What's good Joshua Ross back again with another video got another wrestling video for you guys Who is the king of the cutter? Basically the cutter is I guess you could say like a variation of the RKO It's it's that same type of maneuver, but different wrestlers perform it differently and they call it different things like DDP causes The diamond cutter is it's a variation of the same move It's more known with Randy Orton's RKO as his finishing move a lot of people know it as the RKO But it's actually just a variation of a cutter. We're about to check it out And I'm gonna give my opinion on which cutter I feel is the dopest You know I'm saying I didn't know more wrestlers use this move. So this is this is new to me You know I'm saying so I appreciate all the love and support on this channel you guys have been really showing love all the new Subscribers we're almost at 10k I just appreciate that so much bro from last year starting the channel around this time to where I'm at now This is such a blessing. So I love you guys and let's get into it. See who has the best cutter That's the classic one I love that one that's Telling you man Classic RKO he sold that just the way his neck hit the mat he ricochets with that shit Okay, Matt Hardy Yeah You know what the twist of fate is pretty much like a very it's a it's a cutter Like you it's it gives that that RKO type of feel just the motion. He just he he twists us into it I you know what I never really thought of it like that. That's crazy It's a fake not a bad move I remember that bro boys was like, how could you how could you mad? What are you doing?  Oh Man, he really swung on that one. He swung into that one.  I know when these crowds come back y'all better have energy for everything Be appreciative motherfuckers Give me that mr. Kennedy. I Didn't even know you see three I had a variation of that move. I didn't know that Well, I mean to be fair you see three was buried on arrival at the main roster and you barely saw him in any matches So I who would really know his moves like that? He was getting some love in NXT Okay, I like that I like that When you compare it to the twist of fate, I like this one better so far. This is the The best one even though it's only just been two wrestler songs. I like this. I like a twist them into it I like that That was nice That move could literally get over if they just got behind them It reminds me like a variation of the f5 like it's it's I like it man That move could literally get over but it didn't get behind the wrestler All right, this is before my time Mark Miro. I'm gonna have to lace me up We're not before my time, but I'll remember this wrestler Okay Little bit sloppy there Well, yeah, this is kind of a little bit before my time. Yeah This is early 90s early 90s Early to like mid 90s. I want to say so I was a little kid. So I definitely didn't know like just Wrestlers names like that other than the main ones. I still like you see three is better so far. He's That's the one I like the most so far. This This is cool. He sold it. He sold that at the end Now that was nice. That was nice Alex Riley. I didn't know he had a form of that a variation of that. I Didn't even know that Okay Okay, I Still like you see threes so far right now so far in this video. I like you see threes This was dope. This is not bad What makes the move also better is if the opponent sells it so Oh, no, not crime time I'm beyond switch you that crime time gimmick was so racially like like Racially charged bro. Like why is do black cornrows baggy jeans and Tim's? Oh My god, and the name is crime time.  That was so Got a little Vince, man So super racially charged Alex Riley taking charge That was it was I I still like easy threes to Easy threes has a like a nice little motion to it like a nice little more of a spin to it RP test the ones I've seen so far That was pretty cool, but the ones I've seen so far. It's like they put them on their shoulders. Oh My god The only one is not like that is Matt Hardee's I wasn't bad. I like that one I actually kind of like this one too Because he's like he does an extra rotation on it It's like he does an extra rotation. You know what? Oh No, oh No, I Thought he's gonna do it on the bar before I barfire board. I don't know man You know what I think so far right now, I'm gonna give it to test right now Test right now is the best-looking one so far on this video. I like the extra spin. He does before he hits it So I Ain't no rhino to this movie Okay, he doesn't like spinning to it. Oh, okay. Never mind. I take it back Yeah, he kind of just He gets him on top of the shoulder and then he kind of hits the move and transition going down.  I didn't know Boba Ray did it either. What? Okay. Wow You know what I take that back cuz 3d is pretty much that I'm I'm so I'm slow 3d is basically a cutter in midair pretty much. I think you know, yeah, it's a cutter in midair Yeah, it's 3d is basically a cutter in midair except it has someone else helping with it Yeah, that's basically what it is You know what I'm going bubble Ray. I'm going with Boba Ray Only because of the 3d. That's the only reason why I'm going with Boba Ray. The 3d is just It's a classic move, you know, he's not hitting the 3d Like the fool 3d. It's like a it's a one-man 3d I hope they show it. You got to show it in the clip. I just want to see the 3d I hope they have it in the clip. I just want to see one 3d bro. Come on Shout out Shout out to the commentary team It's a cutter They put jr. I was like that's a neck breaker. It's a cutter.  Yeah with his uh with his move Yeah with the twist of fate pretty much Just like matt Yeah, pretty much just matt And I mean if you seen if you seen jeff's I mean if you see matt then it's it's the same It's pretty much It's it's literally the same move Yeah, it's it's pretty much the same move. You've seen matt hardy do it Jeff jeff will do it too It's so okay now we get into the nitty gritty Dp man. Now we get into the nitty gritty man Okay Oh, Jesus You know what just I got to go with ddp so far right now Only because it's It's ddp, bro like it's And you see the crowd's reaction when he hits it like That plays some parts of the finisher move too. Yeah In the way the rest will sell it too Give me that So so right now Oh, that was a nice one. So right now i'm i'm gonna i'm gonna have to say ddp is ddp is holding it down As the the best cutter obviously right now so far in this video Give me that Oh I think my opinion is about to probably change because it's I think my opinion is about to change It changed I should have known randy orton was probably gonna be my favorite one on here only because let's You know, I tried to I didn't know which other wrestlers had did it You know this the variation of this move But when randy orton does it it's different now seeing the diamond cutter And then right after that seeing randy orton's rko It's It's so fluid. It's quicker than ddp's diamond cutter like he Randy orton randy orton hits it so quick like he's boom and he gets like this elevation like he's horizontal in the air like Just look at this Look at this boom When it gets hit it's just give me that it's like he's just horizontal in air like it's it's so nice. Look at that I hope they have the clip where Monday night raw was taken over by the wrestlers and basically triple h He was like kind of the guy triple h and evolution was running Monday night raw And the other wrestlers took over raw and they gained up on triple h And he hit probably the best rko I have ever Seen him hit and it's one of the best up there when he hit Triple h, but this is when triple h had the little lamb chop sideburns going on And he was begging for his life triple h was begging for his life And you know, it was maven. I forgot who else was out there. It was it was like maven Jericho, there were some other wrestlers out there and Bruh, he's begging for his life. Everybody hit the finishing move on triple h and randy orton They held him up. They held him up. Everybody held him up. He's begging randy orton.  I hope they have it on here Please tell me to have that clip Of course, this is this one right here Please tell me they got it. Please. I hope they have that clip That was a good one too, of course, you know, you got to put this one here I don't think they're gonna put it on here man, dang dang man Dang bro, I really wanted them to put it on there Damn, bro I'm actually kind of disappointed right now Not gonna lie to you. I'm actually disappointed that they didn't put that clip if y'all know what clip I'm talking about Comment down below if y'all know what clip where randy orton rko Triple h into another dimension when they finally took overall when they they the wrestlers Made a stand for themselves and said, you know what evolution?  If y'all remembered that clip Comment down below that to me was one of and this was we talked about the young randy orton This is right after he left evolution He was at this point, uh, I think he had won the world heavyweight championship And then he had lost it. So he was in the feud with triple h and he was a face at this time So comment down below if y'all remember that rko if I had to give the list if I can remember It'll be randy orton ddp bubble ray only because of the 3d Test I'll probably go with ec3. I know there was some other wrestlers like rhino and uh mad hardy and jeff hardy But for me those the variations that's seen in this video that would be my order What would be your order from all the our wrestlers that was in this video comment down below as well What order would you rank the cutter? Would you give randy orton the best? Would you put them in the middle like I want to I want to get you guys ranking on this? So man, but hopefully I enjoyed that video Just wanted to check it out since we did check out some of the best rko compilations I believe last week I wanted to kind of continue the uh the topic of rko's and cutters and stuff like that But I appreciate all the love and support on the channel man if you like this video give it a thumbs up And uh more wrestling content is on the way. I appreciate all the love and support once again I gotta let y'all know y'all y'all really are Amazing and y'all hitting that subscribe button like crazy. And I love you guys for it More content on the way. Appreciate y'all kicking in with me. I'll see y'all on the next one. Peace


