Hello, my friends. Today is a very big day because I'm gonna meet up with these two. If you've been watching my channel in the past year or so, you probably know John and Mira, the most amazing dog packing duo in the entire galaxy. But I wanna give you a quick little intro about how I met these two. It was back in January 2020, right before the pandemic. And I was riding my bike down the Baja Peninsula on the Baja Divide. And I was getting ready to camp and set up my tent and lo and behold, these two just rolled up to where I was kind of in the middle of nowhere. This nice friendly fella with a Canadian accent rides up and it's this guy, how's it going? Ah, good Ryan, how are you? Who's this? Yeah, that's Mira. How old is she? She's about two and a half now. Whoa.  And from that point on, we rode for the next week together in Baja and had the time of our lives. We were really fast friends. Lead the way Mira, who needs a GPS when we have you? Okay, I went home, they continued their bike ride and then I started to get ready to ride the Great Divide mountain bike route. And out of the blue, I get a phone call from John saying, hey man, you want some company? And of course I said yes. Okay, Mira, one last stick before bedtime, ready? Go get it. We rode the Great Divide through Montana, a little bit of Idaho, Wyoming and Colorado. And the last time I saw these two in real life was a very teary goodbye in Steamboat, Colorado. I love you. And whenever I say goodbye to somebody who means a lot to me, who I have an emotional connection with, I get sad, you know? I didn't know when I was gonna see them again. And it turns out it was a very long time. It's been about a year and a half. And we tried to meet up, but because of COVID and border closures, I couldn't get to Canada, he couldn't get to Colorado, so it just hasn't happened. But two months ago, he and Mira left on their worldwide bike tour and they've been making their way down south on the Western Wildlands route. And now today, they are in St. George, Utah, waiting for me. And I'm gonna get on a flight and meet them. And I am so excited. And I'm excited for you to see them again as well. I know they're a fan favorite and we're gonna have the time of our lives riding the Western Wildlands route through Arizona. Hey there, do you enjoy my videos? Do they make your life better? Well, then consider supporting my channel on Patreon. You'll get early releases with no ads plus a lot of other fun stuff. Link is in the description. I'm here in St. George, Utah, very close to John and Mira. All right, I'm in my lift. It's a Tesla, it's rad. My driver, Jared, is cool. All right, here we are at the hotel. John, I'm here. Is this really happening? Is this real life? Oh, is it Mira? There she is. Hi, can you remember me? Oh, you're so sweet. There she is. How are you doing, baby? How are you doing, Mira?  Oh, Mira. Oh, look at you. Do you remember me? Look how beautiful. John, my man, I love you, brother. I'm gonna see you. Oh. Hey, Mira, hi, sweetie. Hi, sweetie. Yeah, we're gonna have some fun.  We did it. We met. We're here. Oh, and if you're wondering why I wasn't traveling with my bike, it's cause it's already here. I sent it. Thank you, Dave, at Priority, for letting me use your FedEx account. John built it for me. It looks like Mira just took off. Mira. Mira, hey, mom.  Did your dad tell you I was coming? Did your dad tell you Uncle Duzer was coming? Yeah, look at that. You're smiling. I can see it. I can see it. You want to ride bikes? Yeah, you want to ride bikes? I got some sticks for you. So where have you been? She's just following me. I'm trying to do an interview, but okay, give me a second. Give me a second. Hey, give me a second, all right? So where have you been the last couple months? Well, the last month I've been here in the wonderful US of A. Before that, back in Alberta, in Canada, trying to deal with this border situation. I've been ready to go for a while now. Go where? What are you doing? South, I am riding south until there is no more south left to ride. Yeah. And then I'm going to ride north. Until I get home again. Yeah. You've been riding through some cold stuff. Totally bad. Oh, man. You know, it came south. You think, oh, it's going to be warm, but we're in the autumn and I think it's getting pretty close. And so I've had some very, very cold mornings. You know, water's frozen. The two of us are shivering in the tent and it's not until midday that we're getting warm. So it's been painful sometimes and we're not dressed for it. We don't have the equipment. If you have the equipment, it was going to be easier. But now, hey, we're in Utah. We're in lower elevations. We can control where we go a little bit and it's warm days, lovely nights, stars. Yeah. Now it's good. Yeah. It's really good. I've noticed that you also have a pinion and gates drive. Yeah, man. Look at that. And you have a custom bike that you've made out of titanium. Yeah. Look at that bad boy. I designed that with a builder out in Maine and the pinion. Man, it's been great. You know, it's amazing. You don't think it's a thing. You know, you're lubing your chain, taking care of the derailleur, all that kind of stuff. But it's a lot of time out of your day and stress.  And the other thing, people talk, they give it a hard time. They say, all these things, it's really hard to shift under load and all that kind of stuff. But you can shift way faster on these than with a derailleur. You don't have to pedal. So the, you know, undulating terrain, you can just go through multiple gears and be in the right one. And I, you know, whatever mud or weather it's, yeah, it's been great. I love it. Awesome. Yeah. Well, I've been looking forward to this for a long time. Yeah. And here we are together in a hotel and tomorrow we set off. And it was terrific. It's been great. Yeah. It's a lot of fun to mirror. Mira is super happy to see you again. Yeah. I'm so happy to see you, Mira. Yeah, I'm so happy to see you. You're gonna sleep in my bed? Are you gonna sleep in my bed? I sure hope so. Is it okay if I borrow Mira tonight? One night, how about that? Okay, deal. Yeah. But if there's any cold nights out there, I want this cuddle, buddy. I don't want any deals off. Deals off. I'm excited about this, my friend. We're gonna have a great time. Yeah, we are. We're gonna have a great time. Oh, look at this sweetheart. You're so cute. You're so cute. All right, good night. Hi there, cutie. Good morning. I'm sorry I don't have any sticks. At least not yet. Buenos dias, John. Buenos dias, semi-go. You ready? Okay, okay, okay. All right, looks like it's gonna be a beautiful day in the desert. Oh yeah, look at that. Some pretty solid continental breakfast, my man. Yeah, it's terrific. It's a great way to start your day. Nice warm food. And I think somebody else wants a little bit. See it? Whoa. Hello. Yes. Look at that. Are you ready? Yeah, do you want us to get on our bikes already? Boarded this hotel. I've got the bike pretty much all set. All the clothes and light stuff go back here. I have lots of water because we're in the desert and we're not gonna have a ton of access to water. I got a water bottle there. Got a bottle here. All of this area is food and some electronics. I have a wide bag here. It's about three inches. My legs don't touch it, but it's close. Got my snack bags up here for easy access to bars. The drone is here. The GoPro. The Wahoo navigation. And you know what I just realized? I forgot to pack up my toothbrush. So I'm just gonna shove that in somewhere. I know, we definitely look like twins. We both have the same blue shirt and- Sibler black shorts. Yep, exactly. Sleeves, wear your sleeves. Oh yeah. You got them on there? I love it. Some people have confused us for brothers on the trail. Yeah, we're not. Now we look pretty similar. And look at this. Look at this, sweet girl. No crashies, no flaties, no webbies. All right, everybody out of the hotel. So we were all fired up to ride, but we're having a little bit of November rain, which I'm guessing is kind of unheard of. When I landed yet last night, it was beautiful and sunny and warm. We are in the desert. I doubt they get many rainy days here. I'm sorry, but there's a little bit of a rain delay. I know you want to get going, but it's cold and wet out there. Hey. So John has a YouTube channel now. You should go subscribe to it. What is it? It is Omni Tierra. All right. Yeah, all one word. All right, we will link that right here. We'll put some letters right here. Omni Tierra. Okay, here it is. I haven't seen the jump in a while. Hey Mira, hop up, hop up, hop up, hop up, hop up. Yeah. Are you ready to ride bikes? Yeah, you are. You're so excited. All right, here we go. Day one, riding with John and Mira, crossing a highway. Excited to be in the desert, although I came to the desert to be warm and it's kind of cold right now. It is November after all. So we're not actually on the western wildlands route right now, but we'll get there in about a day or so south of Kanab, Utah. John has built us a route on Kamut. You ready, John? Oh, I'm ready. He's ready. He's been riding by himself or by his lonesome. Oh, come on, you got Mira. Oh, that's right. You got Mira. Yeah. That's true. But now you got me. We're one and a half bike backers. One and a half. Love it. This is one of the nicest things about dog packing.  Life is good. Life is good with the Mira. Oh man. Oh, look at her go. Yeah. Dog sled driver. Look at Mira go just pulling away. One excited dog. John, it feels like we're back in Baja where it all began. I like this dusty desert road. What's up, Mira? What's up, my girl? Look at her go. She is in her happy place.  Somebody's been around. So this is the road that we're going to take. And then it goes super steep up that mountain. You can kind of see the road up there. I think we're going to be walking a lot. How is it going up super steep roads like this with a super heavy bike and a dog? That's about like you'd expect. It's slow. Oh, hi there. You don't care about the hill. Yeah, I mean, it's slow and hard work. You just got to pace yourself. The one thing that is nice is that these bikes, I mean, even, you know, bike-back-and-bike is not going to lift up the front wheel. But if you can have the weight in the back, it's got great traction. Oh, wow. So that's it, huh? That's about as steep as it gets. Here we go. This is a real big one, hike a bike. We've come a long way, but we still have maybe the steepest part left. Come on, buddy boy.  