Hi, everyone. Welcome to the last talk of this session. This will be Daniel Holmes talking about using R to produce clinical reports in patient records. Thanks very much for the introduction and thank you to Stefan Kedaki for inviting me to speak today. I'm going to be picking up on some of the things that Steven Masters spoke about earlier and maybe make allusion to what Patrick Matthias will be speaking about later on. I'm going to talk about how we use R to produce clinical reports in specific reference to a condition called primary aldosteranism where R plays a role in the entire data automation and reporting pipeline. So what is primary aldosteranism? It is the most common form of curable form of hypertension. Most hypertension doesn't have a well-defined cause and so it's just treated with medications. The primary aldosteranism has a specific underlying cause. It can either be from excessive growth of the adrenal glands or it can be due to a tumor of the adrenal gland usually on one side and occasionally on both sides. When it's caused by a tumor and it's only on one side, you can just take that tumor out with an adrenalectomy. Otherwise you can use medications that are specifically targeted to block the effect of aldosterone. This causes people to have a chronic hypertension that's particularly resistant to medication and to have low potassium. So these patients have specific clinical features that will help identify them as possibly having primary aldosteranism. They tend to be resistant to the usual medications like ACE inhibitors and beta blockers. They tend to present with an incidentally discovered adrenal mass. Medicine is notorious for having unusual nomenclature. We call these incidentalomas. They're discovered incidentally on CT scan. Hypertension in a young person or hypokalemia that is low blood potassium in response to the normally employed diuretic medications. So biochemical screening is undertaken with the concomitant measurement of aldosterone and plasma renin activity. And in allusion to what Steven spoke about earlier, these two measurements are notorious for high variability between the vendors who manufacture the kits to measure them. And so the thresholds for diagnosis and screening are heavily linked to the analytical methodology that you're using, whether that be a lab develop test or a commercially available kit. In any case, clinicians being what they are, they need something simple. So the combined information of aldosterone and plasma ren activity is taken by means of a ratio of those two. And that is what people usually use to help screen for primary aldosteronism. This is an illustration of the so-called renin angiotensin aldosterone system. And not terribly important to us, except to say that the target analyte for measuring plasma renin activity is the ability to generate angiotensin one over a period of time. So there's endogenous angiotensinogen. And we measure how much angiotensin one is generated over a period of time buffered at pH 6.5. And then, of course, we measure aldosterone itself. And this is just an illustration of aldosterone's actions, which are to retain potassium and to waste water. If you think about that, if the water has to, sorry, retain sodium and waste potassium is what I meant to say. When you retain sodium, water has to come with it and it causes the intravascular volume to expand and causes the high blood pressure. So these data are generated off a mass spectrometer, as I'll show you in in a moment using a lab develop test. And our data workflow strategy when we started out was to manually transcribe them, which is one of my beefs is that we spend a lot of time trying to make perfect analytical chemistry. And then we manually transcribe the results into our lab systems. So that doesn't make a lot of sense. And we were manually adding our interpretive comments also, which often are canned or just stock comments. So here's the analytical and data workflow that we developed. The patient sample is taken. Well, first, actually, it's taken to this liquid handling robot from Hamilton. It's subjected to a number of treatments for aldosterone. It's extracted with methyl tert butyl ether that is dried down, reconstituted and and then thank you Citrix for telling me that I need to update. You can bounce there in the right corner for a few minutes. And then after the extraction, the methyl butyl ether is dried off and and the sample reconstituted in methanol water. And then we can measure aldosterone using a multiplexed HPLC system connect to a sci-x mass spectrometer to get patient identifiers. What's actually just the barcode that's on the tube, which isn't a patient identifier, it's a sample identifier. But to get it across, we use R to just do some some data munging. It's through a shared folder ends up over at the mass spectrometer. And then again, ASCII text output comes from the mass spectrometer, but we can't interpret those results by themselves. We need to marry them with the clinical data, which is not on the patient barcode identifier. So in order to marry it with the clinical data, we have to get that clinical data out. Now at the time that I developed this workflow, data innovations, which is appearing down here was not available. And so and the lab information system people did not want to help me with this