Felly, y theory of quantum information is the extension of ideas from classical information theory and computer science to the quantum realm, because we know that quantum mechanics behaves very differently to our everyday experience and has all sorts of interesting effects that we don't see in our everyday life. Quantum information theory is the theory that tries to harness these effects for our advantage to do interesting things that we can't do with normal physics. Quantum computing, quantum information are becoming increasingly more important and especially right at the moment because in a few years time we'll start seeing very large scale quantum devices being developed, examples being the work going on here at IBM also elsewhere which can really solve problems which we don't know how to solve using our normal computers and this could really be the next significant change in the IT industry and it could affect a number of other important industries worldwide. So I think now is the time for students to try and understand how these machines really work. There are several ways that they can do that. One way is they can go to a university and do some courses to do with quantum computing, quantum information. I teach one myself at Bristol but there are many excellent courses worldwide including ones available online. But now they can also experiment with online quantum computer simulators or even real quantum computers. For example IBM's own quantum experience cloud based quantum computing interface is a nice example of this. So there's a number of different ways that they can get into this area from just small scale tinkering to really full on preparation for a career in quantum computing. So the interesting thing about quantum algorithms is that they are based on very different principles to classical algorithms and they try and use these interesting quantum effects to do things we can't do without quantum mechanics. Because these effects are so different to our everyday experience it makes it hard to write algorithms in this way. So we've seen that even though there's been a lot of exciting work done on quantum algorithms we don't have as many algorithms as we would like. There's still a lot of interesting challenges ahead. One way in which this is changing is that soon people will be able to run fairly large scale algorithms on real devices and even now they can already run small scale algorithms on real devices. So I think that we're going to start seeing more quantum algorithms being developed like both intrinsically new algorithms and ones based on optimising and refining existing algorithms now that people have access to real devices to play with. So I think it's an exciting time in that sense. I wish there was a magic standard straight forward technique that would just take a classical algorithm and give us a quantum speed up. Unfortunately there isn't in full generality and there are algorithms where we know that we can't achieve a quantum speed up. But there are some fairly general techniques that we do know which are often based around choreograph and quantum interference in some clever way to try and achieve a desired result. So we know for example some fairly general purpose techniques for speeding up the solution of constraint satisfaction problems and certain optimisation problems and I think finding new approaches for general speed up of classical algorithms is an exciting direction for the future. I think the killer app for quantum computers at the moment seems to be simulation of quantum systems, quantum physical systems. So this is something which is very hard to do in full generality on a classical computer. But we know some very clever quantum algorithms that enable efficient simulation of quantum mechanical systems which could have applications in areas as diverse as material science, drug design, this kind of thing. But also I think an area which is very interesting is quantum speed ups of hard optimisation tasks which could have very wide ranging impacts in all sorts of different industries because in almost every aspect of life nowadays there are algorithms behind the scenes solving hard computational problems and I think that it will be very interesting to see to what extent these kind of optimisation problems that are going on behind the scenes can be accelerated with a quantum computer. A quantum algorithm for accelerating a class of classical algorithms which are known as backtracking algorithms. So these are algorithms for solving constraint satisfaction problems classically which can be seen as trial and error type algorithms. You try a solution, if it doesn't work you try a slightly different solution etc. And it turns out that you can get a fairly substantial quantum speed up of these algorithms in some sort of generality. So this is a kind of a general framework that we can accelerate but then an interesting question is what specific problems can we target using this kind of approach. And in some joint work together with a student we are able to show that the famous travelling salesman problem a certain algorithm for this can be accelerated using a quantum algorithm. So I think this is a very interesting direction for future work because there's a whole world of these algorithms out there based around similar paradigms and it's possible we might be able to find some interesting quantum speed ups there and these could have a number of different applications to constraint satisfaction problems but also optimisation problems more generally. In the near term this sort of quantum computers that we have are not going to be perfect they're going to be kind of noisy, they're going to have errors, faults, things like this as well as being relatively small compared with what we hope we can build in the long term. What problems can we solve with these kind of noisy near term devices especially problems that we really care about solving? What interesting challenges can we address with the sort of machines we're going to have in the coming five years rather than the coming 20 years?


Check out these jalapeno pickle poppers. I just made two different ways.   Parchment paper, plate, and squish. Ah! Pickle, cream cheese, and jalapeno. Potatoes crunchy, everything bagel.  Should look just like that. Now you can also do it like this. Pickle, jalapenos, cream cheese. Cheddar cheese. Lay on your thinly smashed sausage patty. Mash it down around the edges. Push in the thin edges around the sides. Look at that thing. We're gonna bake it in the oven, right on this parchment paper. Going in at 400. Now that's looking Dan O' Mike. Now that was Dan O' Mike. Yum, yum, get you some.


All right. Here we go. Welcome. I'm so excited to be here with all of you and be celebrating the grand reopening of City Hall Park. It feels like we have just a little break in the weather here. In general, I'm blaming Doreen for this and her desire to see the interactive storm water art exhibit working fully. At least that's a benefit from it. But sorry we don't have better weather for you but we got a lot else. Let's dive right in. And let me do just say if people can't be mindful of, I see almost, I see everyone's got masks on. We're all going to have our masks on except when we're speaking. Thank you for that. Try to keep distance between yourself. We've got a big enough space here. I think we can do it. So here we go. In her seminal book, The Death and Life of Great American Cities, Jane Jacobs revealed the rarely-munchened, unfortunate truth that many parks fail to achieve the promise that they represent. For every vibrant city park, she observed, there are dozens of dispirited city vacuums called parks eaten around with decay, little used, unloved. To be great spaces, she wrote, city parks, quote, need the boon of life conferred upon them. That was the core problem we were trying to solve with the transformation of this park, to give it more life. For many years, City Hall Park was amazing on summer Saturdays with the farmers market here and much of the rest of the time it was dramatically underused. The park's design and amenities did not draw people into it. Soils were eroded and compacted and the lighting and lack of activity left many potential park users with a sense of unease and they didn't come in. We could see that there are ways that improving the design could help City Hall Park both withstand better the times of heavy use and be more welcoming for other types of uses too. We knew we could create features that would help more people enjoy it from spaces and amenities to support eating and small gatherings throughout the day, to improve accessibility, to a fountain that would be a destination for families, to more benches so that people could sit and talk to a range of different spaces for music and cultural programming. This was the opportunity that the community called on us to make good on in 2011 during the Imagine City Hall Park public engagement process led by Burlington City Arts that involved hundreds of members of the public. We knew it wouldn't be easy. There had been prior efforts to address these issues over the decades that had not been successful and sure enough over the years since this administration committed to getting this done we faced many challenges. Soil conditions drove up the cost dramatically resolving important decisions about trees and expanding sidewalk and event hard surface areas added time and brought some controversy. When in the summer of 2018 after eight years of active planning the City Council made the decision to send this project back to a new committee to consider design changes again. There were a lot of people who doubted that this would ever happen that we would ever get to today. However we stuck with it. We addressed the rising costs by finding new philanthropic and institutional funding sources and taking some of the work in-house and doing so in a way that kept the cost of taxpayers under a million dollars. We sustained the will and focus and today we know that it was worth it. At long last we have a public space at the physical and cultural heart of Burlington that is alive that is worthy of this great community and that is accessible and welcoming to all. A park that is truly built for everyone. So you know having addressed some of the project history I just want to reflect a little longer on this present moment. We are gathered today seven months into a pandemic. We are wearing masks. We are keeping physical distance from each other. We are going about our daily lives in ways we never imagined at this time last year. We have plans to use this