the 60s, Greer, who is a kind of a pseudotumorcerabribe, Maven, when it was called Benign Intercranial Hypertension, advocated for weight loss, then Newberg, she was an internist in the 70s. And she had a bunch of these patients and looked in their back of their eyes, some of them she took photographs of, put them on a rice diet, about a 600-calorie rice diet for several months. And she showed that they were able, in three months this person lost their papillodema just by going on this rice diet. So this is the first evidence we had that diet actually worked. Dr. Sugerman in Virginia does bariatric surgery, and he was finding that his bariatric surgery patients who underwent bariatric surgery for their IIH had a definite improvement in their condition. And then Len Johnson and Mark Coopersmith found the same. This summer, this study was published in the British Medical Journal. And this was 25 women with IIH. They followed the women for three months and got a baseline on their headaches, on visual situation, et cetera. They put them on a 425-calorie diet for three months. Can you believe anybody could stay on a 425-calorie diet for three months? That was the most amazing part of this whole study. And then they followed them up after the diet. But this is really incredible. I mean 425-calories. So they lost weight. They did lose weight. So their weights definitely declined. Here they are at the beginning. And then they went on this diet. And then they kept the weight off. So all of them lost weight. And their intercranial pressure went down, which was really remarkable, on average about 80 millimeters or 8 centimeters. And their headaches got better. Their papillodema improved, but only four developed completely normal intercranial pressure at the end of the study. So this is really the first study where they used a case. The cells is a case controlled, but it's the first really prospective cohort study that's ever been done in this condition showing that weight loss really does improve the headaches. It improves the intercranial pressure. It improves papillodema, et cetera. So we're embarking because in the Cochrane review, there's no adequate therapy, no evidence for any adequate therapy. We are embarking on the idiopathic intercranial hypertension trial, IIHTT. And it's a randomized trial with mild visual loss. And it's comparing diet alone versus diet plus acetylzolamide. And the hypothesis is that acetylzolamide plus diet would be superior to diet alone in restoring vision to in people with mild visual loss. But at the same time, we're looking at genetic factors, proteomic, genomic factors. We're looking at metabolism factors and vitamin A in the serum and CSF in these individuals. We're one of 39 sites across the country. As you can see, most of them are on the East Coast. So we're holding up the West Coast and Intermountain area. And this study is just underway. We've enrolled two people into the study. And it's just kind of gaining momentum at right now. Well, aside from weight loss, what else can you do with these folks? Acetylzolamide has been used for, you know, 30, 40 years. And it's not an easy drug to use because it's got a lot of side effects. But for many of us, we feel like it's pretty effective. And the biggest problem is using the correct dose. Most people need at least one gram. Even children need a higher dose than what they're often given. If they can't tolerate acetylzolamide, we also use methazolamide, which has fewer side effects, and sometimes lasix or furosamide can be used. Then there are other medical therapies. Topiramide, which is an anticonvulsant approved by the FDA for migraine, will also in decreased intracranial pressure a little bit because it has some carbonic and hydrazine abition. And in one study, it was as helpful as acetylzolamide. So if you have somebody with a lot of headaches but not so much visual loss, topimaxima or topiramate might be a good choice of medications. Some people think steroids are indicated in this disorder. The problem with steroids is as you withdraw them, there's all kinds of rebound in intracranial pressure. So most people kind of avoid the steroids because there's weight gain and you get diabetes and everything else. So we probably don't use it. For a while, there was some interest in these cardiac glycosides like digoxin, but that's gone out of the favor. Octreotide does work, but it costs a million dollars to put somebody on this so you don't want to do that. And some people with polycystic ovarian syndrome have had benefit from metformin and diet. This is in women. Now, there are surgical treatments if people's vision drops. You may not think about lumbar puncture as a surgical treatment, but there are times when we use lumbar puncture to temporize the situation, get people out of this acute situation. If they're losing vision, get them in the hospital, put a drain in, get that fluid off of the nerve right away. You can do that quite quickly. We don't use sub-temporal decompression. This was a procedure where they actually took the temporal bone off the brain and left the brain swell on the pressure. Well, you can imagine the unsightliness of that. So nobody really wants to do that. The two procedures that are most used are shunts. And the shunts are gaining some popularity, again, because there are adjustable valves where you can actually dial in your pressure of what you want, because some of the problems with these shunts where they'd over drain, under drain, and you could never get the pressure just right. So they're gaining popularity. Optic Nershift Fenestration, we still use that. And I'll show you some data that supports our use of that. And then Gastric Bypass. For some of these people, there's so many new procedures, lap band therapy, et cetera, that are pretty