because they were stretched with other things. So I discovered this language expect, which I use to strip information directly through a text interface to the lab system. This is all run by bash under Ubuntu. And using that, we get data from the laboratory information system, which is SunQuest. We marry that clinical data produce an Excel file, I know shameful. And the Excel file is used to to review the interpretive comments that have been auto generated. And then a flat file is sent over to data innovations and then goes to SunQuest into the electronic health record. So I would just like to talk a little bit about expect because it is kind of a hack that is useful in certain circumstances. It's a it's an automation language for text based interfaces. We were not permitted to have an ODBC connection to the lab information system. And so because we had a text command line interaction with the lab information system, we could use we could automate that interaction and get the information from the text file that gets dumped. So expect is an extension of the TCL language that is, you know, used for for automating any kind of text command line interaction. There's alternatives to this in in the modern era, using a specific automation languages. But since we're working on a macOS and Linux, we didn't have we didn't have the benefit of auto hotkey, which is a good example. There is no there is no extension of R that lets you use expect. So these are having to be run by daughter processes. But there is a Python extension that will allow you to imitate the expect language. This is the interpretive process that is applied to our samples. In the middle, we have mostly normal people. These patients with a high aldosterone to plasma renin activity are considered a positive screen for primary aldosteronism. We have an indeterminate screen in the orange. We have other conditions where you have high aldosterone, high plasma renin activity, such as renal artery stenosis, reninoma, laxative abuse, etc. We have medication effects, Addison's disease, that is to have low adrenal activity. And the pink domain is sort of like prolonged recumbents that is patients in hospital or something like that. And a couple of other miscellaneous categories. But this is the interpretive algorithm that is applied by the R script from from the mass spectrometer, uniting it with the clinical data. So R has permitted us to find some other conditions to we found a number of cases of ACTH dependent Cushing syndrome caused by ectopic carcinoid syndrome, carcinoid tumors. We found lots of Addison's disease we found inappropriate dexamethasone administration before primary aldosteronism screening that just happened yesterday. For example, we have a few opportunities for improvement. I've been using TCL widgets because this was developed before shiny existence, we could move this whole thing to a shiny interface and we could incorporate, incorporate more mass spectrometry quality metrics in the reporting. And it would be nice to have full automation of some of the interpretive letters that we need to write for the tumor localization procedures, which I haven't had a chance to talk about here. I would like to acknowledge people that help me tirelessly Grace Vandergoogten, who does all our mass spectrometry, assay development and MSACL for promoting applications of R and Python to mass spectrometry. And of course, our laboratory technologists who make this possible. Also Dr. Janet Simons and Dr. Andre Matman, who are my user base. We are a user base of three for this. But they provide me important feedback on how to improve the process. And, and I appreciate that very much. And with that, I will I'll stop and I will tell Citrix to remind me later. Thanks very much, Daniel. If you have questions for Daniel, you're welcome to contact him. At this point, we're going to start the birds of a feather for today. Thank you very much.


Welcome to Think Tech Hawaii, where community matters. This is Finding Respect in the Chaos, and I am Cynthia Lee Sinclair, and I'm so happy to have you guys here with us today, and I'd like to introduce you to my guests that are from the Teen Alert Program, which is a really important program. When we think about the things that are happening in schools right now, how important it is for us to teach young people how important healthy relationships are. And so I'm here today with Cassace Bellman and Lydia Grasso, and they work with teens in our local schools here. I was, first off, thank you guys for coming. I really appreciate everything that you do out there in the world, and it's just amazing. I got lucky enough to be invited out to Farrington High School yesterday to watch them in action, and so I have a little piece of video that I'm going to share with all of you so that you can get a feel for what they do in the classroom. Could you run that video for us, please? I'm Cynthia Lee Sinclair, and I'm here at Farrington High School, where we're going to be watching Top 808 do one of their presentations for the students here at the school. We've got an agency called the Domestic Violence Action Center. So we're here to basically educate you more about what is abuse, how to know if it's happening to yourself or to a friend, what resources are available, and also how you can maybe have a healthier relationship. So we want to make sure this is an interactive class. We're going to ask you folks to do some group work, watch a video, come up to the board, help us out with some stuff. We also want to make sure this is kind of like a talk story. So if you have questions, please let us know so that way we can address whatever your needs might be.  