new space in the remaining months of this pandemic which we hope are short to keep our downtown vibrant and to help sustain the many small businesses and organizations that are facing massive challenges right now. As people start to experience this revitalized park I hope we'll serve as a beacon of renewal and remind us that there will be life on the other side of this pandemic and that our city will get through this and truly not just rather truly will be stronger on the other side. Finally the history of pandemics suggests that once we do get to that other side it will quickly become hard to remember the loss the uncertainty and the dramatic disruption of our lives that COVID has wrought. That is why today I am dedicating the park renovations to the Burlington residents who we have lost to this coronavirus. We have a plaque here that is going to be installed just on the other side of the plaza that will be permanently installed and I'd like to read it to you here's what it says. A comprehensively redesigned city hall park reopened after a year of construction amidst the largest global pandemic in 100 years. At the time of the opening the city had been living under emergency order for more than six months. Masks were required in all public spaces and group gatherings were severely restricted. This park renovation is dedicated to the Burlingtonians who died as a result of the novel COVID-19 coronavirus. In the years to come as children play in jets of water and crowds assemble to enjoy each other and our city's great music, food and events. Let us never forget that these joyous scenes are fragile and that their continuation can only be guaranteed through an ongoing vigilant commitment to public health and to science. We are joined today I believe if you could raise your hands by Ross Farnsworth the director of the Burlington Health and Rehab and Alicia DiMario. Ross and Alicia they're in the back. Alicia I may have like to say is the director of Birchwood Terrace and thank you for joining us today and I hope you will convey to all the families who have lost the lost loved ones in the early months of the pandemic that we are thinking of them in their loss today. Finally I'd like to close by a pretty substantial round of acknowledgments. You don't have a project that takes this long and involves this much effort that doesn't require taking the time to thank a lot of people and I'm gonna I'm gonna try to do that here.  First of all I want to thank the city team. This project has been a feat of cross departmental collaboration that goes beyond I think anything else we've undertaken together in the last in the last eight plus years and it includes the parks, recreational waterfront department, Burlington city arts, the department of public works and the water resources division of DPW in particular involves CEDO and the office of city planning and there are certainly things that had that the city attorney's office spent a lot of time with basically just about everyone in every department ended up playing an important role before this was done. I'm particularly grateful to Laura Wheelock engineer and project manager extraordinaire for steering this project through complicated soils remediation work. Where is Laura? Thank you Laura. And for delivering this project Laura I think it's important to say on time and on budget but for the delays caused by the pandemic itself this construction proceeded exactly as it was supposed to and how many other city projects you actually see the budget coming down over the course of construction. I haven't seen it before thank you for what you did. I want to thank and we're going to hear from in a moment Vijay Komai who on his very first days on the job as city arborist plunged right into the controversy had to go to public meetings to speak about the trees in this park the passion of Vijay and his team have contributed immeasurably to this project and even and he helped in ways as well that helped deal with the budget challenges taking some of the work for the plantings and the trees in house he's been out here day after day in recent months getting ready for this beautiful opening. Thank you Vijay and thank you for your whole team. I want to thank the rest of the parks team who put great care into thinking through how to maintain this park and keep it as welcoming as it is today not just an opening day but every day going forward and who and the water resources team who I mentioned they work to ensure that the project would sustainably improve storm water management in our downtown core it's a big issue right in the core the management of storm water and these beautiful gardens around us are not just pretty they're not just here to to enhance the experience of being here they also play an important function in protecting Lake Champlain and I want to thank the Burlington City Arts team for their thought about how to bring this park alive through arts and cultural programming. There are so many partners that played a role in getting to today and helped build support for the project and shape it in important ways over time I want to call out the Preservation Trust of Vermont and AARP for being key partners and I particularly want to recognize the Burlington Business Association and Kelly Devine. Kelly where are you? There she is Kelly for all that you did throughout the history of this project to get us today and in true partnership to make this an important part a successful part of downtown. This project has involved vision and technical skill from designers architects and contractors thank you to Wagner Hodgson, Sussman, Land Shapes, S.D. Ireland, Du Bois and King, Wait, Hendo and others. We wouldn't have gotten today without the support of generous private donors who helped add important features to this park and without whose help we wouldn't we wouldn't it would be a very different place I particularly want to thank Tony Palmerlow we're thinking of him today and we have Ernie Palmerlow here who in his own right has been a great champion of this project and so many others and who we'll be hearing from in a moment we're so thankful for the civic commitment of the Palmerlow family and I also want to thank the PCOR family which made an important contribution to get us over the final financial hurdles as well so thank thank you to all those partners and all that team I sorry I two other important bodies that played a key role in getting us today making this project better the city council was highly engaged in this project from start to center to finish I see Councillor Mason here with us who went through every step of the way over the last eight years thank you Councillor Mason I'm sure I can't I haven't seen her yet but I'm sure councillor is councillor Paul if she is councillor Paul here she if she isn't here in person she's here in spirit and has played a great role rounding up philanthropic contributions for some of the benches that are here if any other city council that can't quite see with the mask the umbrellas can you raise your hand I see new city council Sarah Carpenter is here and we have Franklin Paulino here as well and Brian Pine is standing there in the back thank you Brian for being here Brian was on the inside on the city team when this started and played a role then thank you to the city council for the partnership and thank thank you to the Burlington Parks Commission which also played a key role and I believe Nancy Kaplan who is the chair for some critical years and was a great champion this project is also here so one more time let's have a big round of applause for all the partners that got us today so now I will turn the podium over to someone who has seen the potential of this project from the very beginning who went out and got a big grab from the national and down to the arts to get this process the match into the all-part process kicked off in 2011 the great Doreen Kraft fun what fun thank you morrow um there probably isn't a person here today who's standing who doesn't need to be thanked if anyone is ever overlooked in these gatherings please know that you are deeply with us because it did take a village to bring this beautiful civic space to life though discussed informally for some years it was in 2010 that a group of citizens neighbors business owners and park lovers finally declared that city hall park was not serving its purpose as the central public plaza and green space in the downtown of Burlington there was deterioration and neglect in a space that many thought was the gateway to our city and we knew we could and must do better with oversight from the city administration the Burlington business association parks department police department preservation trust of Burlington king street center tom levitt then at the merchants bank now at northfield savings bank ernie pomerlo and his family along with an army of dedicated citizens who formed a task force to commit our energy to realizing a park that better represented the natural beauty cultural compassion and diversity of Burlington funded with a grant from the nea imagine city hall park was a nine month engagement process that leveraged art as a driving force collecting the multifarious needs designs and ideas that our community had and distilled them with an abundance of creativity into a single space with rain garden storm water mitigation expanded access interactive installations historical preservation and flexible event space that is available to every single citizen i think we then have more than achieved our goal this park is beyond beautiful even in the rain in the midst of the pandemic and a long overdue national conversation on racial equity i have come to more deeply appreciate our parks and wildways the green spaces throughout our urban core our parks are who we are they bring us together to converse to play to relax and to consider ways forward in shaping the future i am so proud that this public civic space is blessed with the intentions of thousands of burlingtonians and vermoners but our work on city hall park is still unfinished the park is and should remain a work in progress one that will need us and generations to follow to nurture it to engage it to protect it so that it continue to tell the ever progressing story of who we are as a city in closing i want to thank a few more people i want to thank sarah cats for my team who is in charge of the public art installations and the gorgeous work that you will take a tour on today with cat clear tessa o'brien artist i want to thank zack williams and uh his team for all that you have done to create spaces in this park