I'm so impressed that you can ride that. Monster up these mountains down. Props to you. Oh, look at that view. That gives you an idea of how high we've been climbing. Whew, look at that. Bouncy, bouncy. I wish I could bounce right now. Mira, look at you. That hill didn't even phase you, did it, Mira? One fit dog. Fazed us. That was hard. That was very hard. So we have been riding on the historic Honeymoon Trail. It says here, the Honeymoon Trail, also known as the Old Arizona Road, was a series of wagon routes taken by early Latter-day Saint pioneers, also known as Mormons, from Arizona and Southern Utah settlements to St. George to be married in the Mormon temple. It was used from 1872 when construction on the temple started to the early 1900s. Do you know what that means, John? We're on our honeymoon. The relations are around me, buddy. This is the best honeymoon I've ever been on. What about you, Mira? You're in on this relationship. This road is really smooth and nice. It's interesting how quickly you can be on, like, just a totally busted up, crappy, sandy, washboardy road, and then all of a sudden it's smooth. And it's nice to be able to get into a rhythm, be able to pedal and enjoy a nice evening. You know, there's really nothing better than magic hour in the desert. Everything just comes alive, the colors pop, and it's just beautiful. Nice, good for her. She's, hey, baby, there's your bowl right here. There's the water bowl. Right there, right there. Just get all cozy up with that water. Did you, don't even shake off that mud on me. No, no, no. Mira just jumped into this mud hole right here. Mira, come on, girl. What are you thinking? No, don't jump on me. Do not jump on me. Day one. Day one down. Yeah, it was a struggle that you could go on today. We had some problems, but it worked out good. Worked out good. Yeah, we didn't leave St. George till about noon, you know, little rain delay. We went to the grocery store. John broke the cable and his pinion had to fix that, which I was very impressed with how fast he fixed that. And, uh- It was my fault, by the way. It was John's fault. It was a break. The break was my fault. He broke it. He was too aggressive with the shifting. Yeah. But it's all good now. And I think we're gonna camp here. What do you think about that, Mira? Do you like this spot? Mira, come here. Mira, you are so dirty. But I guess you deserve, because I haven't done one yet, it is time to throw you a stick. It's been over a year since we played fetch. Mira, give me your stick. Mira, Mira, I got a stick for you. You ready? You already have your own stick, too. You want this? You want this, girl?  Yeah! Oh, it feels so good to be playing fetch again with you. Yeah. Give it to me? Yep, you still play the same. You play this hard to get game. Give me the stick and we will play. Ah! Drop it. Drop it. Okay. Brrrrrrrrrrr. Ah, it feels good to be out here in the desert with John and Mira riding bikes. Beautiful sunset. We have a nice flat spot to camp, playing fetch with the dog. Yep, this is what I had been envisioning for well over a year since the last time I saw John and Mira. I'm happy. I'm happy. Goodbye, son. Thank you for a beautiful day. And lighten the way. So we decided to camp away from the water down in a little wash because it's a nice wind block and it can get a little chilly here at night. It is November, even though we're in the desert. And there's John bundling up and there's Mira waiting for somebody to throw her a stick. Shall we go on an evening walk?  Let's go on a little evening walk. Totally. A stroll. A stroll. I love these because it helps just loosen up the muscles, moves your legs in a different way than just charging on a bike. Calms everything down. You get to like kind of reminisce on the day. You get to hang out with your buddy. Yeah, totally. This is so fun, you know. I really, I've said it so many times now but this really is, it's exciting to be here with you. Yeah, it's a super treat. I know. I guess we both often travel alone. Yeah. And then, you know, to have someone that, you know, we have a similar manner of traveling and all those kind of things, like, it, yeah, just really adds to the trip. Absolutely. Yeah, Mira. We love you so much. We love you so much. Good night, Moon. Good night, John. Good night, Mira.


It wasn't a good start to the new year for one Bemidji resident over the weekend. The Bemidji fire department responded to its first fire of 2017 shortly before five Sunday morning at the 1200 block of Thomas Avenue southwest. Firefighters arrived on the scene to find a pickup truck burning between a house and a garage and were able to quickly extinguish the fire, preventing the fire from spreading to both buildings. Four firefighters and one engine were used on the scene. The fire caused an estimated $40,000 in damage, but nearly $125,000 in property was saved. The cause of the fire is currently under investigation by the Bemidji fire department. The fire department says that the fire appears accidental in nature.


Well, they've been playing since December, and it's all led up to this. The Midget Club volleyball program has three teams playing at the junior national championships this next week in Minneapolis. The Power 14 and Black Eye 17s are already underway, and 16s start tomorrow, a busy week on the big stage. Teams all across the nation, even Puerto Rico, will hit the courts in pool play format. A great opportunity in the last go-around before the high school season begins. You know, there's teams from all over the country. First day of the tournament, we're going to play a team from Indiana and two teams from California. There are teams from Puerto Rico that will be there at this tournament. So it's quite the endeavor. I'm just really excited to walk in the gym and just see so many teams, like how different teams play volleyball, how different parts of the country do. I think we're all really excited because there's like a Puerto Rico team, which is like really cool, just because they're from Puerto Rico. Now, the 16-use squad consists mostly of a Midget athlete, some called up from the 15-use squad, but also two players from outside the area, one from Rozo and one from New York Mills, who just won state and softball, a huge commitment racking up the miles, including two-hour trips for practices. It's going to take a lot of dedication, two hours away, but I was like, I'm for it. Came, tried out last year. I played with this group last year, and then this year I played with the 15s, but they brought me up to go to Nationals. And so I've kind of played with them before, and it's not a hard transition. They're really good group girls and really fun. If you've enjoyed this segment of Lakeland News, please consider making a tax-deductible contribution to Lakeland Public Television.


Tommy here from Orange Systems, and we're going to talk about Call Stranger, the terrible universal plug-and-play problem that was just discovered, and terrible? I don't know. That's probably not a good enough adjective to describe the level of problems that this is very likely to create, but I think if we get ahead of it, we're going to be able to mitigate it. Patches are available, but not everything is going to be patched. So we're going to talk about mitigation, not always patching. So there's ways to block this, and I'll talk about ways you can protect yourself from this as best you can. But first, if you'd like to learn more about me and my company, head over to LawrenceSystems.com if you'd like to hire a short project, there's a hires button right at the top. If you want to support this channel in other ways, there's affiliate links down below to get you deals and discounts on products and services we talk about on this channel, including a link to our Patreon if you like to become a Patreon supporter. We also have a swag store where you can get shirts and other items that are for sale, and that changes from time to time what's available and what's not. So go ahead and check that out frequently. And finally, our forums. If you'd like to have a more in-depth discussion about this video, suggestions for new videos, or just reach out, say hi and talk tech, our forums are a great place for that. Alright, now back to the content. So we'll start right here with CallStranger.com. Data exfiltration reflected, amplified, and TCP DDoS and port scan via UPNP subscribe callback. It's a triple threat. This one CVE 202012695 has three methodologies here. And they say billions of devices. And let me tell you show you why right here. Windows 10, probably all versions of Windows, including servers, UPNP host that DLL Xbox one. And then the list goes on from here. Asus, RT and 11, Belkin, WiIMO, Cisco, X100, Cisco X 3500, D-links, WPS routers. There's just a long list of these. HP DustChat, Photosmart, OfficeChat, MV, NEC. Yeah. And this is the list as of June 9th, 2020. This is going to be updated, they said, as they learn more devices. So how do we figure out if a device is vulnerable? Any good security researcher releases their code. And this is all available on GitHub. You can go through. It's all in Python. They have testing and, you know, they've really documented the whole schema and breaking down exactly how they did their testing. So they can, you know, go in here and dig into it and does, what a mess. And we'll play with the code later, maybe. But for right now, it's you can see it's just kind of a mess overall. Now there's a good write up over here at Blaping Computer on the same topic. Call stranger UMP and Pbug allows data theft, DDoS attacks and land scans. Now the way Universal Plug and Play works and why they said land scans, and this is one of those problems is it's allowing something to grab the Universal Plug and Play ports and change them. So if you're not fair with Universal Plug and Play, it is a security nightmare, but a consumer convenience. And what I mean by that is in the olden days of the internet, in the earlier days of me playing games, it was always, you know, going through the details and port forwarding things in your router to try to get a game to work. Well, obviously they wanted the gaming industry and other industries related to that needed port forwarding and all the different IoT devices now taking advantage of this. The UPNP was designed to just automatically and universally plug and play those ports. So you have an Xbox, for example, which is one of the vulnerable devices listed on here, and that Xbox would go talk to your router and say, I would like you to open these ports so we can play this game. And a router would say, no problem, let's go ahead. And the router firewall would open up the ports and away we go. Now you can see this is really convenient, because now I don't have to try to walk someone on the phone. Oh, to play this particular game, here's the list of ports. Here's all the settings, TCP, this and UDP that and port this and port that. And, you know, that's really challenging. And Universal Plug and Play solved that. And from anyone who's doing security research, it's just a place to keep poking at. Now, generally speaking, you're safe with UPNP, generally speaking, because the device needs to call out to play the game. So it does so in a manner by which talking on the inside of your network to make that external connection. Now, what this vulnerability is, what happens is some of these devices have it facing WAN and LAN. Or some people, for reasons beyond my knowledge, because it, well, there's not good security practice. I, you know, don't know the way to describe it, have put