benign, that really do help with weight loss and probably are more curative. And then the new kid on the block is Venus Stents. How many of you have heard of Venus Stents for IIH? Well, good. So you're going to learn something this morning. So Venus Pressures. For years it's been known that if you increase your Venus Pressure, you will increase your Intercranial Pressure. This is 1930s work. Direct Correlation. And so about 15 years ago, John King in Australia noted that people with IIH had Venus Hypertension by measuring their Venus Pressures in their Sagittal Sinus Transverse Sinus. And if he took the fluid off, so let's say he did a lumbar puncture after he measured the pressure, the Venus Pressure would dive down or drop. And so he and a bunch of some of these guys in Australia, they'll try anything, and they did. And they put a stint in these people with sinuses that look like this. Here's this beautiful open sinus. And they found, voila, the Intercranial Pressure went to normal. So they thought, well, we got a new treatment for Intercranial Hypertension. And so they started doing this dramatically and have a large series, which I'll show you. All right. Now, this, however, is just somebody who, I just want to show you kind of somebody who had a lumbar puncture who had a change in their Venus Sinus. So here they are at baseline. They have this kind of tight-looking vein transverse sinus vein. Then they do a lumbar puncture, and that vein actually opens up. They do a second lumbar puncture and lower the pressure even more. It opens up more. And then after the lumbar puncture, they've put in a shunt to keep the pressure down and that vein stays open. So it's clear that getting rid of the spinal fluid also will open up the vein. So you can open up these veins by putting a stent in, or you can just lower the Intercranial Pressure and get those veins to open up in many cases. So here's a case of the stent. And then the problem with these stents is, okay, you put it in and here's one week later the person's already getting a little stenosis right here and the pressure is going back. I mean, you can't keep putting stents in because you get into trouble. Well, I kind of tabulated all these stent cases, and Matt Thertell reported 22 of these. He also was from Australia. Almost, these are all Australia cases. And you can see that they improved. Their papillodema mostly resolved. But there were complications. Many of them had thrombosis. One person got a subdural hemorrhage, restenosis, and now there's been one death in the Australia series. So it's not for everybody. Steve Felden from University of Rochester did a nice meta-analysis of what procedure is the best for vision in IIH. And he covered stent placement, VP shunts, LP shunts, optic nourished heat fenestration, and in both acute and chronic cases. And you can see that 80% of people with the optic nourished heat fenestration did better versus all of these other procedures. And granted this is a meta-analysis retrospective review of other people's outcomes, but at least it gives you some idea that probably optic nourished heat fenestration for visual loss is probably still the procedure of choice. Safety, these stents have serious AEs and at least 20%. And death has been reported now. And you can see that every procedure has serious adverse events. Hopefully not death, but you can see that this can be a problem. And often re-operations. Now bariatric surgery, this is just from one series, but a lot of these people do get problems after the surgery, but they have very few re-operations or needing treatment. So stenting I think is not a first-line option until we understand what causes, in what cases can we have reversibility. So if you take the spinal fluid off, that's a much safer treatment than putting a foreign object in somebody's vein that you can't ever retrieve. And we really need to understand kind of the safety issues. And maybe there are cases where with people with fixed tight stenosis that don't go away with lumbar punctures that are keeping the pressure high, maybe this would be a treatment we can do. And for sure we need more controlled trials. I do want to alert you about this problem, fulminant IIH, because this is the one that gets ophthalmologists sued. It's the only condition in neuroophthalmology where I've been asked multiple times to testify is this fulminant IIH thing. These are people who come in bad papillodema. And the problem is delay in recognition. They've had headaches and they've gone to the ER and they went to their primary care and they went to, and they went finally they get to an ophthalmologist who finds that they have papillodema. You just have to jump on this. This is one of those emergencies that you just take on and say, I'm sitting with this patient until they get inertia fenestration. I've got their fluid under control. I might put a drain in at the same time to get the pressure done. But the problem with this is that even you do all this stuff, even give them 2 grams IV of acetazolamide to lower their pressure, IV methylpredicillone, they still end up blind. And the only plea on this one is just early recognition. And so residents who are going out into practice, I'm just warning you that this is the one condition. You don't just say, hey, come back and see me a couple months. If they've got field loss, you got to jump on this one, okay? Because this is really a bad one. So IIH is a perplexing condition. We really don't understand it. And it's probably more common because of our obesity epidemic. We definitely know there's a venous contribution that can't be ignored, but I don't think it should be stented. And I think this is chronic. There's a lot of people who have a chronic form of this disorder that have elevated pressure for years. I do want to tell you