that will allow many many types of public engagement and display i want to thank heather ferrell because now for the gallery the bca center gallery this is a new backyard and a much larger responsibility of what that gallery will mean to this city park i want to thank the water wheel found beth montorey rolls thank you so much for your amazing leadership and contribution to making this park possible and to my board members and leadership lori roe and france stoddard you're amazing to all my colleagues i love you hello everybody i'm tom levitt i'm president of northfield savings bank i grew up at 1888 north avenue berlington vermont then it was 05401 now 05408 and uh i had the pleasure of standing here at this location on the occasion of our nation's uh bicentennial with uh mayor gordon pockett as he dedicated a brand new city park fountain and i was with my girlfriend now my wife of many years diane just freshly out of burlington high school so the seahorse spirit lives um and if we live again in a beautiful new space that came to be because of our community citizens and many community investors and i'm delighted to be here with urney today um as one of those key investors in this project but it really took so many hands over that 10-year period i want to thank kelly divine and the burlington business association for their leadership for the way they rally the best in business principles we are all corporate citizens as we stand here in this great city and this gem this treasure is is brought about because we have vital business in the city of burlington because we have people that are employers and paying taxes and providing capital to the city so that all can be included and that we can all stand here today and celebrate such a beautiful asset to our community it is our front yard i think that the vitality of this park going forward is really going to be important the fact that we do want it to be safe we want it to be healthy we want it to be totally inclusive so northfield savings bank i'm proud to have some of our team members here uh will be underwriting programming in this park not only this fall but all through next year to make sure we're reaching out to community organizations across the spectrum here in burlington bringing these young people and some not so young to the park so they can showcase their soul so they can showcase their creativity in their arts here in this space so i am very proud to be affiliated with that effort to have northfield savings bank as a good neighbor across the street being part of this not only today but in the future a healthy city hall park equals a healthy burlington so thank you all and thank you mayor weinberger for your leadership hi i'm kathryn monstream and i have a gallery across the way and i'm a painter and if we were at a wedding today we would say that this is really good luck because the gods are crying tears of joy as we all are um what i love about this space is there is room for everyone at this park there are new corners nooks more benches there's perennial gardens and the orientation of all the structures is so welcoming to locals and visitors alike and to me i don't know why but it looks bigger i don't does everybody think it looks bigger it's now a true destination something i probably wouldn't have said before and it's just what a great city like burlington needs a true city hall park we can be proud of it now and when friends and family come to visit we will take them to the waterfront church street we'll be down at the maran plant maybe the uh 40 foot um filing cabinet but now this will be part of our tour when we bring people here and it will be a great place for people to visit when the first designs were proposed some folks resisted and what i think we forget is that shelter and farms isn't naturally beautiful and you're like of course it is it's this gorgeous swath of land on the lake shores of lake champlain but every tree every shrub every curve of the road was planned and designed so while Frederick Olson wasn't available we were lucky to have the good design and creative eye of Wagner hudson who put together this amazing design solid landscape architecture and that's what we needed to reimagine this space is true design personally we are so lucky we across the street we look out on the from the gallery we have big windows and we see the silver maple and watching this progress has been incredible we're sort of like little kids at a construction site each day looking a new palette of rocks the sod trucks when the trucks came with grass we were like just jumping for joy so it's been really surprisingly pleasant to be a business on the perimeter of this park during this transition um i want to thank the city for making that effort because certainly we had some hesitation about what would it be like during this for our little business and i think all of us would agree that the the parking was sort of maintained as best it could it was relatively dust free and entertaining every day so i'm really grateful for all the work that happened to make uh our businesses um be able to stay open and um i also i think my family for being here today tour silly nails and my husband al because this has been like their playground and now we haven't been able to come here and i can't wait to buy them a lunch have a picnic i promise the murals from kkd thank you hi i'm jeff hodson from wagner hodson landscape architecture city hall park has evolved since the late 1800s when it was pretty much just a and a green and over the decades chris crossing paths were added at least two different fountains have lived in this park and um you know while both while modifying a beloved park is not always the easiest job to take on um it's definitely one of the most satisfying um and we've really enjoyed the process and are really happy with with the results i want to mention amy houghton is in the audience she was the project manager for our office thank you amy for everything um some of the the new park features i wanted to point out making the the park more accessible was was always a big goal and um we were able to achieve that through shifting walkways around um we improved greatly the ecological health of the park there were a lot of contaminated soils in the park they were replaced um aerated the trees we added over um 600 shrubs and 900 perennials and introduced a lot of new tree species and also the rain gardens that have been mentioned they can handle i think it's 90 of the rainfall that happens that falls on the park and it also treats uh half of st paul street so um that's really important for the for the city because it takes that that capacity out of the combined sewer system and it allows the water to recharge into the soil the high efficiency lighting that we've put in through the park adds safety and atmosphere um and the seating options we've added a lot of seat walls benches but also movable furniture which in these covid times is turning out to be even more important than we ever realized and also the portland lou the bathroom um a very uh high-tech prefab well thought out amenity for the park before i go i just want to thank the countless city staff that helped make this possible and like morrow said it was almost every department i think um but also the contractors and subcontractors that took you know a 70 page uh 70 sheet construction set and brought it to life uh creating this park they were amazing to work with s drland landscapes and uh john turner consulting so thank you very much hi i'm vj home i and i am the city arborist um as mayor wineberger said my very first day on the city payroll was the first drb meeting reviewing the plans for this park it was a packed house um i immediately found myself at the center of what would become a very long and very spirited debate about the future of this park i learned some things very quickly that night the first thing i learned was why my predecessor decided to retire when he did yeah i'm laughing now i also learned that burlington residents are really really passionate about their public spaces but at the same time i learned that the city team that had been working on this project for years before i got here that as has been said involved people from departments across the city were equally as passionate about our public spaces and were committed to making this park the best that it could be in the weeks and months that followed that first meeting i spent a great deal of time in this park evaluating the health of the existing trees i studied the plans for the park's reconstruction i did a lot of research on my own i met regularly with the whole city team and the design team and i listened very closely to all the concerns that were being raised in the public process i ultimately came to the realization from an ecological standpoint that this park was failing badly it was quite sick many of the existing trees were in severe decline and it had been in decline for years the soils throughout much of the park were very compacted and were degrading by the year and with each passing storm and my agenda throughout this process was to ensure that the plans to redesign this park would address the issues that had led to the park's decline over time and that ultimately the work that we did here would strike a balance between the public use of the space and the long-term ecological health and sustainability of the park for generations to come fortunately i've been in this business i've been in this profession for more than 30 years i started when i was like six um we've learned a lot in 40 years through science and research we've learned about the importance of mitigating storm water runoff and how to incorporate plants and to build structures to help make that happen we learned about more about the proper planting of trees to ensure their long-term health and which species are best suited to specific sites and urban settings we've learned of new innovations that allow us to incorporate trees in the hardscape areas and provide them with the soil volumes they need to grow to maturity very important we've learned about the importance of having a diversity of species of trees in an urban space as well as a diversity of age classes of trees and we've learned about the importance of supporting the health of our native pollinator populations which have really been known to be suffering in recent years and how to use native plants to supply them with the food and habitat that they need to thrive and survive we believe in science so we incorporated all of what we have learned into the design and reconstruction of the