Family. The topic of this retrospective is distributed teams. I don't think there are many people who would disagree that, on the whole, teams who are co-located tend to be a lot more productive than those who are geographically dispersed. Yet, it's an increasingly common reality for a team to be spread across offices, countries, or even continents. Now, our initial advice is to avoid that wherever possible, but for those of you that can't avoid it, we've designed a retrospective to help give that team a greater chance of success. For this retrospective, you'll need the following resources. You'll need several pieces of flip chart paper, some sticky notes, and some marker pens. You could prepare a team charter template in advance, but this isn't essential. We strongly recommend you to try everything you can to get everyone together in the same location for this meeting. But if this is impossible, then ensure that everyone has access to an online whiteboard or collaborative space that allows people to simulate the writing, posting, and moving of sticky notes. Hook. We intend to use the metaphor of family as the theme for this retrospective, and our suggested hook is this. We've often heard people say that being part of a great team is a bit like being a family. This is much harder to achieve the further apart everyone is, but it's not impossible, and as we are far apart, it's even more important for us to develop a sense of team. The aim of this retrospective is to create a family charter to unite a group of dispersed individuals with a common identity and a set of values. As always, feel free to come up with your own way of setting up the retrospective and introducing the theme to get everybody engaged. Events. You only need to think of the Simpsons or the stereotypical family Christmas to know that there's no guarantee that co-location ensures a happy and effective family. And the fact that long-distance relationships can also blossom shows that being physically separate from one another doesn't automatically doom a family relationship. We want to begin the events section by discovering a little bit about each other, and the format we'll use for this is the good old family newsletter. Pair everybody up. Of course, if you have an odd number of people, then it's okay to have a trio. Then set them the following task. Your job is to find out about the hobbies and interests of your colleague and write up a short couple of paragraphs summarizing your colleague and one or two of their recent highlights that will be included in the latest edition of our family newsletter. Give them 20 minutes to break off and find out about each other. Wherever possible, try and encourage people to pair with others that they know the least about, rather than the people they already know. After 20 minutes, ensure everyone comes back with their couple of paragraphs, and they can read them out to the rest of the team. Meanings. Families, as well as knowing about each other, also tend to have some common values and principles that bind them together. They also have a common identity, a sense of who they are as a family, and this helps guide their behaviors. We're now going to look at how we can apply some of these insights to our team and begin the process of creating our team's family charter. We're going to begin by asking everyone, in their groups of two to four people, to look at values. Ask them to think of their own family, families they know, and also famous families. These could even be fictional families from a movie or a book. And with those families in mind, ask them to take the sticky notes and marker pens and complete either of the following two sentences. A great family, or in a great family. They might come back with, a great family always apologizes after a fight, or in a great family everyone looks out for each other. Take one at a time from each mini group and add them to the value section of the family charter. If anyone is struggling to think of what a great family does, then invite them to think of what terrible families do and state the opposite. As a facilitator, encourage the team to cluster the stickies so similar values are next to each other and then consolidate, before leading the team through a discussion to prioritize in order to pick their top five values. Ensure that everyone is happy with the values that have been decided upon. If somebody seems a little unsure or unhappy, then explore that with the team and make it clear that it's important that everyone is happy with all of the values. Perhaps one of those values can be tailored slightly in order to make everyone comfortable with it, but be prepared to ask the team to change their selection to one that everyone is happy with, else. Instead of the family newsletter exercise, there are other exercises that can help create bonds between team members. Here are a couple of examples of others that you may wish to look at doing instead of or perhaps including in the retrospective. The first alternative that we love is called the Kevin Bacon game, where everyone shares a number of facts about themselves and their teammates attempt to find examples of where they share a connection. Another alternative exercise that might prove useful, especially in terms of helping create bonds between members, is the Penpal exercise. Here, team members from different locations are paired up and asked to write a Penpal letter to each other. While this is fast becoming a lost art in our digital era, Penpals tended to introduce themselves, their interests, their hobbies and their recent experiences, while also asking questions of their Penpal. They often included a picture or two as well. Decisions. Now we have some values that we agree on. You're going to guide the team in filling out the rest of the family charter. The next step is to look at the specific behaviors that the team are prepared to commit to in order to demonstrate that they are living the values of a great family as a team. Take each of the values one at a time and ask the team to come up with specific examples of a behavior that apply to this value by completing the sentence we commit to. For example, if the value is, in a great family everyone looks out for each other, then the behavior sticky might read, we commit to offering our help as soon as we suspect someone might need it. Invite the team to write these on stickies and add them to the behavior section of the family charter. Once the team have at least one or two commitments for each value, we then need the team to come up with their identity. Start off by asking the team to come up with a team name that they all feel connected to somehow. Perhaps they all like country music and computers so they might call themselves Johnny Cash. Add their team name to the team charter and then ask them to devise a logo or a symbol that represents that team name. And finally ask the team to come up with a motto. For example, team Johnny Cash might have the motto, we get rhythm and walk the line of quality ensuring no person or feature burns out in a ring of fire. Close the retrospective by asking everyone to look over their shared team charter and to sign their name to it. Remind them this is their team charter and it's up to them to put it into practice. You may wish to ask them what help they need from you in order to put this into practice. And it might also be worth reflecting on it and revisiting it in a future retrospective. Of course, if this is a distributed team, as is highly likely, and you are unable to get the support needed to bring them together for this kickoff meeting, then as I mentioned at the beginning, you will need to replace the physical aspects of this with more electronic alternatives. The good news is there are many online whiteboard and sticky note tools available, but do some research on the options beforehand.


Good morning everyone. Welcome to our subspecialty rounds. I feel like I sounded like a game show host almost That's the proverbial it's time to start tab So completely unrelated to Grand Rounds, but I hope you're all following this there. There is a new Jeopardy champion That is approaching our own Utah's Ken Jennings. So Ken Jennings made like 2.5 million or something on Jeopardy And this he's a his profession is a professional sports gambler, but he also knows a lot of trivia And he's got this really interesting approach to Jeopardy where he goes really big on these daily doubles So Ken Jennings average daily intake from Jeopardy was around 36,000 dollars and this guy his average is up around 70 And he's made certain certain when he's had wins over a hundred thousand dollars a couple of times So has nothing to do with our next speaker, but I wanted to really draw in your attention for dr. Dave David Dries It's always meaningful for me to introduce a former mentor someone who taught me in training and today is our pediatric subspecialty rounds and We are honored to have you and David and learn more about surgical approach to superior oblique causing If that is indeed what you're speaking on Thank you, Jeff. Well, if if you ask me questions at the end of this, I will not answer in the form of a question And in addition, I would appreciate 70 thousand dollars today at the end of the talk if anyone So yep, I'm David Dries and one of the pediatric ophthalmologists adults for vismasurgeons today I Do want to acknowledge a few individuals Griffin Georgine helped me with some great photos The entire staff in the pediatric ophthalmology clinic Extraordinary extraordinary technicians. We have a fantastic orthoptist Julie There are a few outside docs who've helped me with this talk as well and then also for Sophia fang our first pediatric ophthalmology fellow this lecture is for you actually because this is a Framework an intellectual construct to begin to think about how to operate on these patients with superior oblique paris is so these patients end up with Diplopia in three dimensions and Their deviation changes in different gaze positions So they might have vertical to pull up your primary gaze that worsens and down gaze So they're pretty tricky and we have to figure out how to help them One of my patients photoshopped this for me He had Diplopia torsional and vertical and down gaze had a lot of trouble going down the stairs so they really need help and if This entity presents as a congenital entity Torticulus results a compensatory head posture to get the eye straight and This ultimately results in facially symmetry neck aches headaches even arthritis into adulthood So what are our goals? well, we're trying to alleviate or maybe even eliminate Diplopia in an area centered in primary gaze and in down gaze to help with driving and reading gaze and This of course helps the compensatory head posture as well and With congenital superior oblique paris is our idiopathic Here's a key point if you operate for the vertical deviation if they have extortion and a v-pattern any horizontal misalignment the extortion horizontal misalignment tends to follow The muscle that you operate on for the vertical deviation, so that's kind of nice however on the other hand Patients with a neurologic or traumatic causes superior oblique paris is they often need their vertical deviation of course addressed but also Directly addressing surgery with additional muscles their extortion and their horizontal misalignment So Diplopia in three dimensions. This is an easy lots of questions How many muscles do you need to operate on one two or even three muscles and which muscles and why choose those muscles and What does a surgeon do with a lack superior oblique tendon or other congenital anomalies of the tendon like an absent tendon? or diaphanous tendon with an ectopic insertion and What if other muscles have been contracted look if you live with an eye up the inferior oblique the antagonist to the superior oblique will shorten and become contracted and The superior rectus can become short and contracted over time So those two muscles can undergo contraction and can need to be addressed surgically So it's fairly complex. So where do we start? Well, a good start is where the patient has hypertropia and where their hypertropia is the worst What we call a pattern of incomitance for those not familiar with that word. I'll be using it a lot Incomitance means a deviation of the eyes Changes in different gaze positions Look at this patient left hypertropion primary gaze and when she looks to the right you really see the left hypertropia And this is a typical finding in patients with superior oblique preces with contracture of the inferior oblique and Overaction of it. And if you thought well, I need to weaken that muscle. You've already cracked the code to much of this lecture You choose the muscles that match the pattern of vertical and competence is the first step in deciding what to do Let's look at these diagrams of the superior oblique and the superior rectus in the right eye We all know the superior bleak is a depressor It's an AB doctor and in torture in primary gaze What happens with the superior bleak when the eyes in adduction? Well, it's vertical action is much greater You can see that in this diagram in an ABduction. It's a much better in torture And its vertical action is reduced so with the superior bleak there's no question that You're going to Think about operating on the oblique muscles when you see more vertical deviation in the adduction Please look at the vertical rectus of the right eye The vertical rectus is mainly an elevator It also has other actions But let's concentrate in the vertical action when the eyes in adduction It's still mainly a vertically acting muscle