some of these devices with UPNP directly on networks, directly public facing on public IP addresses, essentially not behind firewalls, and some firewalls, some of the consumer ones and some of the devices also have this problem where they're listening on the other side, they're listening on the WAN port. So this allows all kinds of pivoting in and out of the network. And if these devices themselves that are behind a firewall also call out to a server and have that malformed information, they are going to perform what they referred to as a pivot. So they reached out, got bad information, pulled the call back, and then they can pivot within the network and essentially reflect and act like essentially like a cross-site scripting attack. And there's like a lot of little flaws that could go wrong here. Now, how do you protect yourself against it? And let's just scroll down here. We do have some mitigations and protections about it. So despite patches being available for almost two months, updating all devices is unlikely to happen anytime soon, if ever, which is just the fact of things. People don't update things. And if they don't auto update, no one bothers to load new firmware on their devices. It mainly depends on the vendors to implement, fix, and it takes time when dealing with the protocol of vulnerabilities. Furthermore, many devices will no longer be supported and are not able to receive updates. That's just common. These devices get out there, unless there's an extreme market pressure to do so. But let's talk about fixes. So not all UPNP stacks are available. There are a couple that are not. So there's going to be that issue that if you have a device, which is not easy to tell because this is a developer choice and you may not be aware of what the developer used to build the device you're using, but let's go down to the actual mitigations here. Disable unnecessary UPNP services, especially for internet-facing devices. Now, this is just a really important thing, and you may or may not be able to, depending on if you have a consumer device that has that ability. Check intranet and server networks to be sure UPNP devices, routers, IP cameras, printers, media, gateways, etc., are not allowing data exfiltration. That's going to be a little bit tricky, but I'm hoping that in most corporate networks that are properly configured, you shouldn't have UPNP devices in there able to open up ports. That's just definitely not a policy that you should allow. Go through network security logs and check if there's vulnerability that's been used as a threat actor. Contact your ISP, DDoS Protection vendor if there are solutions to block traffic generated by UPNP, subscribe, HUTB, notify. That last one is where I think we're going to see a lot of the mitigations. So a quick search on show Dan showed that there are about 5.4 million devices out there listening for UPNP requests. That's where we're going to see a major issue here. And many of these devices are probably owned by consumers, some of them owned by businesses that misconfigured them, or IT people in general who just did not configure these well. And we're probably going to see a bunch of mitigations coming directly from the ISPs. Not the first time this has happened. Years and years ago, when the internet started becoming more popular via cable modems and such, the first problem that was discovered rampantly was that, well, people were just plugging it right into their computer without a firewall and then publicly sharing their printers and publicly sharing their files. Whoops. Because years ago, that's just how things were and no one really put a lot of thought to it and Windows didn't even have a firewall by default back then. And the ISPs were quick to step to the rescue of all the fun that was being had of people sending things to random people's printers that they could just find publicly exposed internet, which unfortunately we still have printers exposed to the internet, but you'll see more filtering going on undoubtedly to help mitigate this because it causes a big burden of massive traffic going back and forth with a DDoS if all these are exposed and people send this mail formed packets on UPNP and turn these into basically just ready and waiting bots to go do something and make a bunch of noise on the internet. So my guess is we're going to see a massive amount of filtering, which is not necessarily a bad thing. That's how the ISPs solve the problem to some extent with the home users. The enterprise users where they're just getting a pipe and no filtering at all, that's where I'm hoping, I don't know all those 5.4 million how many of them are enterprise versus home, but boy at least some of them definitely are. So we'll see those devices hopefully just get knocked offline or something. I maybe someone will say, Hey, maybe we should fix this because they see some massive amount of traffic. I don't know. The good news is it's not as, I mean, it's bad, but it's not as bad in terms of your home users, your consumers, your devices are not going to turn against you and take over your network.  Those should still be, if you want to follow good security, those should still be on a separate network. And also, and I use my laptop as an example, my laptop comes into hostile networks all the time and this is running Linux, but you can do this the same with running Windows, turn the firewall on. You don't need, unless you really have a need, you don't necessarily need anything inbound on your computers to be listening. So if you are sharing a network with one of those devices, don't worry about it too much. If the Xbox is over there and it's on the same network, likelihood of them turning the Xbox to turn an attack to your Windows 10 computer, Windows 10 laptop or Linux laptop, pretty unlikely and those type of devices because they're well updated. If you have some random kind of off brand as cheap as you could find IoT devices, well, there you may have a problem. Keep those on a separate network if they need internet. They're the most likely to be vulnerable from things like this because many of those devices, when it's a race to the bottom of price, one of the things quickly sacrifices any type of firmware updates, proper vetting that they even used a more modern stack or any security validating of the device ever. It was basically done is lowest bidder. How cheap can we get this thing working? Don't worry about just using the same password on all of them.  So I'll leave the links to the Bleeping Computer article, the CallStranger.com and the list of updates. So if you have one of those devices listed on the vulnerable list, see if there's a firmware update. If you have a commercial firewall and I'll throw out there because I do a lot of videos on PF Sense by default, PF Sense and many other commercial firewalls do not have UPNP enabled at all. It is something you have to forcibly enable. Alternatively, if you didn't want UPNP because you had it on previously because you wanted some game system to automatically talk to your router and put you decided maybe that's not the best idea, even though it's really convenient, you could also just look at manually mapping ports in there. That's another way to kind of mitigate this in case there's any further problems found with UPNP. Those are my thoughts. Go ahead and read up on it here. I'll keep you updated if there's something more to it. But for now, we'll see how many of those 5.4 million devices get turned into some type of major botnet and cause chaos on the internet. It's a matter of time now that the research is out there or it's could have been already being done and this research is just highlighting it. We'll figure that out. It's always better to know and patch than keep this all a secret. It's about getting the information out there. Thanks. And thank you for making it to the end of the video. If you like this video, please give it a thumbs up. If you'd like to see more content from the channel, hit the subscribe button and hit the bell icon. If you like YouTube to notify you when new videos come out. If you'd like to hire us, head over to laurancesystems.com, fill out our contact page and let us know what we can help you with and what projects you'd like us to work together on. 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Everyone it's your girl Kenzie here from Leighton sports cards, and I'm ripping 2021 panini flawless football hobby one box break number 31 left-side serial number Again, here's a look at the random results. You can always find these at leightonsportscards.com Excuse me underneath the results tab link is also in chat for you again Everyone Sam will also be reading off who hits what as we go Just remind us is a left side serial number You got a number assigned to you randomly through random org Any card pulled that same left side serial number is yours So for example if you hit number two you'll get any cards number two out of five two out of ten two out of twenty two out of twenty five Here we go Not a bad one either Go everybody best of luck. We've got quad rookie showcase for the Cardinals Rondell more 20 of 20 bookends 20 spots Anthony B on the 20 spot And we've got rookie patch for the Dolphins 24 25 Jalen waddle Patrick P Patrick P on the 24 spot To color of waddle patch And we've got patch auto three out of 20 James Robinson for the Jags three spot Patrick P again Patrick P very nice Game one.  They are on the game more. That's 20 No, it's it's it cool. We've got Earl Campbell greats from the oiler 17 of 20 17 spot Harper B Harper B There you go. Harper Got another greats this time from the Rams a Torrey Holt seven of 15 Is Don G don G on the seven spot honored ink bunch of throwback out of this one 2002 NFL MVP from the Raiders rich Ganon. That is nine out of 25 Adam K Adam K on the nine spot. Thanks rich Ganon And We've got patch auto for the Broncos three of 25 Javante Williams three spot Patrick P again Patrick P That is sick Magnet it really is it is so soft Love this shirt this one in the late in gaming the late in gaming one is the same material We've got 14 of 20 for the Chargers Antonio gates 14 spots Curtis Curtis E on the Ruby there. Yeah, KP.  How about nine of ten flawless penmanship Aaron Rogers? boom Adam K There's no diamond in this car So I'm gonna put the diamond guarantee with the Yeah with the gates because Patrick Mahomes is the patch as it makes sense There's no there's no diamond on this one. So I'll go with the only card with a diamond nice Aaron Rogers Who'd you say again? Adam K on that one kink rats Adam. All right, that'll do for the first left side serial number We've got another one coming up in a few minutes. Thank you everybody