park and i think the results are visible today the ecological health of this park has been restored and and i'm confident that it's been done in such a way that it'll be sustainable and will thrive for future generations and i look forward over the next several years and and hopefully decades watching this park thrive we planted 22 new trees hundreds of new shrubs and 3,345 or 35 perennials and ornamental grasses by completing the plantings with our in-house staff we were able to source all of the shrubs and all the perennials and grasses from two local growers so we supported our local economy at a time when we all know that was probably more important than ever and not only that it greatly reduced our carbon footprint because we weren't trucking these plants in from great distances and the growers we worked with are as passionate as they come and as good as what they do and it's evident in the plants that you see here today a large percentage of the plants and trees are species native to our region and thus they're well suited to the site will support our native pollinators while providing a display of color from may through october the aeration and mitigation of the soils throughout the park in addition to the state of the art irrigation system will ensure the long-term health of the trees and turf it's been a real pleasure for me to be a part of this team to make this happen I've learned a lot you know people from across all departments got to know everybody really quickly but I especially want to acknowledge members of our parks and recreation department they're kind of behind the scenes that help get us here today so there's our park leadership Cindy Cindy White our director and Derek Roche our head of facilities and facilities and maintenance supervisor for their guidance and support along the way to our parks planning team who wait in throughout the design and construction process to our facilities crew who are here the last two weeks fixing you know putting the finishing touches on everything from hanging banners to trash receptacles and all the above they've been training on the new irrigation system and fountain system and its upkeep and maintenance and moving forward they're going to take on that responsibility to our grounds crew who you know has already implemented an intensive program for taking care of the turf in the park and especially to my tree crew who took on this project with me never questioned it brought their passion and expertise every day and they're still talking to me so I'm happy about that so thank you good afternoon my name is Ernie Pamela I'm here with a number of our members of our family to celebrate this moment with all of you and I think it's really important again I know we've done this but Maro your your your efforts and the amazing team around you in the city I need to thank you for your vision but most importantly for your commitment we would not be standing here were it not for that amazing team I go back like Tom I was born here in many of you a few blocks from here to put a little history on it I played in this park when the tickets at the Flynn Theater were 25 cents so we talk about evolution I played here there was a canopy of absolutely exquisite elm trees they went away they were replaced you've heard about different fountains we're in like the fourth generation here this is natural evolution the only constant in life is change and what an exciting time to see this final change the family here is dedicated to one thing to help the park but there's a little memory I wanted to share with you all mom and dad wanted the fountain and the handicapped accessibility and memory of our sister Ann Marie who was a teacher of disabled but she saw the world through a wheelchair and to be able to now have this park she would come and spend time at the farmers market and it was very challenging though the sidewalks were narrow things were rough but so to be able to participate with the community and the city to have a handicapped accessible park of this magnitude and the other fun thing that fountain not only is going to you're going to see in a bit splash park we're getting a little practice now but the splash park for for children but it's accessible to children in wheelchairs and to me that was magic so our little part in this is to enhance that but I wanted to say thank you for everybody here and everybody this has been a long road but one worth traveling thank you well first I want to start off by saying what an honor to be speaking here and representing an organization that I love so much for those who don't know me my name is Mila and I've worked at King Street Center for five years now and one of the many things that made me fall in love with my job is the fact that King Street has always made it a point to be involved in our community as much as possible this park has been part of our daily walks with the toddlers for many years and I don't know exactly know how many times but we definitely have a lot of falls laughs tantrums and lots of moments of curiosity and gross motor exploration in this very park by bringing King Street kids here of all ages it becomes part of their community and in return we hope that it becomes part of the neighborhood their families also come to think of as their own which is a place to gather play and enjoy it is an iconic place in Burlington Vermont and we are extremely excited to be walking the toddlers through here again and a small story we actually walked through here the other day while the fences were still up and one of the toddlers went for a peek through and was like whoa so I think the toddlers approve of the space and thank you thank you Mila all right thank you all for sticking through this in the rain and long program we've got just two things to do to close out our program today um let's say let's actually three quick things to do one these benches help finance the park Doreen anyone who's interested in and helping us get over the final kind of fundraising goal finish line there are still opportunities see Doreen and her her blue piece of information for for more secondly in a moment we're going to get asked for some help in launching the new fountain for the first time officially and we are so happy to have a group from king street here to to help us do that and they've been incredibly patient and done a lot better than I think my kids would have done uh waiting here through this all so we're going to turn over them in one moment and then as soon as that's done I just I hope people will will stay around and we're going to try to do a socially distant group picture Zach Williamson will help us lead us through that so with that let's go to the fountain and our king street students and I get here's where we're going to do it if you can help us we're to uh we're going to count down from 10 together ready


Marching band, the marching band is a group in which instrumental musicians performed while marching, often for entertainment or competition. Instrumentation typically includes brass, woodwind, and percussion instruments. Most marching bands wear the uniform, often of a military style, that includes an associated school or organization's colors, name or symbol. Most high school marching bands, and some college marching bands, are accompanied by a color guard, the group of performers who add a visual interpretation to the music through the use of props, most often flags, rifles, and sabers. Marching bands are generally categorized by function, size, age, gender, instrumentation, marching style, and type of show they perform. In addition to traditional parade performances, many marching bands also perform field shows at sporting events and at marching band competitions. Increasingly, marching bands perform indoor concerts that implement many songs, traditions, and flair from outside performances.


So you don't know how to swivel, not a problem. If target is set to edge loop and you left click on an edge it will swivel that edge around a pivot. Where the pivot is depends on the face, your mouse was hovering over when you left clicked. So if this face is glowing red then the pivot point will be here, but if this face is glowing red then the pivot point will be there. It also works for partial edge loops too, so if you click on an edge that has points that are only connected to three edges it will stop the swivel at those points. And if target is set to single edge it will look like a normal expand movement control, but that is because it's trying to swivel from two points at the same time. For this target to work properly you have to click on an edge that is surrounded by open faces. So if we delete a few faces and then click this edge you will see it swiveling like so. Hope that helps and as always hope you have a fantastic day and I'll see you around.


Great. Okay, so hi everybody. Welcome to Grand Rounds. Today we have some really great presentations from our University of Utah fourth year medical students and then these are currently rotating with us to be respectful of everybody's time. I'm just going to give everybody maybe like a 30 seconds one morning if you're kind of coming up to the 10-minute mark and then we'll have an additional five minutes for everybody for questions. So to start off we have Caitlyn Cooper. She is from Minnesota and currently on the neuro ophthalmology rotation. Something interesting about Caitlyn is that she recently hiked through the peek-a-boo and spooky slot canyons in southern Utah and the heat of southern Utah was sort of a very eventful trip and ended up ending with her party having to call the search and rescue. So definitely ask her about that the next time you see her. Her presentation is titled virtual reality as a screening mechanism for glaucoma. So take it away, Caitlyn. Thank you so much for the introduction, Dr. Hu. Let me share the screen All right. I am so excited to speak with you guys today and discuss glaucoma screening. Okay, it's working. So what I'm discussing is a clinical research study that was designed by Dr. Olson, Dr. Simpson and myself that we've been working on for the last two and a half years. So as far as financial disclosures, I have none. So I'd just like to start by saying that I am intimidated to be speaking on glaucoma in front of a group where every single person on this call is definitely more of an expert than I am. So bear with me. We'll start from the basics. Primary open angle glaucoma prevalence is 2.85% and a population of 50 plus. The incidence is 0.38 per 100 person years at 50 plus and the population is 44.7 million worldwide. When