about the novel library. Every chance I get, I advertise this joint project with the University of Utah at Coast Health Sciences Library and the North American Neuroophthalmology Society. And on this website, which is free to everybody in the world, we have a patient portal. And you can go to the patient portal and get brochures for your patients on pseudotumor, many other conditions as well. Some of them are translated into Spanish, Hebrew, German, I can't remember all the languages, but there's like seven languages. And at up-to-date, this will take you to an up-to-date search for the recent five years in PubMed of IIH articles. There's a support group website, and there's some other tools. And then these are all downloadable in large print format as well as regular print format for your patients. And so I have left about four minutes for questions here. We can turn the lights on. It's a whirlwind tour, yeah. You know, I love venous pulsations. I love them, I study them, I adore them, I look for them. But no, you can't use them. Because there are cases with actual documented venous pulsations with an opening pressure of 500. And a documented. Okay, so I mean, you can't use them completely. Now it makes you feel warm and fuzzy when you see those little venous pulsations. There is, you know, if you were going to take people and say venous pulsations are present, how many of those have increased pressure? Probably very few of them would, okay? So you can still kind of use it, but it's not something you want to hang your hat on. If you've got somebody who's obese, chronic headache, no papillodema, but you don't know and they've got whooshing in their ears and maybe they've got pain between their shoulder blades and maybe, you know what I mean, you don't know. You may have to do an intercran- you have to do a lumbar puncture to know for sure. Even though I love that sign, you know. There's some people who believe if you saw them and they went away, then maybe that's a better sign, but you really can't hang your hat on it. Yeah, Randy. So fascinating. But it sounds like this is another moment, because I follow some of you, I've got some of you, and you're right. It's a chronic disease. And they put up with their symptoms of dialogues or they quit because they wanted them and then they get the other symptoms back. I mean, well, they can get a dramatic weight loss. They just smolder and keep going on. And I agree with you 100%. That's what's very exciting about the IIHTT trial doing the proteomics genomics, doing vitamin A, because vitamin A has been associated with it, doing genetic studies. I think this is going to be very helpful and may open this up a little bit. But it is complex. I think this is definitely a complex disorder. It's not a easy schmoozy. Oh, yeah, it's just obesity or it's just this or it's just that. Yeah. I don't know of any long-term sequela to the brain from high pressure, okay? In our study and in the Penn Study Depression, you really have to look for depression because that really exists. And that's a brain disorder too, as you know. So I really feel like I'm alert for depression in these individuals, but I don't know of any brain pathology that's long-term in any of these individuals. So it's not like they're going to have difficulties or anything else. I mean, they're going to have problems with headaches and they've got to get those under control, which can interfere with their ability to go to school and things like that. Yeah, absolutely. And if kids, there's kind of an endpoint with kids. I mean, I've followed kids that have it and they kind of grow out of it and they never have it again. You know what I mean? If you can get them over that hump, you're fine. The older kids can be chronic. But those little kids, they really outgrow it pretty quickly. Yeah. Yeah, that's common. You know, 10, 20 percent. So, yeah. Six nerve palsy is common in this disorder. So diplopia is a common complaint. Yeah. You can see a skew. Complex diplopias have been reported. I saw a kid with bilateral six, bilateral sevens and almost a total ophthalmoplegia. I mean, she could raise her eyes a little bit. I mean, it was just dramatic. She got the lumbar puncture and everything started moving again. It was really phenomenal. I've got a, that case I've got published in one of my articles. Yeah. With, without. Well, I mean, that's, it's not rare.  How many total, I'd have to look at our, you know, data, but I'd say, you know, 10, 20 percent. What would you say, Judith? I don't think that number is known of how many would be medication related. Yeah. So if somebody comes in skinny, go after them.  What have you been doing? Well, you kind of have to say what, and if they take drinks, these drinks now, oh my gosh, some of these drinks have like, oh gee, you know, if you look at the ingredients on these energy drinks and vitamin drinks, oh my goodness, it's like taking 20 multiple vitamins every day. Well, so you really can't, you really have to look at what they're doing. Yeah. What's the etiology of? Acetazolamide. Acetazolamide. Okay, acetazolamide is a carbonic and hydrogen inhibitor. It's, right, it's a mild diuretic. It's not a heavy diuretic, but what it does is it keeps spinal fluid from being made in the brain. So it lowers the CSF production. Well, there's, you're right. And some people wonder about that.  So we'll know whether acetazolamide is doing anything. Everybody's getting weight loss, but the big thing is that it's either acetazolamide or placebo. It does work. It does work to lower the pressure, but obesity is probably one mechanism, or having people lose weight is a mechanism, but that's why this study is going to be important because it's going to answer some of those questions. Great. Well, have a good day, everybody. Thank you.