If you're looking for a video on a specific topic, simply type in what you're looking for in my channel, Search Bar, and if I have videos addressing that topic, it will take you right to them. What's up, you guys? It's Adana. Welcome back to my channel. As promised, I'm going to be doing an in-depth review of Kaplan's Cubank.  I will provide a link for that in the description box below. You can access the Cubank on your computer or on your phone, which is what I'm going to do because my kids actually have an appointment to go to a dentist's appointment. So let's go. So we're at the dentist's office, and I'm going to be doing the Kaplan, like, Cubank right now because I need to study, right? So it says a 25-year-old woman comes to the healthcare provider for an annual exam. She's been feeling well over the past year. Her past medical and surgical histories are unremarkable. Her past OB history is significant for term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medication. Which of the following supplements should this patient take? So it has folic acid, four milligrams per day starting preconceptionally. Folic acid, four milligrams per day starting in the first trimester. Vitamin A, 10,000 IU per day starting preconceptionally. Vitamin A, 10 milligrams IU per day starting in the first trimester, or no supplements are needed. So I'm going to go with A. And then let's see if I got it right. Explanation. The correct answer is A. Oh, I feel good.  That says the correct answer is A. Several studies have established a relationship between folic acid and the prevention of neural tube defects. And it goes on to talk about what choice B was and what the recommended dosage is. And then choice C, why that one's incorrect. And then choice E, of course you need to do prenatal vitamins prior to actually becoming pregnant. So no supplements at all is just incorrect. All right, well let's go to the grocery store because they're done. All right, so as you can see, we're here at the grocery store and I did some light shopping, but I'm also doing some study. And that is the beauty of having this Kaplan Q-Bank on an app. You can take it wherever you are. And you guys can take it wherever you want to go as well because I have partnered with Kaplan to give you all access to this app with a 15% discount. So I will leave that link in the description box below where you'll be able to access this app for 15% off. You can also go right now if it's setting for the pants or didactic year for 20% off because they have a back to school special. But let's do this question. It says a 20 year old man is brought to the emergency department three hours after ingesting 50 tablets of 325 acetaminophen in a suicide attempt. He's nauseous and vomiting but no other abnormalities on physical examination. His temperature is 37 degrees Celsius. Blood pressure is 135 over 80, pulses 100, and respirations are 20. Serum cinaminophen concentration is within the range of probable toxicity. But serum transaminase and other hepatic markers are normal. Which of the following is the most appropriate next step in management? So it has activated charcoal, acetylcysteine, it has phenylcyclamine, activated charcoal and acenocysteine and gastric lavage. So I'm gonna go with D. I know that you can do activated charcoal and acetylcysteine especially within the first eight hours and I think four hours for activated charcoal. So let's go with D. We'll see. The correct answer gets me. My gosh guys, I learned something in didactic gear. I feel really good about myself right now. Okay, she's starting to get a little crazy but it goes through and it gives you the correct answer and why the other answers are wrong. Since she's getting a little crazy, I'm gonna go pay for these really quickly and we'll be on our way. So we're here at the park, had to bring the kids because they were acting up. Gotta get some of that energy off, but I also need study. So I'm doing another question and this question says, a 43-year-old man with recurrent history of peptic ulcer disease associated with diarrhea and strong family history of duodenal ulcer disease is suspected of having Zollinger-Ellison syndrome. Socretin is given as a rapid IV injection to test for gastronoma. Which of the following results would support the existence of gastronoma following secretion administration? So the question answers have gastrin released from antrum, increased serum gastrin, inhibition of gastric emptying, inhibition of gastric secretion, stimulation of pancreatic. HCO3 secretion. Okay, so I'm gonna go with the increased serum gastrin, that's B, because I know with ZS, like Zollinger-Ellison syndrome, you're supposed to have elevated levels of gastrin. I don't really know about anything else with the whole where it's released type of thing if that goes with another disease, but I'm gonna do that one. So, no, not that. And going with increased serum gastrin, let's see what the explanation says. B, gastronomas are gastrin secreting tumors. Yeah, patients who have gastronoma have high serum gastrin levels, which lead to hypersecretion of gastric and consequential duodenal and gigenal ulcers. So it tells you, oh, let me see that. The answer that I had that was that I was questioning. A, it says secretin inhibits antral release of gastrin, but it stimulates release of gastrin from gastrin tumors. Okay, so it would inhibit gastrin release from the antrum. So that's something that I need to just kind of go ahead and brush up on. And again, it tells you what you would review Zollinger-Ellison syndrome. So again, another test question down. If you do like five or ten of these a day, you're gonna be a beast.  And there's how many days in the year that you're going to school for until you have to pass your pants. I have 14 more months of this, so we've still got this. Oh, I gotta go, she's gotta pee, gotta go. The bathroom break is done. We have averted a crisis. Gonna wash our hands and then we're gonna go and actually see these little ones because they're hungry. Go ahead and wash your hands. But again, I still need to study and still have to keep up on my questions. So I'm gonna do that very shortly.  Are you done? You're just playing right now. You're done. She's done, you guys. Let's go. You're done. All right, but still got my phone. So we're gonna do this next question. And on this question, we're gonna be talking right now. It says a 25 year old main man sustains multiple stab wounds to the abdomen when he's mugged while jogging. The assault takes place in the evening. He is dumped by the attackers behind thick vegetation and is not found until the next morning, at which time, exploratory surgery reveals multiple small bowel and colonic lacerations. What? All of the lacerations are repaired. In the post op period, the patient has persistent hypertension, even though he received adequate fluid infusion and his central venous pressure is 12 millimeters per mercury. Further studies done with the help of pulmonary artery catheter revealed high cardiac output and low peripheral resistance. Which of the following is the most likely diagnosis? Adrenal insufficiency, cardiogenic shock, hypovolemic shock, neurogenic shock, septic shock.  Let's go with hypovolemic shock. I'm really just guessing on this one, but I would think since he was mugged and then he was staying over there overnight and he wasn't found until the next day. Maybe he is volume depleted. Let's see if that's. So I was wrong. The correct answer is septic shock, which also makes sense because he's been there overnight. His small bowel was perforated. So there's probably some type of infection going on, but it tells you the signature of septic shock in the normal volumic patient is high cardiac output and low peripheral resistance, which is what they made sure to say in the question, Sam. So that's something that I'm going to write down and remember so that I can go back and study it for later. But right now I have to go eat something. All right, so the kids are fed. I haven't started eating yet, but I'm going to do that. But before I do that, I want to get into this last question that I'm going to do for you guys. It says, an eight-month-old boy is brought into the office for a regular checkup. He is developing well and does not seem to have any particular problems. He is still breastfeeding, but has started solids at five months of age. He enjoys strained vegetables and fruits, cottage cheese, soft meats.  She's interested in recommendations as to introducing other new foods in the months to come and expects him to be eating almost everything by his first birthday. On physical examination, the boy is sitting currently in his mother's lap and responds appropriately to visual and auditory stimuli. He is in the 19th. Yeah, is that the 90th? He's in the 90th and 95th percentile for height and weight, respectively. The immunizations are up to date. Which of the following foods should be avoided before the boy is one years old? So a lot of times, these questions, just like they will appear on pants, has a lot of these kind of like distractors. So talking about vegetables, he enjoys eating strained vegetables and fruits and cottage cheese. Like we don't really need to know that. Who cares about that? Unless it's really pertaining to something that's happening with the boy. Like if he was not, you know, having really excessive bowel movements or something, then we're thinking, oh, maybe he has like a lactose intolerance because he's eating cottage cheese. But since that's nothing that's happening with him, you just go on to the question and the answer is, it says beans, egg yolk, fish, honey, iron fortified cereals. Of course, you're not gonna stop iron fortified cereals. You need that. They don't get iron as it is. Fish, I mean, yeah, you might think of mercury. So that's kind of like a little bit of a distractor. Egg yolk in the same thing. Beans, no, you need protein. But I'm gonna pick honey because you don't give honey to kids under the age of one because of botulism. So I'm gonna do that. I'm pretty sure about that answer. Explanation. The correct answer is D, honey. Solid foods can be introduced four to six months. Before this time, the risk of adipi is increased and infants are not mentally ready to take solids. It says honey is to be avoided in the first year of life because there's increased risk of infantile botulism. And that's something that you just learn automatically anyways in PA school. So that's it. That's Kaplan's Cubank in a nutshell. You can go in there and also create your own tests. You can talk about the different tasks or specific systems. So if you just wanna learn about cardiology, you can just ask for cardiology questions and you have up to 99. So it may have 200 possible questions but each test can have up to 99 questions. And if you do three to five questions a day, you're gonna be a beast in cardiology when you're done. So be sure to go on over to the link that I will leave in my description box for Kaplan's Cubank as well as the other resources that they have for you. You will get 15% off if you use my code, which is the down of 15. And you can also do the back to school code, which they have until September if you're studying now and you need a little extra help, which will give you 20% off. I hope you guys enjoyed this video and thank you guys so much for watching. I will talk to you guys next time. Bye.