discussing screening for glaucoma, right now the USPSTF recommendations is that you don't do it. The studies that they looked at to make these recommendations were a combination of IOP visual fields and fundus exams. Those were what were used for screening and they said most tests that are available in a primary care setting do not have acceptable accuracy to detect glaucoma. And of course when we talk about most tests available in a primary care setting, we're talking about a ton of pen, a rudimentary fundus exam and visual fields by confrontation. They stated that the evidence of effectiveness of screening for glaucoma on clinical outcomes is lacking and that the balance of benefits and harms therefore cannot be determined. They noted that early screening and treatment might help to prevent small visual field defects, but we're not clinically detected by the patients, but no huge outcomes on vision overall. So why should we care about screening? I'm going to kind of go from here and build a case for glaucoma screening. First study I want to talk about is the early manifest glaucoma trial, 255 patients with primary opening ankle glaucoma that was already diagnosed. Two groups, one they received trabeculoplasty and betaxyl all the second no treatment. Over six years they were followed up every three months and there was a 53% progression rate when you look at visual field. At the end of the study they noted that the treatment group had half the disease progression as compared to the control group. So that's great for early glaucoma treatment, but why would we want to find and treat glaucoma suspect patients before they develop glaucoma? So second study that I'm going to talk about, ocular hypertension treatment study, 1636 patients that did not have primary opening glaucoma at the beginning of the study did have ocular hypertension. There were two groups, one was treated with ocular hypotensives, the other one with no treatment. They were followed for an average of 60 months, every six every six months, excuse me, and there was a 7% progression rate to glaucoma in this group. So what's cool about this study is that the treatment group had less than half the rate of progression to glaucoma as compared to the control group. It was a point for hazard ratio with a 95% confidence interval of 0.27 to 0.59 and a P of less than 0.001. So while you could argue that perhaps the number needed to treat, considering we're talking about 1636 patients, right, the number needed to treat might be pretty high, so it might not be super clinically significant, although I do believe it is, but you might argue that, but you definitely couldn't argue that this isn't a statistically significant study. So why not use IOP for screening then? So next study that I want to talk about is a Swedish drive model. There are 32,918 subjects that they looked over 10 years to create a prediction model based off of age and IOP alone. The IOP cutoff that they used for this study was 25 millimeters mercury. There were 406 glaucoma diagnoses in this time in this population. 57% of these diagnoses had an IOP of less than or equal to 21. So they found with this model that they created that they had a 32% sensitivity with a 99% specificity. So it was great in the fact that it had very few false positives, but a lot of missed cases. In fact, there are a lot of missed cases of glaucoma worldwide. There it was a meta analysis done that they estimated that out of the glaucoma population, greater than 50% of them were undiagnosed and specifically they did one in Thessaloniki, Greece, where it was 57% what they found and these are in developed countries and I know the map has Italy, I just didn't know how to change the figure. So that kind of brings me, hopefully I kind of built this case here for why screening might be important. So that brings me to the screening test that was developed. So this was developed by Dr. Kidari who as I understand did his residency here at the University of Utah and Jonathan Olson and Dr. Kyle McDermott who works in the company that Dr. Kidari started in and in discussing with them what they considered important in this screening test that they were developing through virtual reality for glaucoma. These are the characteristics that they thought were important. The first one was a detection of visual field defects kind of obvious, right? Also contrast sensitivity, velocity sensitivity and that it was less uncomfortable in time in terms of been Humphrey, right? So this video that I took of myself because of COVID and I don't really have any friends anymore. So this video you can see putting on the headset and it's not too bulky, not very uncomfortable, pretty easy to adjust to different patient settings. That piece in the front gives a 120 degree field view and what I'm looking at is kind of targets and I'm targeting them with my vision. If I were to stand up and turn around I would have a 360 degree view almost like a spear, right? This was the first time I'd done virtual reality was this game. So just kind of explain it for anyone like me who's never done it before. And what the patient sees. So when you put this headset on this is the first screen that you come to this is kind of the instruction screen and right over target you'll see a hollow circle. That hollow circle is my visual target. So that represents the center of my vision right now. It's right on the horizontal permitting right in the center of the screen as I move my head that circle moves with my head and I use that circle to target different objects. So right here you see the this circle with a cross on it and that is when I rest my vision on it for a second or two it blips and it goes out of screen and you move on to the next portion of the game. So here's an example of one of the screens that you would see on the game. You see one circle with the cross on it and then the other circles don't and they're moving they move at different velocities.   So that's how the visual fields are tested and again that's 120 degrees of visual field testing. So study design we have three patient groups a control group with no evidence of glaucoma a glaucoma suspect group and this is through chart search the patients that were actively being managed as glaucoma suspect and then the glaucoma group and specifically looking at primary open angle glaucoma. The measures that we all the patients needed to have a current in the last six months IOP for both eyes OCT, RNFL and Humphrey visual fields. So inclusion criteria and based off of the initial data that Dr. Kidarian his team collected we kept our inclusion criteria from 40 to 70 that was just for the IRB and statistical analysis because that was the initial data that we had and then a visual acuity of 20 over 40 or better. For exclusion criteria the first one was extensive video gameplay. We arbitrarily set a limit of five hours per week for extensive video gameplay which probably unsurprisingly was not an issue in this age group and population and that's an interesting point is that the data that we're collecting probably would only be accurate for this generation or this group of people because once you have extensive video gameplay that probably does change your parameters of what you would consider you know a cut off or sensitivity and specificity. We also excluded prosthetic eye or unilateral vision. We excluded pregnant women which again has not been an issue in this age group and individuals with corneal or optic nerve pathology or retinal dystrophy. As far as so just this is just kind of a side note doctors Olson and Simpson are incredible because as I was chart searching I would see these these diagnoses and I wasn't quite sure you know if these would affect the study or not so just keep this running tally of diagnoses and then text or email them every couple of days and they were so nice and this is kind of this running list you can see they got a lot of texting emails these are acceptable and these are the unacceptable comorbidities. Risk for the study you there's a slight risk of nausea playing virtual reality and apart from that there weren't really any other risks that we could think of to put on the IRB. So for preliminary data there aren't enough patients enrolled to say how how good this screening model is but I can say that I've had the glowing combination of it is way better than the blinking light test so the patients don't hate it as much as they hate the visual fields. As far as next steps for this test or for this study really manpower since 30 years started and fourth year's kind of shaping up to be pretty similar I haven't had a lot of office hours to devote to this study when I could be recruiting patients. So if you guys get any emails of medical students or pre-med students or anyone that's looking for a project send them my way this is super awesome a very fun project to work on. So we references huge thanks to Dr. Wilson and Simpson to the fourth floor research team and all the techs and doctors who let me steal their patients before they were dilated. Do you guys have any ideas any questions about this study? Awesome thank you so much Caitlin. Right now we'll open it up to questions you can feel free to raise your hand or and we can unmute you or even throw in some chat questions. All right well we'll just move along if there are any questions of course for Caitlin feel free to put them in the chat and we can also go back. Our next presenter is William West he is from Sandy Utah and went to BYU for undergrad. We've had some fun seeing kids in pediatric ophthalmology with Dr. Jardine during his rotation. His hobbies include climbing, water sports and quilting you can think that last one to coronavirus and he is presenting a case report on unilateral epitheliopathy after lesic. So we'll get him up on the screen perfect. Okay let me get my screen shared here so I appreciate the opportunity to share this case that we were able to see in the corneal clinic. We saw a case of unilateral epitheliopathy after the case consists of a 36 year old male who returned to our corneal clinic was referred to us back to our corneal clinic for epitheliopathy about six months after we performed an uncomplicated lasic procedure bilaterally for correction of myopia. The patient complained of worsening vision in in his left eye exclusively as well as an increasing sense of irritation and foreign body sensation. His past medical history was negative for any trauma to the eye however he did have a history of redness and episodic irritation in the left eye. He had also been diagnosed with a single episode of contact