Hey everyone, just a reminder, today is the last day to register for NomCon CTF before the competition starts tomorrow morning. So if you haven't heard, NomCon is a virtual conference being hosted by myself, Nomsack, the Cyber Mentor, and Stoke, and I'm hosting the Capture the Flag, kind of just like I did for VersaCon, so I'm super duper excited for this one. All new challenges, tons of new challenges, and it's getting started tomorrow, June 12th at 8am PDT, running for 31 hours and going until June 13th at 3pm PDT. So right now, we have just over 2400 users registered, and I'm super duper excited because 2500 is where VersaCon ended. At the very end of the game, that's how many users we had registered. So if before Friday morning, before the game starts, we're past 2500, then we're doing better. We've got even better numbers than before VersaCon ended. We're starting NomCon CTF even better than before. And there are tons and tons of challenges, and I'm so excited because all of these, I think are really, really cool. Anyone can play. There are challenges that tailor to every single skill, every single, I guess skill level, right? If you're feeling like, hey, I'm a beginner. I don't know how well I'm going to do with this Capture the Flag. There are tons of warm up challenges, and it will slowly stretch you to more intermediate or advanced or complex stuff. So I'm really, really excited about it, and I hope you guys play. There are in fact prizes. So if you go check out the rules page, there's some support. Hey, you can contact me on the Discord. You can contact anyone with the CTF help role in the Discord. And we're going to be having Capture the Flag with a specific flag format, because I think that's a good way to play. And that's just going to be simply flag. And there are prizes. So the first place team, and you can play as a team, right? Let me let me touch on that in the second first place gets $500 US dollars, second place gets 250 USD, and third place gets 100 USD. So you can play as a team registration and login is user based, because I think that makes a little bit more sense trying to just get into the game. There is no limit to the amount of players you can have on a team. If you are working as a team, create one account and share that one account. So that way, all of your challenges that you solve are still illuminated. Hey, you've solved this, they're, they're checked. And that is the progress as a team. With that said, we are going to be releasing new challenges throughout the competition. We did this last time with VersetCon, and it had a little bit of mixed reviews. Some people really, really enjoyed the fact that we did it. Some people said, Hey, it wasn't communicated all that well to some of the players. And some guys got pretty frustrated about that. So what we're doing this time around is that there is a page for challenge releases. And you can see when we're going to be dropping one new challenge in what category and at what time, right? So that way, you know, okay, I want to have my teammate here available for this, for that specific category, because I know he or she is super, duper strong in that category. And we want you to have something to look forward to if you're one of those high flying super strong competitors. And we want to spice up the game and keep it fun. That does not mean that the game starts, oh, at 10 PDT when we say we have a new challenge release, that means that at the very, very start of the game, almost all of the challenges will be available and ready for you. At those two hour intervals, you can see on the challenge release schedule, we're going to be releasing one challenge from a specific category, just to keep things, I don't know, moving in the mix so that you've always got something to do my goal, right? And the hope in having a ton of challenges is that no one solves everything. Because I want to maximize your training value, I want to make the most out of your learning and your education. So that's why we're going to release as many challenges that we can at the very, very start. And every now and again, we'll slowly release more. So you've still got something to do, and it's still super duper fun. Also, I forgot to say this, so I'm just editing it in. I'm giving a talk at NomCon at the very, very end, just after the CTF ends to kind of go over, Hey, these are the people that did incredible things and help make the game. So, so grateful. Thank you. And talk about some of the decisions that were made on what challenges we're going to put in, what we're going to take out, the infrastructure, how it was all built, how it was all made. So please do catch that at 330 PDT on Saturday, June 13th, just after the competition ends. I'd be grateful if you watch it because we do give some love and some special shout outs to the other people that helped me not do this entirely on my own. So thank you for that. I am hoping to stream the beginning of the capital flag, like from my perspective, like, Hey, as the admin, things are kicking off, people are registering, people are playing, the game is going to drop. What's that going to look like on the maintainer side? How am I going to be on fire? What people are going to need help? What things need to happen? So if anyone is interested at the very, very start of the game, I'll also try and be streaming with some of my team to showcase how that looks on that side of the house, not just the player, but from the organizer and the maintainer. Hopefully that'll be kind of cool. Hopefully that'd be kind of fun. Also, not only are we doing the capital flag talk at the very end of NomCon, just like we did with the verset con, I'd like to do it after the game stream, just to chat with you guys, anyone who has any questions and discuss a little bit more, go more in the weeds on the feedback, what people say, we'll put out another Google form, etc. So those three things streaming the start of the game. So you guys get the perspective, the talk after the conference and some of our perspective creating the game. And then after the fact of the CTF, we'll try and stream just to have a conversation with everyone that played. Hopefully they had a great time and just answer questions as more of them come in. So that's it. Please, please, please go register. I'm really, really excited about this game. It's bigger and better than verset con. There are a ton of great challenges. The challenges are just really, really fun and really, really cool. And I hope you enjoy them. I am, oh man, I don't know what to say. I'm nervous and excited and anxious because I got to do final testing today and I want to make sure everything is just right. But please go register. It'd be incredible to knock these registration stats out the door because if we can get past the 2500 before the start of the game, we're doing even better than verset con did. So go register, link in the description. HTTPS. We got HTTPS and SSL set up CTF.nomcon.com. Please go play. Please join the discord server. I'd love to see you there and I'm really, really excited. I hope you have a great time. Thanks.