Thursday at 11 a.m., like a game of the emoji game. So basically what this is is our really high budget operation, clearly. So basically what we're going to do is we're going to read a statistic, and you guys are going to let us know if you think the statistic is true or if you think it's false, okay? Yes. Sound good? Yeah, I know that. Okay, ready? Let's read the first one. Okay, good. President or something. About 20% of high school students in Hawaii report being controlled or emotionally hurt over the past 12 months. All right, what you guys think? Is that true? Or is that false? False. Sorry to wait. Any questions for what I do? No. All right. Can you be an advocate too? Yes. Absolutely. How? I would tell them how I feel that because they are controlling me, I would ask them why do I have to be put down like this, and is there any way that you could probably not do that and change how you treat me and stuff like that? My name's Kevin. Hi, Kevin. Thanks for talking to us. I appreciate it. I love it. I want to pick one thing out of this class that you're going to walk away with that you really learned about healthy relationship, what would it be? Advocacy. Advocacy. And can you explain what that means to you, what it means to you? To make them feel comfortable, you know, help them to understand their choices and other things. I know. All right. Nicely done. We like to, you know, give the students the hope that they can be in healthy relationships. They can help each other out. They can be supportive to one another. And they can also help prevent violence in their communities and that it needs to start on that level so that we can have adults in the future who know how to properly treat it. It is so fun to watch. Even again, I get right back involved in it again. I left yesterday so excited about what you guys are doing and how important it is. I am a firm believer that we don't train them young. It's really too hard to train them when they get older. I should say retrain them when they get older. It's so much better to establish these healthy relationships right off the bat. Can you guys give us a little history about how TAP-808 even came into existence? Sure. So DVAC has been a long domestic violence action center, has been around for a long time. And around 1999, one of the VPs that is now retired, they realized in the agency that there was a need to really reach out and do prevention services, prevention education. Teens were experiencing things that were similar to what adults were experiencing, but at the time there was no service available. So in 1999 they started the teen alert program and around the year 2000 they actually started going out into the schools and giving prevention education workshops to youth in intermediate high schools and some college campuses. That's awesome. So you guys, can you kind of share some statistics with us about teens, what are we looking at as far as, I know it's like one in three women and I know the adult statistics but I don't know the statistics for kids. Yeah, so it's actually pretty similar except it's one in three youth in general. So it's not just the women that are experiencing or female identifying individuals, it's youth in general are experiencing about one in three nationally. In Hawaii it's about 32.6% of high school students in Hawaii have experienced emotional abuse or are being controlled in the past 12 months. Wow, 33% that's just staggering to think that it's that pervasive and wow. Okay, so tell us about some of your programs if you wouldn't mind, right? I know you have not a new one but one that you guys are focusing on right now, young love is real love I think is what you guys called it, right? Yeah, so we're focusing on this new theme or this age old theme of young love is real love because a lot of the time when you think about high schoolers and their relationships and a lot of the times when we talk to them, one of the things that they say is oh no one takes my relationship seriously, I don't get enough credit, oh it's just young love it's as if that's a bad thing. And so we're trying to redefine that narrative and say actually you can have healthy relationships at any age, it doesn't matter if you're in middle school, if you're in high school or if you're 50 years old because when we ignore it, when we say oh it's you're too young to actually be in love then it creates a culture where teen relationships and thus teen dating violence isn't taken seriously. So that's what we're really trying to promote is this idea that it is possible to have healthy relationships and that tap it away and other people are here for you. So when you guys go out into the schools can you share with us some of the specific programs that you mean like I love the little emoji game, I thought that was really cute. But stuff like that, so what kind of things do you teach the kids and how do you kind of teach them because kids are so hard to get their attention anyway, right? Well, I think Lydia