when the eyes in ABduction. It's mainly a vertically acting muscle So what sort of pattern of vertical and competence would you think would match that muscle? Probably a vertical deviation. That's the same across the board in horizontal gaze deviations In the 20th century Napa Moore published the paradigm to begin to classify patients based on their presentation So these are the presentations that patients come in And what you're seeing with these grids is the strabismus exam that we all know from our charting And this is shown as a right superior oblique peresis So patients with a right hypertrophy and primary gaze that worsens across the board and opposite gaze and worse up and opposite Generally, they respond well to inferior oblique weakening surgery. That's class one Nat class two is patients who have a hypertrophy and primary gaze that worsens opposite gaze and worsens opposite and down gaze They respond well to superior oblique strengthening surgery the third class our Worse across the board opposite gaze up and down and as you'd expect oblique surgery is the way to go and Two more classes. I'll talk about our class four and class five And what makes these unique is a vertical deviation worse across the board in down gaze That's probably the most boring slide the lecture And also I I want to say this this is a long lecture with a lot of material So if you need a second cup of coffee go get it Let me talk about the action of the superior oblique to help you understand extortion and esotropia in down gaze That happens with these patients This is a little tricky these Diagrams I want to make it clear Here's the left eye in primary gaze and you're looking straight down the top of the eye And you can see that it's the superior bleak set a presser And here's the this dot represents the vertical axis of horizontal rotation The fibers of the superior bleak when they pull a force vector goes in this direction behind that axis and ab ducts the eye in addition The superior bleak in torts imagine a satchel axis right down the middle of the pupil down to the fovea When this tendon contracts, there's a force factor That causes the eye to in tort But what happens in down gaze Well, what happens in down gaze is that the muscle becomes stronger. It's pulling harder And so it's a better in torter and better ab duct or in down gaze But there's more going on than pulling harder in addition to that The position of the superior bleak tendon changes relative to the axes of rotation of the eye So here's the eye in down gaze, but we're really not looking down the top of the eye like where with this view So bear with me here This view is the eye in down gaze, but you are looking over the top of that eye Just like this diagram And look what happens to this axis of horizontal rotation The tendon shifts posterior to it making Contraction of the muscle at a force factor in this direction ab duct the eye better in down gaze compared to primary gaze And the same is true of torsion Look at the angle of the superior bleak tendon and the muscle An acute angle here in a more right angle here So it's a better in torter and down gaze with respect to the axis of torsional rotation So What happens in down gaze When the superior bleak is weak It doesn't in tort well. It doesn't ab duct well And so extortion worsens in down gaze here fundus photographs of patients with extortion This is in primary gaze. There's mild extortion here The phobia should be no lower than a horizontal midline at the inferior border of the nerve So it's a little bit of extortion here, but with the patient in down gaze you can see there's much worse extortion Because the superior bleak has a greater in torting the action in down gaze when it's weak extortion and here Look an esotropia. So these eyes are not ab ducting as well Make sense Well, let's go back to our starting point the nap classification in vertical deviations and in cometon's patterns So i'm going to go through a series of case presentations to illustrate How to choose which muscles This is a 30 year old professional violinist who plays the violin right-handed and tilts her head to the left And unfortunately she was in a car accident and she has duplopia when she plays her violin Here she has a hypertropium primary gaze. That's worse In opposite gaze and worse and opposite in up gaze Measuring 14 prison diapters with near fixation 18 with distance. You can see the measurements are worse Opposite gaze and opposite up She has mild extortion of about 78 degrees in primary gaze and in down gaze and some inferior bleak overaction So Inferior bleak weakening matches this pattern of vertical and cometons Because these patients as i mentioned have overaction and contracture of the inferior bleak Here is a diagram of the normal position of the inferior bleak muscle on a right eye And here's the left eye showing the recession of an inferior bleak And this is what the recession of the inferior bleak looks like with a surgical photo This is the Left eye here is a green hook on the inferior rectus And here is the disinserted tendon Of the inferior bleak that's recessed from this position To here with the anterior pole of the so-called park's point. It's a roughly 10 millimeter recession So how the patient do the compensatory had position improved Her hypertrophy improved and she it was intermittent. She could control it Her torsion was less the torsion followed along when we operated on the oblique and she's playing the violin better Doesn't tilt her head quite as far as she used to but now she can play more easily So inferior bleak weakening. This is a surgical tool in your toolbox. It's effect matches nap class 1 incompetence Well, it corrects up to 15 prism doctors, but not more in primary gaze and about 5 to 10 degrees of extortion This patient was a little bit under corrected and so you might want to ask the question Should we've done a second muscle? When do you do two muscles? Let me talk about a larger deviation in a 55 year old commercial truck driver with diplopia making driving difficult Look at his photo He has a left hypertrophy worsens In opposite gaze and especially opposite up. He measures 25 prism doctors in primary gaze would near and with distance fixation Larger than the violinist again worse opposite gaze worsen up inferior bleak overaction mild torsion compensatory head tilt And two muscles were chosen because as I said the inferior bleak gets you about 15 prism doctors in primary gaze But you got to get more and for him going to the opposite eye and doing an inferior rectus recession Helped him. He's driving again compensatory head position is improved He's fusing in primary gaze and in opposite gaze and look at the what we call the collapse of the incommittance pattern with him So the inferior bleak muscle has greater action over here inside gaze And so we're assessing it gave us an action in primary gaze and inside gaze And the inferior rectus gave us those extra prism diopters beyond 15 So the inferior bleak is you know inferior bleak weakening is probably the most common muscle that we do for superior bleak paresis and all Strobism as a very familiar and comfortable with it because we do it in children for inferior bleak overaction And so it's tempting to go to that muscle as your fall black plan But there is a situation where it's not the best choice and that's a patient who has hypertrophy And exit torsion in down gaze it does not correct hypertrophy and torsion down gaze well So, uh, it should I think Probably should be avoided for those patients Here's an example of exactly that situation of patient referred from an outside physician This patient had a left superior bleak paresis Uh, a left inferior oblique was done and probably a superior bleak talk would have been a better choice as we shall see In the next case presentation But in any case he presented to me with a small hypertrophy in primary gaze A bit worse in opposite gaze and much worse in down gaze across the board and you can see he really has Uh deficit of depression Across the board here in the left eye and those torsion was gone He probably had extortion prior to the inferior bleak surgery His torsion was pretty much gone and that's that's a nice thing because it made the choice of surgery fairly simple for him What muscle would you do for a deviation that's the same across the board and side gazes? A vertical rectus, so he had the contralateral inferior rectus recessed And indeed had a procedure called a combined recession resection To get even more effect in down gaze don't have time to go into that But if you want to learn about it come ask me later And with this procedure he did really nicely look at these pre-op photos look he has this depression deficit Pre-operatively but post-operatively It's much better and his hypertrophy is actually measuring a little bit bigger, but he controls it And I think that's because I missed that he had large vertical fusional amplitudes at his pre-operative exam But in any case his diplopia is much better But if the inferior bleak is not the down gaze muscle, which one is? Well, I like superior bleak talk for these nap class 2 patients Again, these are uh patients hypertrophy in primary gaze worse In opposite gaze worse and down with diplopia These are patients that do not recover superior bleak function. Well, they tend to indeed have torsional diplopia And uh and it worsens in down gaze. They tend to be from traumatic or neurologic causes So let me talk about an engineer 55 year old male His diplopia began intermittently in down gaze and slowly over time The gaze position of his diplopia crept all the way up to the horizontal midline and that's when he came in Turned out he had a pre-pontine sister and fourth cranial nurse swanoma Thank you, neurophthalmology And here's an MRI showing atrophy of the belly of the superior bleak on the left compared to the right So the superior bleak talk, what is it? Well, we make an incision and isolate the tendon of the superior bleak and lift it up And put suture across the anterior and posterior sides of the tendon Shortening it putting a tuck in it Here it is with the suture here and here and here's the tuck laying on the side of the eye Here's the engineer's exam hypertropian primary gaze worse across the board worse in down gaze A bit uh not a huge amount of torsion three degrees in primary worse in down gaze with a compensatory head posture Here's his pre-op exam as his depression deficit here here And at deviation, it's worse in side gaze. Here's a surgical photo of a tuck You're looking at the right eye This is the superior oblique tendon insertion and that goes up over the hook and back down under the superior rectus And you can see two merciless sutures creating the tuck in that tendon 48 hours later. He's got a little bit of brown syndrome. He's a little over corrected. That's exactly where we want him to be just a little over corrected early And uh look at his incompetence pattern the worst hypertropian down gaze. That's collapsed So it's great news that muscle works for worse Hypertropian down gaze here is seven months post-op fusing in pretty much all gaze positions and he's working again So the superior oblique tuck another tool in your surgery surgical toolbox Uh, it's for class two patients who have a deviation greater in down gaze It cracks up to 15 prison interpreters in primary gaze of hypertropia more in down gaze And corrects 10 uh five to 10 of extortion in primary gaze and more in down gaze Now the superior oblique Talk is a little bit scary for some surgeons and I I understand that it's not a forgiving muscle You can't go back and re-operate on the superior oblique muscle in general very well and the outcomes aren't as good So there's a little bit of fear in addition inducing brown syndrome Who wants to induce brown syndrome in their patient if they have to plug in up gaze? Of course, you wouldn't want to so there's worry about that as well so um And then there are also patients who you cannot do a