back to my channel and happy New Year. I am so excited for this New Year. And today I have a really cool video for you all. I'm doing a regular cleaning video, but I've also teamed up with five other mamas here on YouTube and we are giving you guys a $300 Visa gift card giveaway over on our Instagram account. So the link for that will be below and the other girls that will be joining me and their video links will be below as well are Krista Bowman, Brittany Leish, Lynette Yoder, Lauren Midgeley, motivational videos for you guys as well so don't forget to check out their links below and the link to enter the giveaway will also be below and I am going to try to get as much done as I can while my little ones are napping today so hopefully I can give you guys a lot of motivation. Don't forget to check out the description bar and I think we'll just go ahead and get started. You better turn. All right you guys, so real life kicked in and I actually did not get my cleaning done the day that I filmed that intro. This was actually the next day. We had sickness the week before the girls did and then this day I got it so if I look a little rough around the edges that is why also if my voice sounds a little raspy that would be why as well. But I just started off by getting my dishes all cleaned up and everything done that the kitchen needed and yes, there's a cup under my dishwasher because I have little people that like to climb on top of it and they have already broken it partially so I put a cup under there just to make sure that it doesn't get broken the rest of the way. I washed a couple things, just my tumblers. I don't really like to put them in the dishwasher. I'd like them to last as long as they can and I know it's not very good for them to go through the heat of the dishwasher. Next, I just ran upstairs and collected all of my girls' bedding. I have a little one that is potty trained and so she has to have her little potty by her bed so that she doesn't have any accidents. I see no reason why I should ever let you get without. This little scene that you're seeing is called bathing one, two and three rolled and then the one-year-old getting into the tampon drawer. Oh my word, real life guys. Tell me what you wanna do. I think we're part of something bigger and now my mind is filled with you. I have said this to you guys so many times but I love my spin mop. It is always in the description box if you're curious. Thanks a lot for watching you guys today. Don't forget to enter the giveaway and check out the other ladies' cleaning videos and hit the subscribe button if you're new to my channel. Give this video a like and I'll see you in tomorrow's video. I don't wanna waste my time.


So, welcome you to Krishnaganta Hendrick State Open University and the community radio service of the Krishnaganta Hendrick State Open University, Gyantharanga. This is the first community radio service of the North East and which is managed by the university, but it is its programs are basically run by the community, community living in the vicinity. So, welcome you sir and we are very privileged and we feel very honored to have a guest of yours that is here among us. So, let us start with some questions basically our questions will be small questions, but loaded questions and this will be mainly dropping will be done by you only because people will like to listen to you not us. So sir and he is the dean academic of the university he is with us, he is Dr. Amuraditi Choudhury and I am the registrar, I am R. B. Mohanta, President Varun Mohanta sir. So let us first start with questions on your area of work as we do the constitution in the constitution of India there is article 21a to article 24 then direct to principles of state policy. And again we have plethora of laws and acts like the factories act of 1948, the mines act of 1952, child labour prohibitions and regulation act this is 1986 juvenile justice care and protection of children act 2000. And again RT write to compulsory and free education to children act 2009 in spite of having the constitutional provision in spite of having all these laws why do you feel that some kind of movement is necessary for the protection of the size right. Is there any inherent deficiency in the constitutional provision or in the act or in its implementation sir. Thank you very much first of all I would like to congratulate you for the community radio service. Thank you sir. And it is my privilege and I feel honored to be here on the day when the great saintly scholar of this nation and of Assam professor K.K. Handik was born so today is his anniversary so I feel very humbled about it. To answer your question let me tell you first thing at outset that the constitutions are and laws are very important but society is not necessarily run on the legal frameworks and the constitutional guarantees and provisions there are many more components in it.  But these issues are social evils on one hand, crimes on the other hand and thirdly they are also related to the broader economic and development aspect of society. So, when we talk of evils then we have to work with the communities to change the mindset set of the society where the people respect children, people respect childhood. So, dignity of childhood has to be ascertained by society and we as society as community must realize that exploitation and abuse of children denial of childhood is a social evil it is bad and that has to come very strongly and clearly from the society. So, that is related to the changing of mindset of the people then I as I said it is a crime so we have to have good laws, some laws are good some laws are still weak but more important is the enforcement of laws that requires political will that requires strong monitoring that also requires the capacity of the monitoring and implementing agencies including the enforcement authorities. So, that is one aspect when I talk of capacity it means they are training their orientation their accountability and so on. But also the community itself must know about their rights in most cases when it comes to the children and women they are not aware of their rights especially the victims and survivors they have no idea that what are the constitutional guarantees which ensures and protects their rights they are not. And community as whole does not care for those things so it goes on and on so the implementation has both the aspects the political and enforcement aspect from the government agencies as well as the social aspect where the people should be empowered about the knowledge of their legal rights so that is the second part. And when it comes to the third part and that is the economic part is that until and unless in India or anywhere in the world if we do not have any a kind of inclusive and equitable democracy inclusive and equitable development and guarantee of right to life with dignity which is the fundamental right ancient in our constitution that has to be translated into action in economic terms also where everybody is free from hunger malnutrition and some sort of fear of livelihood so that economic aspect should also be guaranteed. So once we see the whole problem in a holistic framework and holistic perspective then we have to attack it from many corners I have been advocating for many years now it has been established through many of the academic researches and surveys and so on that child labor is not an isolated problem child labor is very directly linked with poverty and illiteracy but the general perception is that child labor exists because of poverty. But for last 35 years I have been trying to argue that child labor also causes poverty and perpetuates poverty child labor also causes and perpetuates illiteracy where the illiteracy causes child labor so what I called a triangular relationship between illiteracy poverty and child labor these three things have to be tackled together because they are cause and consequence of each other they form a kind of chicken and egg relationship nobody can say that who was born first and who could be killed so every the entire spice you could be killed I am not talking about that but this is a research circle and we have to break this research circle by way of killing all these three evils of poverty illiteracy and child labor simultaneously.