lens induced keratitis that was seen to affect just the superior aspect of the cornea. He denies any family history of ocular disorders. He was seen during the interim period in the first six months of his lasic recovery by his local optometrist and we had no follow-up with the patient until he returned via referral for this epitheliopathy. In the two weeks following the lasic procedure he was seen to have perfect vision with no complications with a visual acuity in both eyes of 20 over 15. At one month however he returned to clinic with a sense of irritation and slight loss of vision. He was seen at that time to have a visual acuity in the left eye of 20 over 30 while the right eye continued to have a visual acuity of 20 over 15. On physical exam at that time a plaque was seen to develop from the superior aspect of the cornea and a three week taper of prednisone was started for presumed interface inflammation. The prednisone gave him symptomatic relief only without improving his visual acuity or the appearance of the plaque. At four months the plaque was seen to have grown significantly and now involved the superior aspect of the lasic flap. At that time a second trial of steroids were performed and again gave symptomatic relief only. From the period of four months to six months the plaque continued to grow and a second plaque was seen to develop from the inferior aspect of the cornea. In both cases the plaques started at the limbis and moved progressively toward the the visual axis. At the time of the development of the second plaque the patient was referred back to us for exam. The patient denied any trauma or chemical exposure between his lasic procedure and when we saw him back in clinic. However on careful questioning he was found to have a history of acutane use as a young man as well as a possible history of battery acid exposure to the left eye when he was a young child after a battery exploded. This was not seen by any medical provider at that time and never caused him any problems that he knew of. He also had a history of military service with work around chemicals however no direct contact with those chemicals and as a hobby he performed he was a barbequeer and brewed his own alcohol but again denies any thermal or chemical exposure. The physical exam is pictured here with a well demarcated wave-like coarse plaque progressing from the superior limbis and inferior limbis. Both of these plaques were seen to involve the lasic flap without any invasion underneath the flap. The flap additionally was well approximated without any sign of dislocation or interruption. A sub epithelial haze was visible and on fluorescein staining a punctate staining pattern was seen. There was also slight injection in the superior congenitiva. For our differential diagnosis we included epithelial ingroth, diffuse lamellar keratitis, and central tautic keratopathy as likely in the period surrounding his lasic procedure. These were considered with a grain of salt however because of the lack of any invasion of epithelial cells underneath the lasic flap as well as the lack of visible white blood cells in the corneal stroma. Additionally this pathology that we saw progressed from the limbis whereas these three diseases tend to initiate and grow from the lasic flap edges itself. We also considered limbal stem cell deficiency to be very likely as the limbis was the source of the beginning of this plaque and we also considered OSSN and CIN as necessary parts of our differential. These were less likely in the context of recent lasic surgery being so closely related to the development of the pathology. Other considerations included acutane associated keratopathy also somewhat less likely due to the distant past of only six months worth of acutane use and knowing that acutane keratitis tends to resolve after cessation of the drug. Herpes keratitis was also considered but also less likely due to the lack of a branching pattern in the plaque and due to the fact that it did not get any worse with the use of steroids. A diagnosis of advancing wave-like epitheliopathy was made. This is a subcategory of partial limbal stem cell deficiency. In the normal eye, the limbal stem cells are responsible for the generation of healthy epithelium that covers the cornea. In a limbal stem cell deficiency, the balance, the delicate balance that maintains these epithelial cells and the growth of the corneal epithelium is disrupted. This results in neovascularization and inflammation and often causes conjunctival invasion of the cornea as seen in these photos. In this case, in advancing wave-like epitheliopathy, this is considered likely to be an unusual presentation of limbal stem cell deficiency, whereas normally we would see this corneal conjunctivalization. We instead see the normal growth pattern of epithelium with unusual abnormal epithelial cells creating the wave-like plaque for which the pathology is named. Any limbal stem cell deficiency is known to be caused by trauma or irritation or toxic exposure to the limbus itself and can be partial or complete depending on the extent of the damage to the limbus. Patients tend to present with the classic wave-like appearance of this plaque that was shown earlier and classically it starts at the superior limbus. There are also cases of this plaque being caused by contact lens use or topical medications. In addition to the classic appearance of the physical exam here, the diagnosis was considered much more likely and made due to the multiple chemical and toxic exposures in addition to lasik that this patient had. The patient also had contact lens history which made the diagnosis much more likely. In management of advancing wave-like epitheliopathy, we focused first on maximizing the ability of the cornea to heal itself as well as to minimize inflammation of the cornea. Often, however, these interventions have been seen to be ineffective. Surgical management shows more promising results with superficial carotectomy or corneal epithelial debridement. This tends to give temporary relief with initial regrowth of smooth epithelium, however, almost universal recurrence of the pathology. Use of silver nitrate in addition to epithelial debridement has been known to prevent the recurrence of the pathology. Other things that have been tried include the topical interferon, vitamin A and topical cyclosporine. These all have been used in other limbal stem cell pathologies, however, the data is poor in this pathology. Lymphal stem cell transplant can also be effective. In our specific case, we first attempted medical management, which classically was ineffective. We then tried corneal epithelial debridement with, again, classic results, initial success followed by recurrence of the pathology. The patient has been on a three-month topical interferon trial with vitamin A and has seen some improvement. His visual acuity is now 20 over 50, where it was at worst 20 over 80. Our plan going forward is to attempt a simple limbal stem cell transplant, however, the patient is currently resistant to that course of action. So take away points for advancing wave-like epitheliopathy. It is a partial limbal stem cell deficiency that results in this classic plaque and wave-like pattern, often progressing from the superior limbus. Treatment consists of medical therapy, first attempting to minimize inflammation followed by surgery with silver nitrate, causing the most durable results. These are the sources that I used to research this pathology, and I would like to thank my mentors, Dr. Majeed Moshafar and Dr. Griffin Jardine. Are there any questions that anybody has about this pathology? I have a question. Thank you for the presentation. That was excellent. So for anyone that doesn't know SLET, that acronym, that is where you take from the fellow eye some of the limbal stem cells. And thankfully, you don't have to take a lot.  Anyone from cornea? Correct me if I've led anyone in error. The question I had in your review had you come across any allogenic limbal stem cell transplant from the fellow eye that then caused limbal insufficiency in the donor eye. Again, I would assume that this would run together if you've got some level of limbal stem cell insufficiency in one eye that you'd potentially have some in the other. That's certainly always a risk with this pathology. Clearly the patient is predisposed to having a limbal stem cell deficiency. In this case, this would be a case where those concerns would be slightly less due to the history of a unilateral battery acid exposure as a kid as well as preoperatively this patient complained of recurrent irritation in the left eye only. Had this patient consented to moving forward with a simple limbal stem cell transplant, we likely would have been very comfortable proceeding with that procedure knowing that the same symptoms weren't present in that right eye. But it's certainly always a risk and can definitely occur with removal of limbal stem cells from the opposite eye. Great. Any other questions? Okay. And of course, if anybody thinks of any, we can put them in the chat window. And so we'll probably move on to our last presenter. So last but not least, we have Rhett Thompson. He is from Spanish Fork, Utah. He majored in American Sign Language and undergrad at Utah Valley University. And something interesting about Rhett is that he took a leave of absence during medical school to create a medical education company called physio.com. And today he is presenting on deep anterior lamellar keratoplasty. So Rhett, take it away. Awesome. Thank you, Dr. Hu. So are you seeing my screen? Just want to make sure. Yeah, we are. Cool. Okay. So I'm really thankful to be here. I'm going to be talking about a doc, deep anterior lamellar keratoplasty. So interestingly, the first successful cornea transplant was reported in 1905 by Dr. Edward Zerb. It's an interesting fact. And we've come a long way since then. And right now, in the modern day, there's two broad categories of corneal transplants. There's the full thickness penetrating keratoplasty, which most of us are familiar with, PK. And then there's a partial thickness lamellar keratoplasty. It's just another category. And some of the more familiar ones, some of the conditions that you're usually going to treat with a lamellar keratoplasty or a partial thickness keratoplasty would be something like fuchs dystrophy, in which is just like a posterior pathology. And this would be often treated with a desec or a DMEC. Now, when it comes to anterior pathology, that's where the deep anterior lamellar keratoplasty comes in to play. So let's dive into