tuck. They've already had a tuck Uh or for other reasons you can't do a tuck and and so there is another alternative to the tuck that you can uh go to another tool in the surgical toolbox and that's um A contralateral inferior rectus recession Now if you do that alone, you'll get the hypertropian primary gaze and in down gaze But this doesn't correct extortion well So what could correct extortion? Well, there's another procedure to correct extortion on the same eye as the priestess A nasal transposition of the inferior rectus can help So here's the right eye and if you move the inferior rectus nasally it in towards the eye correcting extortion So doing those two muscles together Can be uh effective and here's an example a 56 year old woman had bilateral hemorrhagic thalamic stroke And diplopia with perinald syndrome and a left superior bleak paresis She has her hypertropian primary gaze at worsens an opposite gaze and worse opposite and down gaze She had a large degree of extortion. So this did definitely need to be addressed surgically And uh, you know, uh a tentative plan of a talk would have been nice, but in the operating room as it turned out The inferior rectus was restricted and had to be recessed And so that procedure had to be done. I knew it had to be done I knew it would correct the hypertropian primary gaze and the hypertropial worse and down gaze. But what about the torsion? Well, she had a nasal transposition of the inferior rectus Which Intorted the left eye and corrected extortion And here she is immediately postoperatively 48 hours later a little bit over corrected in primary gaze a collapse of the incommotence pattern no torsion Looking good there and then much later. She's fusing She's fusing in all gaze positions except down gaze for television when she's laying in bed But the nine months later, uh, that was even better as well. So here, uh, so fee in particular is your go-to plan If you can't do a superior bleak talk for these patients Let's stick with the nap classification. Let's talk about three kind of a straightforward one Again hypertropian primary gaze worse and opposite gaze and worse up and down opposite gaze This patient 12 prism doctors and primary gaze worsens to 20 18 up 18 down Mile degrees of x-cycle torsion What surgery would be best for that increased deviation in opposite gaze the oblique muscles? And he had an inferior oblique recession and ended up in ortho in these gaze positions with a nice result Now is anyone tired of the nap classification? I know I am let's let's let's get away from that for a little bit Let's just talk about something more interesting to me anyway Maybe to you too and that's superior bleak tendon laxity. So these are in uh patients who present As toddlers or infants with a head tilt They have a very long they have a question that yeah That are these generally pretty stable long term? I mean once you get them corrected with these do they generally hold it at a pretty stable level or or do you Often see that they then start regressing back because of the muscle They tend to stay stable unless there's a neurologic, uh issue that's progressive Like a fourth nerve schwannoma Or if they're surgical issues like a slowly slipping muscle, that's had a recession And then there are others where I can't explain their recurrence In the long term but in the short term Not getting their full db corrected. They did but they tend to be stable long. Yeah, they tend to They tend to so back to the infants Here's the main point with these lax tendons talk the tendon and infants and you get the best outcome The best outcome being resolution of the torticolas. That's the main point And uh facially symmetry results in the long term if it goes uncorrected Here's a case. This is a two-year-old. I don't have clinical photos, but her mom very kindly supplied me with a few So here they are backpacking. I know this is hard to see But with the left head tilt, there's a left hypertrophy in that baby Which was somewhat measurable. This is a guesstimate A bit worse and opposite gaze worse with tilt. I thought a superiorly presis given this Right head tilt the compensatory right head tilt and this is what the tendon looked like in the operating room Again, this is the insertion of the superior bleak tendon goes way up high. This is probably 14 maybe 10 to 15 millimeters from here to here. That's a very lax tendon and uh So you you might ask the question. How do we know it's lax for sure? You know, do we have to explore it to find out and the answer is no David Geiden developed what's called exaggerated for induction testing to try to determine if there's a lax superior bleak tendon And let me show you what that looks like You grasp the eye the limbis place the eye and adduction and elevation Which puts the superior bleak tendon on stretch?  So it doesn't work You know how it is with video so here's Exaggerated for suction in a normal eye and I don't know if you can tell but it actually gives a little and goes back and forth One other thing I like to do is check torsion that's extortion of the eye taking it into an extorted position And I want to show that again Here's the exaggerated for stuctions rock back and forward Ding ding ding is the tendon goes over the top of the eye and then you can check torsion Grab the eye at three nine o'clock Extort the eye and the excursion here is about a clock hour a clock hour and a half So that's a normal eye Well, what does it look like when the tendons last? This is exaggerated for stuctions way up. See how the eye is going way too far Two plus ten and like really can't feel much of that tendon going back and forth across the eye Watch the torsion. There's about a two to three millimeter clock hour excursion of the eye So even before we make an incision and explore that tendon six o'clock we have a really important clue that it's nice So here's what the tuck on that patient look like you've seen this from previous slide Suture creates the tuck. Here's what it looks like laying down on the eye And let me show you the end point of the tuck. Remember I said the tuck produces brown syndrome But we want brown syndrome. We want Just the right amount Which is our joke and strabismus surgery. How much did you do doctor? Just the right amount? and uh So just the right amount is you be you take the eye into adduction and then elevate it in adduction And when you feel resistance as the inferior limbis crosses A line between the medial lateral canthus you just feel it then you know, okay, you got the right tuck And this is what it looks like and also this video shows some extortion You'll see the extortion is less than one clock hour. It's like dunk dunk with the extortion but first the First the this is after it. There's the eye. Here's the brown syndrome The horizontal just showing that horizontal line between the canthus So placing the eye in adduction is right here when this crosses the right amount horizontal midline And here's the torsion and then exaggerated forced action. Watch you only goes about a clock. Oh, sorry Here's exaggerated for instructions. Remember And now it's tight. Here's the torsion. Don't don't put a clock on a really tight stop there So that's the end point And so how this patient do here's the pre-op head position Here's the post-op head position with no deviation in primary gaze So this works really nicely for infants with a lax tendon So the superior oblique tuck. What are the indications for the superior oblique tuck number number one Almost all infants with certainly with a lax tendon deserve a talk. They do better It's it's known. It's in the literature inferior oblique recession is not the first choice for these Patients and then adults with hypertrophy are greater in down gaze than nap class two Especially when they have extortion that's worse in down gaze as well All right Now it's time for the second cup of coffee I've got to bolster my energy a little myself Because there's a lot more coming and I got to get through this um How many muscles one muscle two muscles three muscles are there patients who even need three And the answer is yes, there are and let's talk about them And I'm going to give a cautionary note about the superior oblique tuck Illustrated by the next case and the cautionary note is Don't do a tuck if there's already been an inferior oblique recession If you do that combined procedure at the same time or do it sequentially You'll probably end up with brown syndrome and that's what the first case demonstrates So let's talk about that now So this is a child with a lax tendon Look at the size of this deviation 30 prison diopters in primary gaze worsens Large amount of incompetence 45 prison doctors 50 up and across 40 fight down Large amount of inferior oblique overaction large amount of underaction of the superior oblique big compensatory head tilt and You know, it's really tempting when you see this incompetence pattern to say wow Maybe I should operate on both obliques on the eye with the priestess to talk on the superior oblique and an inferior oblique recession Really tempting, you know, it's going to help and indeed that's what I did in this patient and They hear here surgical photos at the inferior oblique recession and the talk And it really is oh, thank you I'll kind of be better than $70,000 right there um So, um, so this patient did have superior oblique tendon laxie and I did do a combined talk in an inferior oblique recession and It worked brilliantly initially With a great reduction of the hypertrophy and primary gaze Collapse of the incompetence pattern although it was still greater across here and look there's still this down gaze deviation So even those two muscles that very powerful combined talk Infra oblique recession Didn't get this deviation and there was still a head tilt And so I went ahead and did muscle number three a contralateral inferior erectus recession and good Position in primary gaze collapse of the incompetence pattern. I was very happy about that better in down gaze and again, unfortunately, I couldn't get this Measure because kids sometimes are kids my toys get boring But the real point and look at her here pretty good alignment in primary gaze and side gazes looking good down gaze looking good But looking up gaze This is pretty bad brown syndrome that eye doesn't go up in primary gaze It doesn't go up in abduction doesn't go up in adduction And there's a reversal in the hyper primary primary gaze and I think as a as a lifetime Of diplopia looking up. That's a pretty high cost to pay Uh to get this other effect from the combined oblique surgery Um, so that's a pretty challenging case big deviation three muscles. Can you get more complex? Well, I can Let's let's make it even more complex to talk about a grandma for uh, those who recall From the past when I presented I presented this before but this is a really nice example of very complex deviations of superior oblique precess Where we really need to break down the deviation into three components Well, let me tell her story and then we'll get to the exam and break it down into those three components So she's 44 year old lady in 1995. She was 44 And she had a large angle 35 prism top your hypertrophy worse opposite With inferior oblique overaction and that was the extent of the documentation I could find Her surgery was a very large superior oblique tuck Mark tendon laxity was noted in that satisfactory brown syndrome that I talked about Was noted in the surgical record Four months later back in 1995. She was under corrected, but she didn't want additional surgery And then way later in 2013 18 years later. She presented to me She'd been living with the plopia and ignoring one image for 18 years and living with the psychosocial impact of strabismus for a long time And she had a really fairly complex complex deviation. So what do you do with these? They're they're a little overwhelming But let's break it down into three components the first one you know Well, and that's the pattern of vertical and combatants