Last fall, at the face-to-face with the PLC, we had an opportunity to meet and talk about areas that we would like to find out some information. And one of the areas that was brought up, I believe, primarily from the Calgary contingency was auditory neuropathy. Who are these kids? What is auditory neuropathy? How can we best support them? And it took me a little while to find Beatrice, but I did find her through my connections with people in the Glen Rose, and Beatrice finally agreed to providing us with some information about auditory neuropathy spectrum disorder. And Beatrice, is that the Glen Rose Hospital as a temporary individual? And a lot of her experience has been in Calgary, I believe at the Children's Hospital, and you can help me out with that, Beatrice, in your introduction. So I'm going to hand over the mic to Beatrice, unfortunately not the camera, and we can all learn something today. So thank you, Beatrice. It's for you. Thank you for the opportunity. It's always good to discuss this with everybody. Make sure we're all on the same page. First of all, I'm going to apologize. I'm just getting over a cold. So if I mute suddenly, it's because I'm coughing. So an overview of auditory neuropathy spectrum disorder. So basically, I would like to kind of look at what exactly it is. Just hang on. There we go. So just briefly about me. As you were saying, I'm currently at the Glen Rose rehabilitation hospital as a temporary audiologist, but I spent a lot of my time at the Children's Hospital in Calgary, and we were seeing these children with this particular set of problems come through the clinic. And a lot of times we were struggling as to what to do with these kids and how to follow up with them and what services and what supports do they need. And so while I do not at all claim to be an expert, I have seen quite a number of cases just from my time there. And I'm finding also with my time here in Edmonton at the Glen Rose, because oftentimes we see quite a few adults with this particular problem as well. So just a brief overview. I'm just going to go briefly into each of these areas. So a quick definition of what it is, a little bit about the anatomy involved, how often it occurs, and what we do to assess auditory neuropathy and the sort of risk factors that you would expect to see and the types of breakdowns in transmission of sound that we would expect from it, and what you would see yourself on the other end after we've found this pattern of results. And finally, the sorts of things that we would look to to try and support some of these kids. So a really brief explanation of what this is, a rare form of hearing loss where sound isn't transmitted from the inner ear to the hearing nerve or from the nerve to the brain. So this is probably the simplest explanation. What it is is just a breakdown in where the sound is transmitted or how the sound is transmitted due to numerous numbers of problems. So a quick little, this is the briefest history I could come up with. So sort of in the 80s, where a lot of those electrophysiological measures were being developed in the 90s, they were noticing sort of a mismatch between their test results. So the behavioral audiograms that you would guess versus the electrophysiological measures that we were finding. And so the term auditory neuropathy sort of came about somewhere in the 90s. After that, there was a whole proliferation of a whole bunch of times. And a lot of these terms were trying to reflect where that transmission difficulty had occurred. In general, there are a whole number more than what I have here, more terms than what I have here. But in general, there are a lot of names up in the literature about this until around 2008. This guideline development conference in Italy, it was sort of internationally agreed that the name used for this particular pattern of results would be auditory neuropathy spectrum disorder. So I'm just going to go back and talk a little bit about the ear. So I'm sure many of you already know or have seen, well, should be familiar with the ear. So very briefly sound will travel through the eardrum and the middle ear system to the nerve cells of the inner ear, and that's converted to electrical impulses that travel along the auditory nerve up to the brain. So you're probably already familiar with conductive hearing loss, which would be problems with the eardrum and with or with the middle ear system and central neural loss, which would be difficulties with the inner ear or the cochlea. But for auditory neuropathy, what we're going to have to look more closely at is the inner ear and how it as it connects to the auditory nerve and also how that auditory nerve sends the information up to the brain. So for this next slide, I'm just going to take a cross section of the cochlea there. So this is just sort of a slice into the middle of the inner ear. So sound pressure waves will come into the ear and it moves the fluid in the ear and that in turn moves or stimulates the the hair cells. So you can see labeled sort of in that middle section there where that box is. We have outer hair cells and we have inner hair cells. So the sound will simulate those hair cells and transmit the sound to the nerve, which is that lovely yellow part of the picture spiral gangling on all the way up to up to the brain. So this is going to become important later. There is a reason I'm going through this. So the outer hair cells in general act to kind of amplify the sound. So there's a little or what they call a motor unit at the base of those cells. So basically what happens is when your ear hears a sound, it actually makes that sound wave a little bit bigger because it contracts and it moves that whole section a little bit more. The inner hair cells, as far as I understand it, their function is to encode sort of the clarity or the resolution of the sound. And that is important to kind of send the information up to the brain and kind of give you that clarity of speech that we're looking for. All right. So overall, the technical definition of auto-tringeropathy would be normal measures of that hair cell activity or that inner ear activity. And we measure that with two different things, autoacoustic emissions and cochlear microphonic. I'll go over those in just a moment. And the other half of this is that the auditory brain stem response. So the electrophysiological measure of the nerve is either extremely degraded or absent. So the general idea is part of the inner ear is intact, but that transmission onto the nerve up to the brain is interrupted at some point. And just keep in mind this describes a clinical profile or a pattern of test results. This isn't really a label for the child. It's just a particular issue that was noticed with a subset of children. We do have different tests to look at different parts of that inner ear versus the nerve and we'll go over that in just a moment. But why we should be looking at this. So about one in seven thousand has been noted previously to have abnormal auditory nerve function. I think it's a relatively new diagnosis, but with the move towards universal newborn hearing screening programs, I think this is becoming, I think the awareness of this problem is becoming quite a bit wider because we know it exists and we're identifying it much earlier. So I think it's more kind of an awareness of a particular problem. So of the children who have permanent hearing loss, it's estimated somewhere between seven to 10 percent of those kids have this particular pattern of results in addition to whatever other issues with hearing they might have. So I think that works out on average of children who have hearing loss, about one in 10 of those children will also have this pattern of auditory neuropathy spectrum disorder. So I'm just going to move on a little bit as to how we measure or establish this pattern of results. So the first thing I'm going to go over autoacoustic emissions. So if you recall that photo of that inner ear, that cross section, we had those outer hair cells. So basically, autoacoustic emissions is a measure of the function of those hair cells. So with central hearing loss, autoacoustic emissions are absent because often this doesn't function with straightforward central hearing loss. But with auditory neuropathy spectrum disorder in a fair number of these cases and finding different rates of present autoacoustic emissions, I think it's sitting somewhere between 60 to 75 percent. Oftentimes, these responses are present at the beginning. There is evidence that this appears later on whether or not they use hearing aids, but at the beginning they do have that cochlear response that you can see. So just moving on, I'm just going to move to the measures of the auditory nerve.  So anytime you have any sort of nerve response, so be it muscle or any sort of sensory response, it creates an electrical potential and that is something that we can read with our auditory brain stem response. So this is just a general definition of that. So that ABR response, it's generated in response to a sound. So the way we test infants, very small infants, is to play very quiet sounds and force that nerve to fire and measure what level it takes for that nerve to fire. Now for, as I mentioned previously, for auditory neuropathy, what happens is that nerve response is either absent or it's only present at extremely high levels and it doesn't look the way you would typically expect it to look. I'm going to keep in mind with this auditory nerve response, it really just moves in one direction. So regardless of what the sound is that you present to the ear, it should look the same. So for instance, if you have a clicking sound, okay that's getting too complicated. So if you have, basically it moves in one direction, that was my point. So besides measuring auditory nerve function, we can also measure a little bit of inner ear function with the ABR response and that is what we call a cochlear microphonic. So basically with neuropathy, auditory neuropathy, what happens is the normal waves that we would see in the auditory brain stem response are absent. However, we do see something at the very beginning and what that response is, is actually the inner ear. So the nerve cells are, sorry, those hair cells in the inner ear also create an electrical response as well. Now the difference between the hair cells in the ear creating the response versus the nerve, the hair cells will actually reflect changes in the sound. So it basically can change direction. So this is how we show the difference between what we think a neural response would be versus an inner ear response. So just to go through and have a look at what a normal ABR would look like versus what that inner ear cochlear microphonic response would be. So just keep in mind, this is not to scale at all. So the measures for the left side are very different than the right side. The right side is actually blown up in size quite a bit. So on the left side, we have what a normal auditory nerve response would be. So if you notice there's a lot of, so they're, and it's marked, so there's one, three, and five. So there are these peaks in the normal ABR response and those peaks correspond to different structures in the auditory system. So for instance, that would be sort of the auditory nerve and the back of the brainstem up to the top of the brainstem. So essentially that's what those peaks would represent or where those electrical responses are generated from. For the abnormal ABR waves, you notice that there's something that's really, really high in PV at the beginning, but the response sort of peters out and you're not getting this nice wavy response that you would expect. So what that response is at the very beginning, this is not a neural response, this is actually a response from the inner ear, from either the inner or the outer hair cells from that inner ear. And you can see the top two lines, the sound presented there is actually exactly opposite as compared to the sound that's presented on the sort of the middle two lines there. So at the very bottom, they've actually stacked those two together and you can see it creates this big butterfly kind of plot. What that butterfly plot is telling you is that the response is actually from the inner ear. So in response to changing the sound that we're presenting to the ear, those hair cells in the ear actually change in direction as well. So it's giving us sort of an opposite electrical potential to each other. So it's sort of a nice double check for us to see if that part of the ear is functioning versus the neural part of the ear. Now in a normal hearing ear, you still have cochlear microphonics. The thing is the nerve response is so much larger that it actually hides the cochlear microphonic response. The only reason you see cochlear microphonic response when the rest of the ABR is absent is because there are no other neural responses. So when we blow it up, we see this nice kind of opposite butterfly plot effect for when we're measuring that inner ear. So for this next slide, I found this photo of one type of auditory neuropathy. Excuse me. And this is just one type of auditory neuropathy. So it's actually a cross-section of a normal auditory nerve on the left side versus an auditory nerve that is affected on the other side. And you can see the fibers on the right side. There's much fewer as compared to the left. So this is one type I just thought it was a little bit interesting to look at. So looking at a few of the risk factors, I know there looks to be a lot of them. Mostly these fall into three main categories. The first would be some sort of neonatal history. So hyperbili rubenemia or jaundice, high jaundice requiring transfusion, extreme prematurity, so below 28 weeks, low birth weight, oxygen deprivation, mumps, sepsis, meningitis. Any sort of lack of oxygen to the brain is also known to be a risk factor to develop auditory neuropathy. And as you can probably guess, we see quite a number of cases, especially with that extremely premature crowd, just because of that lack of oxygen. So oxygen is always a huge problem when you have extremely premature children, when those lungs aren't developed yet when they come out. And so it just puts them at risk to develop this particular issue. The second main set of causes or risk factors for auditory neuropathy would be particular genetic conditions. So as you can see, they have a few in there. So the OTOF mutation sort of in the middle there. And that's actually specific to a type of transmitter in the inner ear. And then there are other ones that basically look at vestibular and auditory nerves issues. So it is known to be part of those particular genetic syndromes. The other main category that you would see would be if there is something anatomically a little bit different.  