especially has done a great job of really bringing in activity based curriculum. So we're really kind of not just filling them with information and knowledge, we're really affirming even in relationship with this young love is real love theme, we are affirming what they already know, right? That their relationships are meaningful and they are very real to them so they should be real to everyone else. So the activities are really just an affirmation of that and really us imparting the knowledge that statistics are saying but we also want to know what's going on in your school and your community and you tell us and then let us know how we can support you. So the emoji paddles is around statistics, right? But then we also have activities where they can identify types of abuse, they can identify tactics of those types of abuse, they can identify warning signs, what else? What other activities? We also do activities where like we have them kind of come up with a practical way that they can speak to a friend who's experiencing abuse so we'll give them a quote and they have to kind of like come up with a response or a friend who's being abusive. Right, I think that's really an important thing too. When I was interviewing that one gal at the end there and she had said when I asked her what was one thing that you could do and she said I would tell them, you know, this isn't okay, is there a better way that you could treat me? Absolutely. And I thought she was paying attention, not so great because kids need to know this. So often, like I wish someone had taught me these things when I was younger because I didn't learn that and I ended up in an abusive relationship later on and it took me years before I learned how to stand up and say, hey wait, isn't there a better way you could treat me? And so I'm really excited to hear that kids are starting to learn these programs because this girl, I mean it was the first thing out of her mouth when I asked her what's one thing and she's like, well I could tell them to stop. I applaud, yes, empower the kids. With all the new gender questioning and stuff that's going on with young people now being able to come out and talk about these things, how does that affect your guys' work? Well, we're a completely inclusive program and I would like to note that many of these things are not new ideas right around sexual orientation, gender identity. It's just that we have a generation now that is giving language to things that have always existed. But the fact that our program is completely inclusive, we try to keep everything gender neutral. When you look at statistics in the Hawaii Youth Risk Behavior Survey, you see that boys are experiencing it at rates that most people wouldn't even believe. And so it is really our, I believe our responsibility as a program to make sure that young boys, young masculine-identified individuals, young male-identified individuals feel comfortable coming forward at the same rates that feminine or female-identified individuals feel comfortable coming forward. And that's a responsibility of all, but especially for the young people. I agree. I think that's great that you guys are doing that because I know that some of the outreach programs that I have seen don't include and aren't so inclusive and they're not as effective. So our questioning in an open way now where they didn't used to be able to do that and so I think that's really important to be able to get out there. So you guys have been around since 1999. Who was the one who first came out with all this? Whose idea was it? Do you know? Well, I mean, I think it was pretty collaborative at the Domestic Violence Action Center, but I know the former VP of the COE department, I'll ask that. I think it's Community Outreach Education Department within DBAC was the one who, she helped develop many of the programs that are at Domestic Violence Action Center. And so she was really instrumental. Interestingly enough, though, Kay Lee, the guy that everyone was talking about, she was one of the first to come out. And so she was really instrumental. Interestingly enough, though, Kay Lee, the guy that everyone just saw. Oh, right. And I forgot to introduce him. I'm sorry. No, no, it's okay. Kay Lee, the other outreach educator, he has actually been with Domestic Violence Action Center and the teen program for almost 13 years now. So is it almost 13 or almost 14? He's coming up on either 13 or 14 years. So he's been around almost since the beginning. So he's seen a lot of changes, a lot of the trends change. He's been around for a lot of that. It's unfortunate. It's great. Yeah, he couldn't be on here today to share how some of the trends have changed over the years because they really have. Next show, because I want you guys to come back again. Okay. Give me an update about how things are going and the kind of progress you guys are making, because I know it's going to be amazing. Absolutely amazing. So can you tell me about maybe a couple more of your programs, like some of the stuff that you do with the kids, like the emoji game and like the other one? And just I think it's important to maybe for everyone out there to hear about these things too. But first, wait, I'd like to know, are you guys in all of the schools? Did you have trouble getting into the schools? Do you have trouble getting