So she had a left hypertrophy and primary gaze that's worse in opposite gaze worse up and down So the nap class three. So, you know, you're looking towards an oblique muscle probably an inferior oblique recession The uh Large extortion that she has 15 degrees at near and in down gaze that needs to be addressed directly with surgery because it's so large She had a v pattern esotropia 30 prism doctors of esotropia and primary gaze increased to 30 and down 18 and up gaze and so Break it down into those three components and The surgical choice becomes more clear an inferior oblique recession I broke my rule about combining the talk and inferior oblique recession with this patient Um Herata, ito procedure will correct extortion for those who don't know what's a herata ito. Let me explain that This is the right eye of a patient. Here's the superior oblique tendon And we want to create extra in torsion to correct the extortion in the patient So we split the tendon into two halves take the anterior half Disinsert it from the eye and then sew it in a position Where it's transposed anteriorly and temporally on the eye giving it a better mechanical advantage Uh for in torsion And then finally for her esotropia with the v pattern a bilateral medial rectus recession with one half tendon with Infor placement remember for the residents and so feel a little the acronym male medials to the apex laterals to the empty space So she had a v pattern the apex so the medials go down Now that'll correct her v pattern esotropia But transposing Recti causes torsion and you know that because I showed you how to correct extortion in a patient by a nasal transposition of the inferior rectus, right? Well, when you inferiorly transpose the medials you cause extortion And she had a lot in the first place and that's why she needed this herata ito. So she That that inferior transposition is going to create even more torsion That she had in the first place So her surgery was an inferior bleak recession the herata ito four millimeter Meteorectus recession with inferior tendon transposition here. She is postoperatively.  So we're feeling pretty good and she confused with prism So I offered her one more surgery Which was an inferior rectus recession on the contralateral eye and after that surgery she was fusing And uh, you know a happy camper that heard the plopio was gone and she had normal appearance So with these large angle, uh, very complex deviations you have to break it down into those three components If you know the tools in your surgical toolbox, which you which you know What each muscle surgery does you can mat you can combine those different tools Once you break down complex deviations into different components And uh, I guess the other thing is don't don't give up on adults after 18 years. She fused so you know adults They they deserve an evaluation. Um, let me talk about okay. Let me, um Jump into what I call the curve balls of superior bleak precess and we're getting there now We're getting there Here's an anomalous tendon. This is a 39 year old female triathlete. Look at this So this is um, the left eye the surgical photo The superior rectus has been disinserted and it's fallen back underneath the conjugal. You can't see it These two four steps are on the insertion of the superior rectus This is the superior bleak tendon. Here's the anterior insertion of the superior bleak, which is in an ectopic position. It's about Two three millimeters posterior to the insertion of the superior rectus And then the posterior tendon was just diaphanous. There was no tendon there that you pull on it And it was just stretchy. It was there was no tendon tissue in there. And so Her her exam too is confusing keep in mind I didn't have the benefit of looking at that photo when I saw her in the clinic and her exam was a bit confusing She had a a deviation a hypertrophy that was worse in side gaze and worse with tilt But it was worse in up gaze and she had no torsion So she didn't really fit the three-step testing But I thought she probably had a superior bleak precess wasn't sure My tentative plan was to do a superior rectus recession Mainly because she had this across the board deviation again the vertical recti or for across the board and so she had that And did really nicely She's fusing in primary gaze down gaze and in up gaze and she actually had a large Compensatory head tilt that was much better after surgery and her diplopia was better as well Okay Two more cases to illustrate the nap class four and five. These are the patients with the deviation worse in down gaze Now these are these are very common. I've only seen about three in 22 years And you know when you look at these patterns you you what jumps out at you is oh do an inferior rectus recession on these patients That corrects the deviation in primary gaze and it helps so the deviation worse in down gaze But there's one little caveat Remember early in the lecture. I said the superior rectus can become contractured and shortened and restricted Well that rarely can cause a greater deviation in down gaze and To teach this let me talk about uh graves disease So we all are comfortable and know about graves disease And if you have unilateral inferior rectus restriction from grazed disease You have a hypotropic in primary gaze and it worsens in up gaze Right Well, this entity was superior rectus restriction is just upside down grazed disease Does that make sense? And so if there is contracture of the superior rectus then operating on the inferior rectus probably won't get the deviation in down gaze But let me let me talk about an example of a patient with a Knapp class 4 deviation. You know this man. He had a Left inferior rectus. I'm sorry left inferior bleak recession and referred in And he had this down gaze deficiency the same across the board And he did not have contracture of a superior rectus when it was checked in the operating room So he underwent an inferior rectus procedure And as you know, he had this nice outcome with his depression deficit improved This patient is an elderly patient. She had nap class 5. She's very interesting to me because this is a long-standing deviation I mean 40 years. I think she had this superior bleak paresis and She only meets two steps of the three-step parks fischelsky head tilt test where her Hypertropia is in primary gaze. It's a little better in opposite gaze. It's a little worse in ipsilateral gaze Uh, and it's worse with the tilt and she had extortion And uh, I wasn't sure she had a superior bleak paresis But I thought that's probably what was going on with superior rectus restriction And here's the clue in the exam the clue in the exam that there's superior rectus restriction Is that there's a hypertropia ipsilateral to the site of the paresis, which we usually don't see these patients In the operating room the superior rectus was restricted with forced suction testing And she underwent a small right superior bleak talk to help her with her down gaze Deviation and a superior rectus recession to help with the restriction and her deviation improved across the board Uh, in primary gaze and improved in down gaze across the board so That's the story with nap 4 and 5 in Infure rectus recession generally is a part of the surgery but sometimes they have contract for the superior rectus Okay, so let me sum up quickly The surgical options are an infure bleak recession Gets up to 15 prism doctors and small amounts of torsion matches in combatants. That's worse inside opposite Uh side gaze opposite the palsy the talk matches Class 2 well up to 15 prism doctors in primary gaze and more in down gaze Corrects torsion while in primary gaze and even more torsion at down gaze But there's a caution about a simultaneous superior bleak talk an inferior oblique recession Next surgical tool contralateral inferior rectus recession Gets a deviation across the board in primary gaze and more in down gaze, but it doesn't correct extortion well So what can we do a nasal transposition of the inferior rectus to correct extortion? Also, the herata edo helps correct extortion with transposition of the superior oblique tendon fibers Uh a superior rectus recession in our triathlete with the ectopic tendon worked well because the deviation was about the same Or maybe a little worse in up gaze and that needs to be done If there is superior rectus contracture in very long standing nap 4 and 5 patients V pattern pretty familiar to everyone media rectus recession with infratenant transposition And so in summary As you can tell these patients have you know pleomorphic presentations and you need to sort them out If there are complex deviations break it down into those three components And then look at your surgical toolbox and look what the tools do and match the tools to the presentation in front of you Uh more than one muscle for greater than 15 prison doctors, maybe three if over 30 Um inferior oblique recession is usually not the procedure for down gaze deviations An extortion more than 10 degrees generally needs to be addressed surgically especially in patients with traumatic or neurologic causes Tuck the infants in most cases don't give up on adults. They confuse Be ready for the curve balls with the surgical plan in case you need it That's different and be aware of the rare superior rectus restriction And i'm finally done after a very long talk. Thank you for uh listening through it This is my happy place playing hockey with my songs So i'll stop there and take any questions if you have


So let's dive into the slides. What do I have for slides? Basically, the idea tonight is to share some tech tips, tech tips that will, especially those that are going to be helpful to nonprofits. And when we run out of those, also, like, toss some questions out there. We're going to have time for that, I think, as well. But I want to start off by sharing my favorite new piece of technology for nonprofits is Canva. And it's one where even though I've been aware of it for a year and a half, close to two years, I really have gotten to see the power of it this year. I first became acquainted with it for building my business cards. And it was really easy to go online. They have these lovely free templates that make it really easy and quick to design beautiful business cards and get them printed for a really nice price. Like, at least it used to be crazy expensive to get the bleed on there and everything may make it super easy free graphics. If you want those and logos that you can put into there and the layouts are really easily. It's also a great tool for it. Nice clean graphics. And I'll show you some examples here in a second as well stock photo photos. I have a lovely bank of stock photos which makes it and they're for they're available for free. And so that's wonderful to be able to plug those into social media or into your website or other places. And so it's a tool that we've have used quite a bit for my side gig. I tell you that by day I'm a consultant by night. This other project with a friend to help nonprofits find the right consultant. It's called philanthropy force. And so we used Canva to build all the graphics that we've put up onto social media. I made it really quick to put all the pieces together and make it look really good. We had an intern do that for us. And we had an intern do this one as well. And it's like really nice looking graphic and all built inside of Canva. And so you really what I've seen is you don't really need to have a high level of technical expertise like you used to with a lot of these tools. And in fact, I have a colleague who on the spectrum of kind of tech ability. She's kind of over on the AOL side of the spectrum in terms of like tech knowledge. And she's able to use Canva and do really pretty graphics with it and make things come out looking really nice including like for a presentation that we did on here on TechSoup a month or two ago. So that is one of the, that's my new thing for this year. So I'm going to turn off the slide share and open