Just keep in mind, this isn't a comprehensive list of risk factors. There are a whole host of other things that do serve as a risk factor for auditory neuropathy. But this is just sort of a nice summary of some of the main ones that we see in general. So I just wanted to use the slide a little bit to show that based on the test that we have, we can occasionally narrow down specifically where the sound isn't being transmitted, but the majority of the time we can't really rely on it because our test results have the tendency to look the same for different areas of where the system isn't transmitting. So we can't really depend on our pattern of results to say exactly where the issue or that breakdown in transmission might be because it would be similar clinical responses for multiple causes. So it just does a summary to this. The main parts that it could break down, so this is just a list. So essentially where the those inner hair cells are, where the auditory nerve, how the auditory nerve connects, and well just essentially just based on the test we have, because we can't tell the difference between the causes of auditory neuropathy spectrum disorder, we can't really predict how a child will perform in a classroom setting or in day-to-day interactions. So this is what we call it a spectrum disorder and why outcomes for hearing might be extremely unpredictable. So in general what we would tend to do for kids, so if we're looking at below six to eight months, we would be doing those otocoustic emissions and we would have those estimated levels from the auditory brainstem results. Now the problem with using ABR in that population, we don't actually know what level that child is actually hearing at. We know it's at least that level but potentially it could be much better than what we're getting from that test. Now for children six to eight months or older, we would also do those otocoustic emissions in ABR but more what we would be relying on would be that behavioral testing in the sound booth because where the child is actually responding would really give us an indication as to whether or not they're able to detect sound in the first place. So just to mention there is some work that's being done right now and it's very preliminary still and you get sort of later brain responses, so higher level brain responses in determining sound differences to try and figure out what levels infants are hearing at. So in that before six to eight months crowd that's the sort of thing we would be looking at. It's not been an Alberta, those tests in particular and I think from what I understand they're still at the beginning stages of using those results to kind of determine hearing levels still so it's still to be to be seen if this is going to be effective to tell where exactly the child is hearing at but still I think we're still relying on that behavioral testing to try and tease apart where exactly they are responding at. So that's the very young kids. Now for older kids I forgot to talk about acoustic reflexes but there are there is a middle ear reflex that relies on function of the inner ear and the auditory nerve and oftentimes those are either elevated or just completely missing in children with this profile. Behavioral testing could be anywhere from normal to profound in any configuration and again that ABR is going to be relatively degraded or absent and the thing to note though the word recognition or the speech discrimination would be much poorer than your audiogram would suggest and the other thing you would see in the school age population would be greater difficulties hearing when there's a lot of background noise or a lot of competing noise and that's that's what we would typically expect. So listening and noise requires very fine tuned kind of timing to to understand speech and to figure out where sounds are coming from and if the nerve system isn't functioning optimally then that kind of creates a bit of a disadvantage for that child and that's where that difficulty kind of comprehending in noise comes from. So that's what school age children there is some preliminary research that shows that for teenage years so sort of mid to late teenage years it looks like some kids with this profile their behavioral thresholds actually get worse and their discrimination or rather their ability to comprehend speech also seems to decrease as they get a little bit older too. The causes of that aren't well known yet but it does seem to be a bit of a trend. So just a bit of a conundrum so we have two audiograms here and everybody here is probably versed with the audiogram so down the side you've got your your decibel to your levels of hearing and across from left to right on that horizontal axis you've got the different frequencies. So just based on the audiogram I guess the question would be would you predict better or worse speech and language for one versus the other? I'm not sure if anybody has a particular opinion about that. From what I've seen previously and from from what I've seen in the literature as well the the audiogram doesn't really tell you a whole lot it tells you where they can detect environmental sounds but it doesn't really tell you about how clear that sound would be or if the signal is reaching the brain in a fairly intact form. So really the question would be what does auditory neuropathy sound like and the answer is we don't really know. I mean the behavioral audiograms may be similar or you might have sensorineural loss that looks very similar but the sound quality might be different very very different for a child with this profile versus sensorineural hearing loss. So really ABR and behavioral thresholds so ABR results and the audiogram are pretty poor predictors of whether or not they're going to understand or they're going to going to be able to obtain enough intact sound to be able to distinguish speech and language. In some cases just as a side note there was some pretty suggestion that those ABR there was some suggestion that those ABR responses would improve but the jury is sort of out on that. It does seem to happen in some cases and personally I had seen it happen myself where the ABR does seem to improve but generally it doesn't improve completely to normal from what I've seen. Whether or not that actually happens it's still to be seen. Behavioral thresholds there is also some question whether or not those behavioral results will also improve and really the jury is out. There's a lot of literature and I mean that that is something that is that is thought to be the case in the UK but I know in North America I think they're moving away a little bit from that because I think the idea was that some of those initial tests ABR tests for neuropathy were perhaps not as clean or maybe a little bit noisier so you can really evaluate some of those responses as you would expect. So just as I guess a little bit of a simulation I did find an interesting sound simulation of auditory neuropathy. So because we don't know what quality of sound the child is getting there might be complete distortion or it might be just like a little bit blurred out. So what this simulation is looking at it actually presents extremely disturbed sound and it just gets comparatively clear. So with any child with that profile of auditory neuropathy we don't know where they are in terms of that clarity spectrum. So this is just sort of nice to illustrate the level of distortion that might occur. So hopefully everybody has their sound on and that doesn't seem to want to work. Okay never mind moving on. If anybody is interested I can send the link to that sound simulation another time. So this is just an analogy to vision because I had a feeling that the sound clip wasn't going to work. So I guess for some children without auditory neuropathy I mean the sound might be a little bit blurred or there might be big huge holes in what they're hearing and really we don't know which end of it they're on or what precisely they're hearing. It might even be even more degraded than what you're seeing on the screen right there. So because we don't know precisely where they are on that clarity scale the idea is that no single approach works for every child with this profile. So some will benefit from technology such as hearing aids or cochlear implants. Some might need a combination of like visual communication and spoken language. If they are using hearing aids or cochlear implants or cochlear implants just that listening technology is going to be very important and I'm going to come back to that in a little bit. So really from what I've seen in the past and from what a lot of the literature states like you might start with one approach and then you have to change just depending on what's happening with the child and whether or not they're hearing enough clarity to be able to develop that speech and language. So as you can probably imagine I'll just for neuropathy this inquire if this requires a complete management team. So this is just an example so pediatric audiologists you would need like the diagnostic the assessments educational audiologists of course prior practice or the sitting or dispensing audiologists pediatric ENT and neurology usually they would need to do some monitoring and to see if there are other other issues involved with the auditory neuropathy. So oftentimes our auditory neuropathy doesn't occur necessarily in isolation it can occur with other types of neuropathies as well so a lot of that though is dependent on what the initial cause or etiology would be. Of course you definitely need a speech language pathologist on board mostly because we need to monitor that speech and language development or rather they need to monitor that speech and language development particularly that speech and language trajectory because we need to know that the child is obtaining enough information with whatever intervention they have to develop that speaking speech and language and if they aren't then that's where we're queued to switch gears and try to try to find another way to support the children. And of course the teacher in the classroom support is very important because oftentimes children with this profile need a little more support. So other professionals that you would probably have on this team would be social work and psychology the psychology in particular because you at some point you would want to look at that nonverbal learning ability of the child particularly if that child hasn't progressed in speech and languages as you would have expected so then you can separate it from language versus there are any sort of cognitive delay as well. In terms of interventions and mode of communication pardon me so a lot of the interventions are really determined by what we see from the child again that progress so the monitoring is really important there and and really what the needs of the family would be. So every every family every case is going to look very different and really we need to take this case by case there isn't a cookie cutter method that is going to work for every child with particular profiles. Now with with interventions I'm sure probably wondering how effective something like hearing aids would be. The current recommendations for and I'm blanking on it's in the States the American Academy of Audiology in the States the current recommendations would be to trial hearing aid technology if that behavioral audiogram is showing that their the levels that they're responding at are insufficient to support normal speech perception. So this is particularly important to give it a go because you know a lot of times like yes amplification outcomes may be mixed but a lot of kids do show quite a bit of progress with hearing aids so it's really that constant monitoring to really determine whether or not they're they're holding their own or whether or not we need to switch gears. You know I mentioned briefly before especially with how the nerve transmits up to the brain those timing cues and the I guess the clarity of sound is not the same as what you would expect. So I'm going to come back to come to this in the next couple of slides. We do know that children don't with auditory neuropathy do not do as well in noise and so I just wanted to briefly mention that there are different types of technology does like hearing aid technology out there to manage that background noise more effectively. So you do have just those different levels of technology so you have your entry level you're mid and you're high and I'm not saying you need to go high level to get those noise management features but oftentimes a lot of those sound management or noise management