that now. So a doc is a condition, a doc is a procedure in which you remove the native epithelium, the bowman's layer, and the stroma. And you leave behind decimates membrane and the endothelial layer. So if you look at this image on the right, you can see a space between the inferior stroma and decimates membrane to kind of highlight the idea of what you're trying to do. You're only transplanting that top part. So the technique is in broad strokes listed here. And I don't want to read them all to you. I would rather explain them to you as I watch a video together of one of Dr. Mifflin's surgeries. So this is a kind of truncated version of the surgery. So here he's trefinating. Oh, I think you have to, we can't see the video. I think you have to actually reshare your screen to that panel. Oh, thank you so much. Here's what we'll, so Dr. Hugh, I thought I would just share my whole screen. So is it sharing it now? I don't see it. No. Okay, that's okay. I'll just explain it. I apologize. It was a good video, but this is Dr. Petty. What you can do just briefly is unshare your screen and then reshare your screen, but select the video and make sure it's optimized for video as you select. And in the meantime, I'll just just queue up a little bit about your company just to let everyone know. So this is something that Rhett created to help medical students in study for their step exams. I'll probably get some of the stats wrong, but as I understand, I mean, it's really one of the top one, two or three resources now utilized by medical students across the country and has become widely known and a well-used resource. And now with that, I'll let you continue on. You'll probably have to do the same thing to get back to your power point. Gotcha. Thank you so much, Dr. Petty. Okay, so now that we're here, so this is again a truncated version of Dr. Mifflin's surgery of a successful doc. And here we've got, we see the trefination and then manual dissection of the stroma, like the top 50% or so of the stroma is what you'd remove. And you're actually going to leave the deeper layers of the stroma because you want to be careful once you're getting closer to the decimates membrane. And so here you can see injecting air into the anterior chamber. And then now this is where we're introducing or Dr. Mifflin's introducing the big bubble and using air to actually separate the remaining stroma from decimates, you create this gap that way and it's a little bit safer. Now here's some viscoelastic that he's putting on here now because as he's going to puncture into the stroma, then it creates that positive pressure where the decimates membrane can actually pop up and hit the instrument that you're using, which is not ideal. You don't want to damage the decimates membrane that way. And now he's dissecting the stroma because there's enough space. It's a little bit safer now that there's this air gap between decimates membrane and that stroma. So as you can see, cutting it into quadrants and then carefully dissecting that. And of course, laying on the new suture and then with suture that in place. So that's the basic overview of how to perform a dolk. Now it's important that we understand the context of a dolk in the current environment because PK or penetrating keratoplasty is typically what's done in order to treat anterior pathologies, even in a situation in which you could potentially use a dolk. So my only point in making this is that the only point I'm trying to make here is that a dolk is really compared and the outcomes of a dolk are compared against a PK. So the reasons that a PK might be more commonly used than a dolk is that the PK is well-established. The very steps and the procedure is very well-established and there's decades of research supporting its use. And also with a dolk, it's actually difficult, at least historically, to manually dissect off the stroma and leave behind uniform tissue. If you can't achieve that, then there's poor visual outcomes. And so a PK is typically has been used. And also it's technically challenging in the sense that it's really easy to puncture decimates membrane. So I want to dive into this idea a little bit more. So this on the right, you can see an image just taken from a snapshot of that video I showed you. And I want you to appreciate just those anterior chamber bubbles that were injected and how it really highlights this superficial or how thin this decimates membrane is. And it's so easy to puncture. And so there's actually evidence that it's been punctured at several different steps during the surgery, like from the beginning with trefination and even at the end when you're just suturing on the donor graft. So traditionally, when this occurs, when there's a decimates membrane puncture, the surgeon would just convert to a PK. And that's still what's typically done. What I want to point out is that there's a couple of studies that I found in which the surgeon actually used a more conservative measure like fiber and glue or something and then proceeded with the surgery as normal and didn't convert to a PK. And so in those outcomes were actually compared to situations in which a delt was performed as normal without any puncture. And it looks so far that the outcomes were similar, which is good. So a more conservative treatment if you end up puncturing decimates membrane may be appropriate, but the basic idea is that you would generally convert to a PK. So having said all that, there are some advantages to a doc over PK. And the biggest thing to keep in mind is that there would be decreased risk of graft rejection. And that makes sense because the endothelial layer in a corneal graft is usually the target of host immune attack. And if you're not transplanting a foreign endothelial layer, then graft rejection overall is very, very much decreased. And so the patient that you want to be thinking about would be young patients in whom you would expect to have a high immune response. So a young otherwise healthy patient would be a good candidate for a doc. Now there's evidence, there's some evidence that the wound is potentially a little bit stronger with a doc, which may be helpful in trauma patients. It's not super clear yet with whether or not that will hold true. The evidence is not necessarily robust for that idea. But something really interesting is that a doc can be performed successfully even with lower quality grafts. So this can be really useful in situations or even areas in which a hospital doesn't have access to healthy tissue readily. And so in those situations, they may have access to, you know, just the anterior layers of the cornea. So and sometimes eye banks will actually even donate these eyes, which can be helpful. And at least no situations can lower the cost of the surgery. Now this is a patient, this is a picture taken from a patient last week. And this is a post-op doc, patient of Dr. Mifflin's. And I want you to appreciate the neovascularization that's coming in, especially superiorly. And if you can follow that along, you can see just how far down it descends. And so I want to point this out because, yes, there is decreased endothelial graft rejection. But, you know, things like this can still occur. So that was just an interesting patient case there. You know, there was a lot of studies that have a lot to say on comparing docs in PK. And the one that I liked the most was actually the most recent and it was performed, it was published earlier this year, it's a systematic review and meta analysis. And in that study, the included 530 doc surgeries and 560 PKs, and the visual outcomes overall were comparable between the two. And then the graft rejection risk was, as you would expect, lower overall with a doc. And then the complication overall was also decreased with a doc, with doc surgeries. And this is the end of my presentation. And here's some of the references. Here's some more references. And I just want to give a special, I just want to thank Dr. Mifflin for his help with this. And Dr. Petty, I want to thank you for covering for me during that awkward moment, which I was trying to get my screen to work. It was helped me a lot. So thank you. Great job, Rudd. And then we also have a question from faculty. It just says iPhones. I'm actually not sure where this question came from. But it just says, can Rhett repeat what he was saying about another method using fibrin glue? They didn't quite catch that part. So yeah, so there's evidence that fibrin glue, there's some several other more conservative measures as well that that some surgeons, I guess, experimented with. This was in the Middle East. And they were able to, so in that situation, they punctured the decimates membrane. And instead of converting to a full PK, which you might expect they actually used fibrin glue and just tried to restore the cohesion of the decimates membrane. And then they just proceeded with the surgery as normal. And there were, there was a five case studies that they studied. And each one of them, according to their reports, actually had the same visual outcomes when compared to docks that proceeded as normal without any puncture and decimates membrane. So the idea that was trying to make is that, or the point I was trying to make is that that is potentially a way to proceed in the surgery, even though that's not really commonly done. And traditionally, you just move to a full PK. Hope that answers the question. So, Rhett, I don't know if you'll be able to answer that, and Ethan, you may need to keep an eye to see if any of the other cornea faculty can answer this. So having trained a lot of residents, I've seen a number of decimates membrane tears, significant tears. I even had a case in an outreach setting where I personally had a small tear. And when I put some visco elastic back into the eye to check something that looked odd, I actually managed to completely separate decimates membrane from the rest of the cornea with visco elastic. Patient did well in the end, but it took me a minute to figure out what exactly had happened. It does seem like decimates is a lot more resilient than perhaps we initially thought. And I'd just be curious if in, in, you know, our cornea, our cornea faculty's practice, they feel like in the future, in these, you know, really technically difficult surgeries, Mark, you made it look easy. If again, with these, you know, tears that invariably will happen, if you think we're going to more and more continue to just proceed with the dalk rather than conversion to PK. So I think that's a good question. And I'll defer to your professionals who have more practical experience with this. But I can't say that I was only able to find two studies that really examined that and they were minimal in their sample size, sort of. We'll unmute you, Brian. Brian Zog has a comment. We'll unmute you here and have a sec, Brian. Good to go, Dr. Zog. Am I unmuted now? There we go. We can hear you. All right. I thought I was unmuted and then I'm not. Okay. So in some of those cases where you have like a really small decimase tear when you're trying to do a dalk, you can actually continue it.  