it up. I do have some backup slides just in case nobody wants to talk but what do you guys have who has a tip that they'd like to share with the group need tool for nonprofits to use. I'll go first. This is Kyle again. So I haven't really used it much. But I've read a lot about it and I've seen it kind of in the same type of discussions where folks are looking to create some apps with kind of like no code experience so there's a platform called app sheet. Like I said I've heard a lot of great things about it and it seems to be a no coding type platform where you can get an idea out quickly and into iOS and Android world. So it might be beneficial to folks looking to have a presence in the app stores. And so, Kyle for for those of us who've never built an app before, like what what kind of thing might somebody who doesn't have a high level of expertise with this what kind of thing might somebody put together. Like an inventory list. So maybe you're building like some type of punch list that a contractor has to go through and in due to, you know, fix up a house to get ready to show or something like that. So, maybe you are really good at creating these lists but not a lot of school programming. So from what it looks like this type of tool could help you take some list type item and turn into an app pretty quickly, just from like forms for Excel, something like that. So I was like a habitat for humanity and volunteers right and they have these assigned roles and we get Sarah yeah you're in role a get the role a checklist and basically work through that kind of deal so they don't have to worry about the pencil and paper kind of deal okay cool. But I imagine they're probably about 1000 different kinds of things. So is it one of those kind of skies the limit and just depends on your creativity kind of deal. Like I said it when you were talking about what could people get into. That's kind of easy. That's the first thing that came to mind I was just reading about the other day haven't used a lot myself, but it looks pretty cool. I just kind of skimming through it. Cool. Thank you. Who else has run into some technology that they have found is really useful making the work use Alan I see your hands up. Hi. I guess we signed up. We were using Google workspace I guess with the nonprofit you get to Google workspace and then we found that there was they give you $10,000 a month for Google ads. You know, we were like that's wonderful. How does this work. Do you figure out where you put it all together but we found a group out of university in Pennsylvania and Philadelphia. And for these college gets to graduate they have to implement this for you. And get a certificate in Google. And so that program is out there.  So we did it and these college students results. Sorry about these college students set it all up and we were receiving. I mean it was just it got really busy, like thousands of people just visiting the website. And so that particular we weren't even ready for that. You know we're just kind of like okay now we know what it can do. But that's out there. I think if you look for add Google ads and stuff and kind of a win win these college students get to get a certificate you get to set up your, your, your ad ads out in Google and so forth so. That's super cool if you were able to dig up the link to that program I would love to share that widely because it's the number one request to get all the time locally. Okay, let me find it. Thank you. Thanks. Thank you on who else has a tech tip that maybe that's saved their bacon over the past year or two, or something that's really exciting. And kind of like I like I haven't, haven't tried this yet but I can't wait to try it. I think I've got something I'd like to share. I have to deal with all sorts of video in my life because what happens is of course you know you do a webinar then they're like, edit that webinar, find the clip in the webinar where is that section there, and editing video is, is a nightmare. There is this new tool called the script. And what it does is it does a, like a transcription of your video, which lots of things do at this point, but what it does is it then takes this text transcript and it ties it directly to the video. So if you cut a bit of copy from the script, it edits your video in place. So this is really quite powerful. So you'll say, so here's my video. And as I click through here, it will, it'll start showing like, here's what that section looks like in the video itself so you can either scrub to the video or scrub to the script. And if you're like, Oh, that's great but actually I don't want that intro sentence. You just highlight that text. Click delete. And it gets, it cuts it all out from video. So that can be really powerful. The other very crazy thing it does is it's got these tools here. So you can say like, I want to shorten a word gaps like, Oh, there was a part section like couple places where there was like a half second gap. And so you can go through here and just say like find me any word gap that's over yours here on the right, over a minute. And, and then just like, like shrink it down to maybe a half seconds you can start, you know, doing these, these mass edits across it. You can also do the same thing with this filler word thing so you do the same thing where it would go through and say find me any instance of um, through the whole script. And then you just say like either show all of them, or click a button and just delete all of them. And so it gives you a really quick and dirty way to not create a perfect edit that you would be able to do with like, you know, in a more professional setting. But if you just need to do a good enough quick and dirty edit. This is a really powerful tool. It's also great for those social media sharing moments, where you are looking for like, you know, someone said something really insightful one great sentence in the middle of a webinar or something like that. You can just go find that text, highlight it here in the text and then just say, what, just make a copy it to a new clip. And so then you could basically go and export that as like a three second video. So that's the script. I think it's super handy. There is a 50% nonprofit discount. Otherwise it's about 10 bucks a month. And if you do this kind of stuff like I do fairly often, it is a real lifesaver. How funny, Eli. Thank you. Thank you. Would it make when you make the arms go away? Does it like make that part of the video go away too? Or is it just pulling them out of the transcript? You get an option. So yes, you can either say, remove all of those and just mute that, but don't like cut the video. Or you can also say and cut the video at each one of those points as well. Oh boy, so you can get rid of those kind of embarrassing gifts and that person who's supposed to sound so articulate and polished like you could make them maybe sound a little bit more articulate and polished than they really were. Absolutely. So in the professional radio world, the NPR people will do that.  I pause way more than that. But they've gone through and done that kind of tight edit to what you've done. And that used to be a team of interns and transcripts. But they were editing actual physical tape, a really difficult job. But now you can just edit the text and it just edits the video as well, which is quite powerful or the audio. Some people just use this as just a podcast creation tool as well. So that's pretty nifty there. The last thing which is nifty but starts getting a little bit creepy and we started hearing about this recently is you can also create fake robot voices.  Well, you could just go there and write that into the text, and it will then create that audio in the video. It's not going to be 100% perfect, but who's looking at webinar videos that closely anyways. So that's something that's possible. You may want to be more cautious with that but it is now a technical possibility, as we're going to see to our horror in the political world very soon. Yeah, all of a sudden podcasts are going to be. Yeah, very different. At least hand I saw go up and I didn't get to see who's it was was super imposed on Eli screen. If there's somebody wants to jump in with a follow up question for Eli. Let's do that first and then we'll take a new comment. Was there somebody wanted to follow up on Eli. I think that is Eli sand. Yeah, it was indeed my hand. Oh, okay. Okay. Well, cool then. But who has a comment or question wants to go next jump in. I don't want to stretch but in the interest of playing along, I'll throw out wordpress my favorite of the, you know, open source content management systems. If you ever find anyone who's looking for a fast website and needs it to be easy to manage on the back end that happens to be my favorite of them, and I don't know if nodding or thumbs up maybe everybody knows wordpress already in my world that you know, this would have been 10 years ago but I have been helping a friend set up a store. There is a big, huge popular plugin called will commerce that everybody uses for e commerce, also free. You know you pay a few bucks for the payment processing but in their case they don't need it. I have a friend or a co worker or you know someone who's looking for fast simple websites. I always steer everybody to wordpress wordpress.com you set up a free account and you have a website, you know, at a wordpress.com address pretty quickly. And then you can always apply your own domain to it and attach it to your email and, you know, make it cooler and smarter from there. I've been impressed with wordpress and and Woo commerce which is a new tool to me but I've been impressed with just how easy they make it to pick up.  Adam, do you have opinions on WordPress or if not you maybe somebody has WordPress versus something like Squarespace. I used to be snobby about steering everyone to WordPress and and years ago I came to appreciate that what matters most is the people in charge of keeping the site up to date are comfortable in the administration console. So I actually think Squarespace is a perfectly excellent option for a lot of people. I have recommended to friends that they set up free trial accounts in both. And of course those aren't the only two players but you know, it's, it takes an hour or two to just try it for free. And usually, you know, whether it reminds them of something or you know there's some some association usually that makes them feel like this is the one for me and and that's all it takes to be often running. I'd be interested if anybody else has an opinion on the matter. So who else has an opinion Squarespace versus WordPress versus any of the other ones out there that fall into the basket of supposed to be easy to use I think Wix also has that reputation.  Oh, is it. Oh, gosh, I guess I just don't even know how to keep it down anymore. I don't have any strong opinions. The only thing I ever coach people on is basically saying, where is it something that you can easily export everything from do you ultimately own that data and control that data or is it something that's stuck in a platform and actually really hard to get out you're going to have someone cutting and pasting in five years. Otherwise, yeah, tools or tools would if you like it go for it.  