strategies aren't really available in the basic entry level technology so basically what I'm saying is for kids who are undergoing for neuropathy kids who are undergoing hearing aid trial they really need to have a good conversation with whoever's defensing the hearing aids just to see what would be appropriate in terms of trying to manage that background noise problem and and seeing what their options would be for that excuse me. So I did find a nice little kind of summary study of comparing children who have that profile of auditory neuropathy versus center neural hearing loss and so this particular study was looking at children who identified via universal newborn hearing screening programs in the states and this is across multiple centers and they matched the kids based on hearing levels so audibility, age of identification, gender, a degree of hearing as I was saying degree of hearing levels so the nice thing about this study is when they looked at these kids they followed these kids out for quite some time I think it was three to five years and as they were measuring different parts of language and teaching language they were finding that there really wasn't any significant difference between the children with that auditory neuropathy spectrum disorder versus the center neural hearing loss so all these kids had hearing aids at about the same age they were identified at about the same age and they have about the same levels of audibility so as you can just glance down that column of auditory neuropathy or the ANSD so that compared to the next column over those differences are not significant the thing to note though at the very bottom so what that third section is that last data point they didn't have enough numbers to really compare those two those were just based on I think about six children in total between those two groups but it is an interesting trend so what that last line is showing is that when you try to do word recognition with a little bit of background noise and look the trend was that the auditory neuropathy spectrum disorder that the kids with that profile do much worse when you put a little bit of noise in there compared to the children who have a center neural hearing loss so the next slide I'm going to show actually goes into that a little bit further I don't know if that's coming across very clearly so basically these are it's sort of a speech sound perception test and so they compared so down the left hand side you can see they compared children who have normal hearing versus children who have center neural hearing loss and children who have auditory neuropathy and each column so you have the SN ratio and the SN that's called the signal to noise ratio so the plus 20 dB most pretty much everybody was normal hearing you can see with the normal hearing children in the study they were getting 96 or high 90s in the particular test so the noise level at plus 20 basically that means you have 20 decibels over and above how much noise there is so the performance of children with normal hearing at that level is really really good if you children with center neural hearing loss do quite a bit poorer than children with normal hearing but then when you look at the auditory neuropathy grouping it drops down to by half and so you can see the effect of noise where for normal hearing subjects it really doesn't impact them at all for children with auditory neuropathy it really drops their ability to comprehend speech and language and it is significantly different especially in that first column the difference is as you as you go down so you have a plus 20 decibels and then you have the plus 10 which means that there's a little bit more noise as compared to the signal and see there's still like the normal hearing children are still doing quite well but the center neural hearing loss drops even further but the neuropathy group is starting to really bottom out there so how noise affects this particular population is pretty dramatic so what that means in terms of what we do in the classroom would be to try and give them as good a speech signal as we possibly can and that's where FM systems or direct microphone systems would come into play so to kind of overcome that huge drop in noise that children with that profile have FM systems are really really important and it really gives a child with this profile who is probably dealing with an already really degraded signal at the best of time it sort of gives them the best chance of catching what you're saying to kind of give them the best support and the best chance of succeeding and I'm not sure if my sound clips are going to work but if they do it would be nice and no they're not going to work if anybody would like to hear these clips I can send them to you but basically it was comparing what it sounds like with a hearing aid only in a noisy classroom as compared to what it sounds like with a hearing aid combined with a directional FM system or a direct microphone system and it really is very dramatic so and that's just with your typical hearing aid use this isn't even adding the distortion that you would have with a child with that auditory neuropathy spectrum disorder so those are the kids with hearing aids so those are mostly mild moderate kids the children who behaviorally respond more in the severe to profound range we would be monitoring them much more closely for something such as cochlear implantation and and this occurs in a handful of cases not the majority of auditory neuropathy cases so in cases where the hearing aids and FM systems aren't enough to provide the child with enough information to develop that speech and language and I mean if the parents really want that audibility in the hearing then we would move to possibly considering cochlear implant and so again that close monitoring of that speech perception and the audibility and the development is also very very important so some of the just as a side note some of the studies of children with auditory neuropathy who have had cochlear implantation just as compared to sensor neural hearing loss in the severe to profound range who also have cochlear implantation when they compare across those two populations auditory neuropathy and sensor neural loss they do end up looking very similar in terms of their language outcomes as well which is sort of nice why that is it's it's sort of just to say that some of the theories which suggests that a cochlear implant provides more more stimulation of the nerve and so it creates a stronger response to travel up to the brain which gives the child more information at that level pardon me in general you're wondering how best to help students so of course the educational ideology to make sure all of the equipment is working at optimal levels checking the equipment regularly and encouraging that regular follow-up and equipment maintenance and again just wearing that personal microphone system or FM system that is the best thing you can do with this particular population in terms of that that follow-up I mean with younger children we would want to follow them quite closely so probably at three to six month intervals school age children I mean at minimum they should probably be seen about once a year if not more even more if there are changes in hearing or changes in how the children are performing or hearing of course I mean those are just minimum sort of follow-ups and I mean private practice you would expect to see them at least twice a year regardless of your age just for regular equipment maintenance so just to summarize really quickly auditory neuropathy this is a label or for a pattern of test results for the child or sorry this is a label for a pattern of test results and not a label necessarily for the child and so that absent ABR at the very beginning it doesn't really imply profound hearing loss necessarily we really just have to closely monitor the child because they might not respond in a predictable kind of way many children with neuropathy or with this profile are able to make good use of their hearing and generally can't predict how so early on when we're still trying to figure out those behavioral thresholds we can't really predict at a later stage how they're going to be how they're going to how their outcomes will be so we really need to do as much as possible to monitor and support the kids at early stages and the other component of this is just establishing that early communication and language and if they're deviating off of that trajectory that's that's that's our cue to really step in and try to figure out what are the supports they might need in place so that is about all I had planned does anybody have any questions thank you it's Sarah I'm gonna I'm gonna actually ask the question because it's something I'm interested in and I'm wondering in your preparation of this um interesting topic if you came across whether any auditory training for these kids with this diagnosis um helped support them in utilizing whatever technology they were um you know in test results benefiting from that's a really good question and no I didn't see anything in particular with this population but I do know that there is an effect of training in children with sensory neural hering loss and a lot of that is top-down processing so I mean you would sort of expect that any sort of auditory training would kind of help them in the long run but that isn't something that I've seen at all in literature if anybody else has feel free to jump in so does anybody else have any other questions I'm I'm trying to watch the participants that I'm not seeing any hands up or any chat you can do either one hi Beatrice hi yeah oh hi my name is Amy um I have a student uh he's in grade three he has a mild to moderate sensory neural hearing loss and plus auditory neuropathy um and I know the school is working really really hard to support him um he's having he's having a lot of difficulties even with number recognition you know if if you say like can't one to ten and then count backwards it's hard for him to get the numbers in order from one to ten even like and he's at grade three um through school or struggling um he has occupational therapy and speech language therapy services as well and we're just trying to work together as a team to figure out you know is there's something else happening here would would the auditory neuropathy be contributing to some of these issues do you feel or I know it's hard to say if you don't have the bigger picture but um because there any research kind of that well report that I think this is where that multi-disciplinary team really comes into play um you kind of um you would in general from what I've seen in the past you would need to look at their non-verbal kind of cognitive ability to do that kind of thing and then you would have to look at the speech perception part of it as well and the like yeah and I know the speech perception thresholds uh it's excellent in the right ear and good in the left I think 98% and 80% based on his last hearing test so would that be words in a quiet or um let me just see I actually have a support here I believe yes in quiet right right yeah um and okay so if speech perception in quiet is that good um yeah and I'm assuming he has the language to comprehend yeah you know like speech-wise but when I mean his reading levels are quite low as well right but right um can I ask Beatrice sorry Sarah would you request a speech recognition and noise from the audiologist to get a better handle on is that would that provide some additional information for Amy um that might give you a little bit of an idea of how they're performing in this classroom I would think um I guess my question is if his non-verbal cognitive abilities um are at that level or if it's the hearing specifically it's sort of hard to piece this apart without all the pieces of the information yeah yeah and I know uh the occupational therapist did some uh visual kind of spatial testing with him and he did quite low on that okay I remember the name of the test I might have that down but yeah I know he's struggling in those areas right right um in all honesty it is really hard to say I mean uh having that autothermopathy profile probably isn't helping matters but whether that's the sole reason for the difficulties he's experiencing it it it's really difficult to piece that apart at this stage I mean he probably needs a little bit more more evaluation to try and figure out each part of this a little bit more for him okay that's kind of what we thought but I I figured oh I'd ask just to see maybe there was a magical answer but we we thought that maybe further testing or maybe even a ed psych evaluation or something along those lines to see if there's another piece that we're maybe missing yeah okay thank you so much Beatrice I appreciate it not at all I'm I keep thinking back to somebody who said actually I think it was Karen Anderson and said um if you've met one child with hearing loss um you've met one child with hearing loss I think we can also add if you've met one child with hearing loss or auditory neuropathy spectrum disorder you've met one child with auditory ASND or ANSD um and so I uh I really appreciate you giving us this foundational information it allows it contributes to our practice out in the field and you know we'll continue to have conversations about kids and individual children in order to best meet their needs and thank you again for agreeing even and I think it's the second person that's presented with a really bad cold in the last few months so um I'm not going to talk to anybody anymore because apparently I have something I'm spreading so have a have a great rest of the day everybody stay dry and see you next month everybody thank you