And then you essentially put that on top of the host decimase membrane and suture it in place. And so in our situation in the U.S., if I am concerned that I've torn decimase membrane and I don't feel like I can keep it in place, which sometimes you can do with an air bubble after you've sutured on your PK, then I'm just going to do a PK because I know I've got really good tissue with endothelium that's very healthy. In other countries, so where this kind of fiber and glue idea came in is they may not have tissue that is viable for a PK. So their only option when they're doing that surgery is to do a dalk. And so if they rupture decimase, host decimase membrane, they don't have tissue that is healthy enough to do a PK. And so they're just, they've got to make do with what they have. And so in some of those situations, they'll just try to reattach decimase once they kind of suture on that dalk tissue. So we're pretty lucky in the U.S. that in most cases surgeons will just convert to a PK if they're concerned, whereas in other countries they may not have that option because of tissue availability. And there's some really cool things that are happening with this where they'll take, they'll take tissue that's PK worthy and they'll actually strip off endothelium and do a DMAC or even a desec on a patient. And then they'll use that anterior lamellar essentially donor tissue to do a dalk. And so they're kind of splitting one donor cornea into two different surgeries to help patients with different pathologies. So kind of different situations where that might come up, but for us it's usually just go on to PK. Great. Thank you, Dr. Zog. Does anybody have any other questions for Rhett? Otherwise, we also did want to circle back to a question for Caitlin. So this was from Dr. Petty. It said, a question we can come back to at the end, but how would you design a study that you could evaluate a subject's experience with gaming? Young healthy gamers will likely score higher than older healthy non-gamers. Yeah. So this is actually a thought that I've been kind of ruminating non for a couple of years now. I think it would be very tricky. I think in 20, 30 years, it will be a lot easier because we would have video gamers in this age range that have been playing since they were little. Right now, even in the 40 to 70 year old age range, the people who have been playing for 20 years, I would hypothesize that their gameplay is fundamentally different from someone who started playing when they were five or six versus someone who started playing when they were 20 or 30. So I think it would be super hard. I think the best that you could do is kind of start with an age group and then study gamers versus non-gamers or start with gamers versus non-gamers and then try to allow for age, try to create a model for age. I'm not 100% sure how it would work. Well, thank you for that. No, it is really tough. I do wonder if, you know, in a large enough study, you could use a multivariate analysis and then, tease that out in the end. Certainly, there will be a learning curve, right? And we even know that with just typical visual fields, there's a learning curve for those who have done them for a number of years versus those who are just starting. But this, thinking about this as a screening device, I think that'll be an interesting element. What thresholds are you putting or perhaps eventually having a different threshold depending on the amount of gaming experience that really does play out as something significant? And I mean, since it is such a complex system, they can build algorithms in. So I mean, the patient, the first thing that they do is they say, this is my age, these are more comorbidities. And I do think that eventually the algorithms, the AI learning models, could account for all of that, which is probably take an end of much higher than what I'm doing with this study. And then final question, are the games fun? Fun enough that people would actually just play them and perhaps auto screen themselves as they're playing a fun game? I will say no, but okay, here's, there's a no but. So this game that was developed, this was kind of, this was developed specifically for glaucoma screening and kind of less time was put into this game than the other games that Dr. Kidari developed. I played those ones. Those ones I would play for just fun. This one. All right, well, great job everybody to all our presenters today. I think if there are no other questions, we'll wrap up here and we'll see you guys all next week.


Hey guys, this is rich from rich TV live and there's some huge news. So the Senate passes Farm bill hemp closer to becoming legal. This is huge news. Okay, the Senate passed a five-year farm bill renewing Agricultural and guys I broke this news first. Okay, so I just got it, you know, like obviously I'm rehashing this now But I told you guys this is gonna happen. Okay, the Senate passed a five-year farm bill renewing agricultural subsidies and food aid for low-income families after weeks of negotiations over Work requirements for food stamp recipients and a last-minute snag over forestry provisions. Check this out the U.S. 867 billion measure, that's right 867 billion dollar measure which also would extend federal crop insurance was approved on a vote of 87 to 13 after lawmakers negotiated the final package scrapped a provision that would have toughened work requirements for older food stamp recipients and those with older children. The provision had been included in the House version of the measure with support from President Donald Trump. Let us tell those farmers and ranchers and growers that are Going through tough times that they're going to be good for the next five years. Wow Said Pat Roberts of Kansas, Chairman of the Agricultural Committee, said on the Senate floor Once the House votes approve So once the House votes final approval the measure HR2 would go to Trump for his expected signature and for 867 billion, you know, Mr. Trump is going to sign that piece of paper Farm programs under current law began to expire September 30th. We made the compromises we needed to make to get this deal done House Agriculture Committee Chairman Mike Conaway of Texas told reporters last month Great work Mike Trump told reporters at the White House on Tuesday that the Farm Bill is in very good shape and our farmers are well taken care of Wow Here we go Big news the bill found a champion in Senate Majority Leader Mitch McConnell of Kentucky Who cheered the inclusion of a provision that would make him a legal agricultural commodity a Boone to some farmers in his home state Under the Farm Bill hemp would be removed from the Federalist of Controlled Substances. There it is There it is and hemp farmers would be able to apply for crop insurance Congratulations to all the farmers in America You now have security Unlike its biological cousin marijuana hemp has industrial uses and doesn't produce a high if ingested Proponents say it has over therapeutic Uses other therapeutic therapeutic uses many many many Therapeutic therapeutic uses such as easing pain and anxiety. Those are just two We know people that have used it for treating cancer epilepsy so many different things so Do your research do your due diligence? Remember Rich TV live is strictly for education entertainment purposes Do you do diligence do your research before you invest in anything that we talk about here? Would you like to get featured would you like to find the news? It's all right here guys all the stocks I'm looking at all the tools I use every day all right here. Absolutely free learn about the CBD business Getting to the crypto game Hello, Richard boy all the information is right here join our secret stock picks group absolutely free We don't want your money. We want your eyes and ears on the price now. What do you think about this news? I think this news is huge. I told you was gonna happen And it's gonna happen people Let me remind you the vote was 87 to 13 87 to 13 and it's for 867 billion with a beat. It's true billion with a beat unbelievable Unbelievable proponents say it has other Therapeutic therapeutic uses such as easing pain and anxiety a provision that would have imposed a lifetime ban on People with drug-related felonies from working in the hemp industry was reduced to a 10-year ban The legislation also includes an exemption letting farmers already growing hemp under existing research authority Continue their operations. Wow. There we go Let's go The bill doesn't include a provision supported by senator Chuck Grassley an Iowa Republican aimed at preventing wealthy absentee landlords from collecting farm said subsidies Grassley said Tuesday that he wouldn't vote for the bill because of the issue Wow, well, you can't guess you can't make everybody happy So That's the big news. What do you think about this news? I think this will be a catalyst for the cannabis stocks hemp stocks are already moving on this news Let me show you guys some of these things because you know your boy likes to break it down You know your boy wants to show you guys. What's up, right? And it's free guys. I want your money guys I just want your eyes and ears on the prize. This is trading view. You can find trading view on rich to be live calm Absolutely free Everything is there. It's not does not cost you anything to use these tools guys and Let me show you some of the hemp stocks that are up today on This breaking news and of course your boy had to bring it to you first, right? So, let's take a look at hemp stocks Let's go hemp ink first in America BAM hemp ink. Wow. Look at that up 28% on this news a 4 cent stock. It is exploding on this news Let's take a look at hemp in Canada hemp go food and fiber a different hemp company priced at $1.60 and up 14% on this news There we go Just two hemp companies that are moving today on this big news What do you guys think if you like this video smash the like button share this video everywhere hit that bell for notifications Okay, because if I win and you win we all win.  You're not winning. You're not watching. I'm out Peace