You have a comment on it. Yes, we did just a very basic Google sites. We do therapies and VR, the mostly firm of mobile VR model. That particular nonprofit started in refugee camps so it's very, we wanted something very simple, and that can be translated into other languages, kind of very automatically. So using Google just just made it part of that made it very easy. So I just wanted to add that but also, if you're looking for kind of low cost meeting things. Mozilla hubs. We noticed a lot of people turning that into businesses are using it for schools in VR, you can access it with your monitor you can access it with your phone you can access it in VR. If you're a VR, I think you can have up to 25 people and have meetings in there and you can design the landscape. If you're a very good designer, you can have the landscape design. That's not what we do in therapies we just do these apps you download a money phone for free. And so we, we manufacture our headsets so it's a different thing that we do. Mozilla hubs is out there I know a lot of people doing great stuff with it if you want to have meetings and you could pop up. If you're inside of it like if you want to put a video, or an object in a meeting like this and it would just pop up on in front of everybody. It's a little bit like WordPress that's why I was bringing it up. So I was just like WordPress for VR. Thank you. Thank you. I'm going to, in response to, oh, lad, hands up, go. Yeah, I have a suggestion so there's a platform called jitsi j i t si. That's a video app video conferencing platform. It's open source product. So it's an alternative to zoom. I wanted to throw out there for anyone that might just happen to want to not use the only video app anyone ever uses for some reason. Well what's the user experience like with it. This is a new one for me. Yeah, it's pretty good it's gotten a lot better over the years. And that's the strength of open source projects to is that it gets community input and support contributions. So yeah, it's it's pretty slick. I'm sure it doesn't have every feature zoom has but it overall works quite well and you can want advantages. People can access it in their browser without having to download a separate app. Okay, so that makes it a whole lot easier to get somebody new to adopt it. Right. Yeah, so that might that might make it more accessible for some some users. Wonderful, wonderful. I've got a question I want to throw back at the rest of you. So I have used a number of different tools over the years just for like screen casting like basically screen recording so I can say like, here's how I did this thing instead of having to write a five step like help document like just shows someone a quick video. What, what are the hot tools these days how are people doing that kind of screen recording and sharing. This is Russell. I'm not sure what the nonprofit price would be but we use Camtasia on almost a daily weekly basis we find it's really easy. We automate a lot of things right instead of trying to show somebody once we have a from a tech perspective we have somebody comes in with a problem for instance. And we'll just do a quick screen capture and it's with all the clicks and then you can do the voiceover at the same time or after. And then it just goes up the screencast and we can share that link and it's really easy to use pretty intuitive you just started and start clicking around. And that's one we've always used and it's, you know, we found that to be really useful so. And that's Camtasia but I can't remember who the company is behind it it's.  Yeah, I think I showed up from Tech Smith, I believe is text method. Yep, Tech Smith. Yeah, I know I've used that in the past I also liked it had a pretty good, like screen annotation tool built in as well just like throw arrows and text on as well. Yeah. Yeah. I'll add one to the mix. It's called share x. You can get it from get share x.com. It's, I think free and accept donations. Pretty cool. Do you have a screen capture tool. Yep, videos screenshots. They have some editing. They have built in my hosting tools to send it to, you know, pick your site like energy or anywhere else, Facebook probably. Oh, that looks really good I'm currently using snag it but I'm paying the more money that I really like to. So I'm going to look at that. I think I have to take both these out I've been using loom and enjoying it a whole lot but yeah, it's good to know more options. There's a there's also this also an app called green shot. I think you can download it as a desktop app. It allows you to capture an image and do like annotation on it like if you wanted to, to, you know, create nice shapes.  That's a pretty nice one. It's called green shots.  You know, for just like a lot of internal support work on these I find these tools super valuable. Well I can, I can share something that's kind of not screenshot related but I'm not familiar with Trello at all. It's a it's a project management tool. I can show you a little bit here I can share my screen for see if I have it up. I thought I had it. Okay yeah. Okay, can you guys see it okay. Yep. Okay, so this is Trello. I'm actually looking for a, I'm an IT manager so I was looking for like a ticketing software. I really didn't find anything that I liked and I had heard about Trello which is kind of an agile, I don't know if you're familiar with agile methodology. But this was something that's kind of related to that kind of in that same vein. And basically, this is not just for IT management like this. I use it right now as a support ticket management like if I get a ticket or like an IT task that I need to do. I'll enter it in here and basically it allows you to create these these cards and in these cards you can create. Oh, sorry, not cards you forgot the name convention of it but a table and a table has a card and each card you create goes into that table, and you can actually drag and drop these cards into different tables. So if you can imagine you can create. Let's say you're managing multiple people you can actually create a new card. You can add a new list. Okay, my name convention is off it's called a list so I can add a list and say this is, you know, john. And I can actually start dragging and dropping things for john to do.  So I can bag it to his, his list. So you can manage tasks for different people in this way. The way I'm using it is not really for that although I, you know, I do see myself doing that eventually. I have actually something for Joshua here so I'm kind of building a list for him to do. But the way I've used it you know I have like incoming things go into this list, and then when they're when they're done. They go to the done list. And that's it, you know, so it's kind of working with different items, and being able to play around with them putting them to different lists. So that you know you can keep track of everything. And each card in the list has a different, you can have different things with it you can create a checklist within a card. So I can add you know this checklist. And I can actually start you know creating sub lists within each card. So, you know, create due dates for when those things will be due stuff like that. I mean there's this multiple things that you can do with this. I've even started doing. Let's see, I have lists of lists. So I created a list of, you know, things to do for laptops, questions for people, things like that. I've also created long term projects, you know that I can't do it right away so I started putting that in there and it's very open ended what you can do with it it's just a great way to, you know, collect all the things that you need to do, organize them in the way that you want them to organize that you want to organize them, and keep track of, you know, their status, and things like that so something I'd really like to, to use and something I just recently discovered I thought you guys might like that. Thank you, Jose, that got me thinking about at my last place I worked there were a number of teams who were using a sauna, which is a similar tool. Yeah, and they were especially they thought it to be especially valuable. They had to have multiple people collaborating on the same project, and they needed to have really good communication about where, you know, if this project had 20 different tasks that needed to know who owns each task. Where are the different tasks in the process and also be able to visualize the dependencies right that be can't happen until a happens and a is waiting on Jose and so. And it's Tuesday and it said it was supposed to be done Monday Jose, help us out what happened to task a right and so it helped them all stay on the same page about expectations and timing and all that kind of thing. Yeah, yeah, I think they're there are competitors in a way. Yeah. Yeah. Alan, I saw you raise your hand. Thank you. Thank you so for sharing. I just found out about Trello. And we brought on to UX designers for people's budget Texas. And they wanted to do slack and I just can't stand that slack thing. Every four years I feel director for presidential candidates. And the last one that put in that slack. It was just a nickel chamber as a disaster. It's something I volunteer for every four years but I can't stand that slack so we, we came to a middle point of using Trello, which is supposed to be public as well so everybody can see it. And we're looking at it and how do we use it to, because we're building people's budget Texas with five community colleges here in San Antonio the Alamo colleges, along with a couple other it volunteers it's kind of a community thing. But I just had to put the foot down on that. I just can't. It just becomes an organism where it's this echo chamber going on that's just like. Trello looks like a good little halfway. We'll figure it out. I don't know if it'll work but thank you for sharing that as it's something that we're going to put up. As a public thing so a lot of the, a lot of our people are politicians, city councilmen. They're not going to go into a slack account. But if you can publicly see this Trello kind of a board. It's almost like a scoreboard of sorts. So if you want to be able to progress and be able to get updated, then it looks much more accessible. But yeah thanks for sharing that. Good thing. I have a question from a friend who wasn't able to be here tonight I'm hoping you might have some answers for her. What do people like for antivirus malware protection for a nonprofit particularly on the free side of possible. What do we love what do we hate for for that. Is this for Windows or for Apple. Let's let's say windows but let's let's cover both while we're at it. Yeah, well windows windows has a built in antivirus already which is defender. I think it's sufficient for viruses. I don't. Yeah, I don't, I don't see a need for antivirus outside of that defender. I mean maybe if anything maybe like malware bites. You know some that's, you know that's, I've used that in the past but I think I think defender should be sufficient. Anybody have any, any thoughts on that. Am I wrong. I agree. I think that's a reasonable recommendation, if budget is the, you know, top priority or one of them on the PC side, and malware bites on the Mac side, you know, I've heard good things about. The typically, I've run into a lot of computers where McAfee is free installed. And it's pretty annoying so what I do I just, I just delete it. I just delete McAfee I don't think it's needed. But you know, you know, they make it seem like it's it's urgent to have that software but I, you know, I don't see the need for it. That's my take. Go ahead. This is this is Russell and I think in the introduction I said I've been in cybersecurity for 25 years and it depends on your budget. I mean, bit defender we found bit defender and malware bites to be pretty good and they'll work on Windows or Mac. One thing you want to look at when you're when you're doing something around there. You're going to want to manage it right so somebody going to be managing it you just want to put it on somebody's desktop and leave it up to them and and so you can buy some fairly low cost things so fast as fairly low cost as well and you can imagine it, manage it from like an SMB small business type dashboard. And then it tells you if people are up to date or not you can look really quickly if you just use like the windows defender, which to be honest I don't think it's, I think that the paid for ones are the free for nonprofit ones are going to be better but you're going to be able to manage it across platform on that and then if you have any Linux or anything in your, you know, in your environment for some reason that a lot of people would you definitely going to need something around there