What's going on everyone Sam here with late in sports cards doing a three-box mixer for Nick or max N We've got one box of 21 22 contenders optic basketball one box of tops formula one racing 2022 one box of 22 at triple threads. Good luck here max I will start with formula one for you max It's got the most packs for sure box topper United States that's pretty cool looking actually postcard Fernando Alonso checkerboard not numbered checkerboard George Russell Sergio Perez There's a sabato con For the checkerboard for Alpine checkerboard of tail for share There's Nicholas Latifi on the checkerboard. We've got the frons tossed for Alpatori on the relic card Not numbered really What are autos like one a case no Charles the player nice one that somebody was mentioning in chat. Yeah, they're asking if we're getting any Imagine we are yeah Be shocked if we didn't So they'll be a fun personal product for sure there's Lando Norris and green of Ayuma you a wassa to 75 nice one there for red are for dams on F2 military Botas base Yeah, that's wild I was in here like my first like week break in I was doing F1 dynasty loose Hamilton on the checkerboard Nice one there. I know I was in here screaming like alone after group breaks happen. That was fun Those are still some of my favorite like hard to fold Louis Hamilton to 10 smash and Vettel Checkerboard the zipper patches are insane.  Yeah, they are anomaly. They're full for today Yeah, we got flag can't hold up for us too too long George Russell checkerboard We have group breaks starting at 5 p.m. So gotta get for us some time to get set up I'm ready to rock and roll. Is it 4 p.m. That's a 4 p.m. Oh, that's a 5. It's 4 p.m. 4 p.m.  I love the checkerboard Borders those are awesome. There's Louis Hamilton again from Mercedes Source red sox showing heavy interest in the Frederick Vesti checkerboard George Russell nice one there to 199 on the aqua That's on that. So last night. This is pretty funny. I have to give myself credit for this is one of the funnier things I've said here Vaughn came in and was like, oh JD to the angels ten years a hundred like or one year ten million or whatever it was and Someone was like wait.  There's Franz Tost Checkerboard peace On to contenders optic basketball We got two more breaks after this two more personals. We got a signed basketball for Cameron G And then we've got a cops chrome black for Taylor and Taylor if you're in here you could always watch on YouTube and twitch as well and Jason kid legendary tandems Kyrie Irving and play in the numbers game red ice for the Nets base base got orange Trey Murphy rookie Two nine forty nine sixteen out of forty nine And nice one here max. How about legendary contenders John Stockton for the jazz there we go 73 out of 75 Congrats, man. That's an awesome card. Hall of Famer right there the all-time leader in the cysts. I want to say I think he's the all-time leader in assists. I couldn't be wrong. I Hope I'm not wrong nice one there congrats now. We got triple threads So clean man, I agree on that one witty sweet shots Hopefully get one of those We didn't forgot this isn't contenders optic as well got Mel opt to two ninety nine and Raphael Deverson 150 We got a white whale There's been a great case so far base and base I Start off with this. We got Aaron Nola to out of 18 And we've got a white whale everybody good luck Good luck here max That's gonna be wow Mike Schmidt Wow blasts Blast and steals there we go max nice one there one of one a white whale Holy cow that is awesome Let's go there we go max Perfect sounds good Taylor Look at that man. So sick come back this one I So awesome love me some Mike Schmidt best third baseman of all time right there Vladdy Guerrero senior to 99 and Hank Aaron to 125 base Yeah, he's got such a gorgeous auto There's Andrew McCutcheon 28 out of 36 grand and Philly For the brewers and then how about a Royce Louis auto 184 out of 199 for the twins I'll do it for your break right there max Thanks again as always my man. We'll get that right out to you buddy