but I would always kind of choose something that you're going to be able to manage it's not so much as it just work but if you got two different things on, on one on Mac and one on Windows, it's, it's never going to be really cohesive on there so I would just, I would say use something that you can have a common dashboard for and monitor and then give you alerts right on that as well in terms of who's out of date or, you know, are they doing scans regularly right. You can force scans with some of these SMB things right you want to be able to, you want to be able to monitor it right just just sticking it on and leaving it people's own devices I think is a recipe for disaster. You know that brings up an interesting thing and I've experienced this with some organizations where they've never, they've just MacGyver their whole tech set up and so you know everybody has these individual computers are not networked or anything like it at all. Is there a way to DIY yourself out of that situation and start to get networked and start to have that kind of hub there so you can manage the security and all the computers and things like that. So you can use I mean if you took, if you took something like like a bit defender or so false or something they actually have everything from antivirus to know personal firewalls that are on there as well and you can manage all of that. It's not necessarily that they're networked together in that sense. On that they're not part of a directory structure that would be a totally different thing if you put somebody as part of your windows directory structure so you should manage to get from an active directory point of view. But if you just have people scattered everywhere. I would, if you put. If you worried about viruses and fishing and malware. The easiest thing would be to find something you're comfortable with with the dashboard that's inexpensive. Get it installed on all of those machines. It also depends do you have control of those machines are they your machines are they volunteers machine right. If it's a volunteer machine you can't put your stuff on it and manage it so if you don't connect to your network that's you know that's a, that's a whole different thing, but you can kind of manage it it's like to say. You use so fast because I actually use that for my, just my home and all my kids so I can make sure everybody's updating stuff. I can see if they're all updated I can see if they're online some of it even has go find your, your laptop features on it. And it's pretty inexpensive. You know so. Let's take, get your take Russell on, you know, the advent of cloud computing and it from my perspective. It seems that since more apps are being utilized from the cloud that there's less I mean you always want to be careful but there's less of a, you know if your computer gets a virus, it's not as critical because you know most of the time you'll be working with cloud apps anyway. I mean you should definitely have antivirus not saying you shouldn't. Yeah, it's not as critical as it used to be. I would completely disagree with that because if somebody clicks on a link or they they get malware they get ransomware. You do that, you know, you do that by clicking on a link right it's irregardless and if they lock up all you know then soon as you email somebody else. They can click on a link there I mean even.  Obviously it's a link to CNN calm, it will dynamically change that link into a malware link, and you will go to a malware site behind the scenes so I mean there's a lot of stuff like that so I would never. If I own the laptops and they weren't volunteers laptops I would always have something up on it. Right ransomware right now is the biggest thing that we deal with. Now obviously we're talking to enterprise, you know customers and things of that sort but every I mean I've seen people small organizations as small as you know 10 people organizations get malware and just lock everything up and they can't do anything.   You didn't know. Now it doesn't make it if you're me if you're all using something like Chromebooks that really didn't have it much of an operating system and you're all using cloud apps that helps you out a little bit more but if you're using email you're pretty much going to be susceptible to it so it just depends how large your organization is and one thing you don't want to do is you don't want to accidentally send malware to a donor, a larger organization that you're dealing with things of that sort. So, yeah, it's not just your organization you can spread it. Thanks. Yeah. Very good. Very good. There are so many different aspects of technology and how it impacts our nonprofits and I love how we're covering a lot of very diverse ground in terms of all the different pieces of technology is one of the reasons I've become a big believer in having a nonprofit community right where I've encountered so many nonprofits where it's, it's a DIY MacGyver job even nonprofits as big as like 20 staff or more. And it's, I've seen how transformative it can be to have an IT professional or ideally a team of professionals that you can call on when you need them. One thing I would suggest and I see this in the commercial space not necessarily the nonprofit space but I think nonprofit space should do the same thing is almost nobody has their own IT anymore. Nobody manages their own IT. If your organization of 100 people or less, nobody has their own IT department generally. I mean they'll have maybe one IT person there to kind of manage everything from an inside point of view. But they're, everybody's using a managed service or outsourcing it so that people are looking after their updates and their security and so forth. I think the thing would be to find out organizations that provide those types of services that may provide a metal reduced cost for for nonprofits because you know, you're kind of one IT guy swimming in everything right and you can't know everything about it and so it's, I would, I would outsource that we do that I mean I worked for our cybersecurity startup, and we don't do any of our IT. It's all outsourced. We don't touch it because it's not our core business.  So it, it, I think I'm hearing you echo something that I've been suspecting for a while Russell which is that one person cannot do it all anymore, and probably hasn't been able to for a long time. That's correct yeah. You may need that one person help coordinate everything inside, but you really it really pays dividends, you know I guess it goes back to budget though but I would, I would outs, I would never try to do it myself ever again. I know it can be very expensive to DIY right and then you hit with the ransomware, because you were worried about some other thing and you weren't able to step on the developments and something else that was also important. Right. Cool. I think we have time for maybe one more you like to have time for one more question or do we need to your microphone. I don't think we have a hard end on this so yeah keep going until you run out. Well, folks, why don't we do, does anybody else have a burning thing that they want to contribute to the conversation or a burning question that they want to get the group's wisdom on. Just briefly I wanted to mention about the point about slack versus something like Trello. In my opinion they're complementary tools. They serve different purposes. I would not use slack for project management. But slack is useful for communication. But you need a permanent store for the things you're talking about because slack will just keep scrolling by and the content is going to get lost, but it's helpful to have a quick way to bounce ideas around. So. And I wanted to mention on the topic of security password management. Maybe, maybe others have have ideas. I'm using one password right now. I know last pass is popular. But in terms of in a nonprofit setting, does anyone have experience with what works well. I've got experience with one pass. And pretty much everybody that I know and kind of my cybersecurity buddies are all kind of default at the one pass for personally use and things like that there's other things for enterprise use but yeah so I would I would echo one pass is something that was, I would definitely push and use but I guess in this context it would be cool if there was an enterprise solution that had a nonprofit discount. I haven't seen anything that really fits that that sort of need at the last pass the kind of end user level. On the other side for enterprise with a nonprofit access. There is I think up to maybe I think about 50 users so for like up to mid-sized organizations auctions got a good support option at quite a low cost I believe for nonprofits. It's obviously slightly different thing is more single sign on but it's another way to sort of help organization, manage security identity and all that. Yeah, we've used octa to I'm familiar with those the problem is something like octa that's you got to you're getting into the realm of a lot of people who are calling together their it are won't really be able to use it because it is a little complex when you're putting in a single sign on versus just password management. So that kind of gets back to reasons why you might want to outsource some of that to a managed service provider. I use dash line password management. It's pretty good. And actually, this is my ignorance I work at TechSoup I did not know they're in the TechSoup catalog but actually they are. So thanks Kyle. Yeah nice to add on to the TechSoup guy something just to add on to the security side to talk about any virus a lot of the starts with safe browsing so anybody has like recommendations for you know good browser extensions like HTTPS everywhere for Google Chrome. Those kind of tools are really helpful to keep people on the right path when they're using the internet that don't know better. Just super thought. What was that one again Kyle. HTTPS everywhere. So like if there was a site that was trying to pose as somebody else's site that was running on, you know, not securely so they could capture using passwords off forms that are unencrypted. This particular tool would force your traffic over HTTPS or prevent you from operating on that site all together. Those are kind of things that people really don't see behind the scenes, but those type of extensions can help save you. So perfect for like my 76 year old mother and or people who's browsing skills are the same level as my mother's. Yeah, and most organizations have a number of people like that. Yeah. Nice. Any other hot tips before we wrap up for the evening. Or burning questions. What's the next meeting. November, first Monday in November, my friend Tristan Pierce is going to be presenting on how to build an awesome quick books stack basically how to leverage your your basic nonprofit accounting package. I'm looking forward to it. Yeah yeah Tristan's a good guy he knows this stuff really well. All right well, folks thank you for joining us tonight this has been, we did this one a year and a half ago. And I think we covered two or three times as much ground tonight this was really neat I think we went deep and broad I have personally a bunch of pages and notes. Thank you everybody for coming on and sharing your ideas and your experience this has been, yeah, certainly very fruitful and I think this will be a good one for anybody who's watching this and video later. Be sure to get the chat because there were a couple of thoughtful people tonight who were dropping every time somebody mentioned a product that somebody was dropping into the chat. We'll actually go there and check it out so if you're if you're seeing this somebody later be sure to get the chat as well and thank you to those of you who were dropping those things into the chat box for us. You like any parting words. Nope. How about you're all great. Thank you so much for sharing your expertise I learned a lot. Thank you and we hope to see you next time. Thank you. Thank you. Thank you. Thank you guys.