into some of the schools? How about that instead? So we'll go to whatever school invites us. Okay. And we've been really fortunate. So, you know, a special shout out to some of our schools that we go to all the time, like Kamehameha and Waipahu and... Waianae. Waianae High School and Intermediate. And then other schools, you know, we're trying to get into and we found we're always trying to get into more and more schools because the more students we can talk to, like the more likely we can do that. Absolutely. So do you hear that out there, people? I want you to invite these guys into your school because what they're doing is really important. And we need to take a break, but I'm really hoping you'll stay with us. I'm here with PAP808, which is the teen alert program here in Hawaii. This is Think Tech Hawaii. I'm Cynthia Lisa and Claire, please stay with us. Hey, that's you. I want to know will you watch my show? I hope you do. It's on Tuesdays at one o'clock and it's out of the comfort zone. And I'll be your host, R.E.B. Kelly. See you there. Hello, everyone. I'm DeSoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech Hawaii every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech Hawaii. Welcome back. This is Think Tech Hawaii, where community matters. You're watching Finding Respect in the Chaos. I am Cynthia Lisa and Claire. And I am here with some of the TAP808 teen, which is the teen alert program. I'm here with Cache. Sorry, I almost said it wrong. And Lydia. And I'm so happy to have you guys here. I really appreciate that you've come out. I know that there is something going on in February called a teen violence, no. Help me out with this. Teen dating violence awareness month. And I think there's maybe a lot of people that don't know about that. I know for me, I was like, what? And I'm pretty up on all these things. And I still had not ever heard of it. So would you please go ahead and explain what teen dating violence awareness month is all about? Yeah, teen dating violence awareness month is basically, it's a month where we really take the time to celebrate healthy relationships and also talk about some of the challenges of dating and really give teens the opportunity to do that conversation, to lead that conversation. Because we love going to the schools, but they're the experts. Yeah, they're the ones who are experiencing it. So it's really a chance to hear them. Right. And it's been around for a while this teen dating violence awareness month in February. I did never know that. I mean, we hear about Black History Month, but we don't really hear about this. I think it's important to start hearing about it and to really get the word out, which is why I'm really glad that you guys came out today. This has been really amazing for me, anyway, to have you guys here. Why don't you share with me if there's something really important that you would like the public to know about some of the things you're doing here in February, some of the extra programs that you've got, like that. Well, we kicked off February or Teen Dating Violence Awareness Month with going to Big Island, was it? And we were at Cal. And why Cal? Why Cal? So that's how we kicked it off. Those were the first two days of Teen Dating Violence Awareness Month. And then we've just been really trying to do a lot of lunch rallies. What else have we done this month?  It is fun. So a lunch rally is where we basically tap it away, comes out at lunch, usually on a school campus that we are already on. And we set up tables, we have prizes, we have games, we have a spinning wheel, we have a card game, where they get to test their knowledge kind of about the issue of Teen Dating Violence and Healthy Relationships. We gave away some Jamba Juice gift cards at one of the lunch rallies. And it's really fun, the kids have a good time and they like the prizes, but it's really good that we're getting the actual information out there too. Right, something that will catch them, right? Exactly. So what kind of future plans? Where are you guys going from here? I mean, what kind of stuff is in the works for Tap 808? Lots of stuff. Yeah, we have a lot of cool stuff coming out. Well, I think that, you know, there's some things that we're kind of trying to create like we're really working on a youth advisory council which Cache has really like spearheaded and really helped to like create it. I'm just trying to figure out what the best way to like, you know, get youth to be engaged in the issue beyond just, you know, in that classroom but really helping them to be advocates on their campuses. So that's kind of one of the biggest things I think we're working on right now. It seems like a sort of a nationwide thing that's happening to kids. High school kids are raising up and saying no more, right? No more violence in our schools. No more violence in our relationships. They really are finding their voice. And I know we're sort of far removed from it here in Hawaii than in Florida, say, but I think it's important to get it going here for across the board. So do you guys have any plans to like put this into maybe the legislature, maybe starting to get some real political action going to with this? Around the issue of teen dating violence. Well, you know, I don't, you know, if legislation stopped the violence, we wouldn't be having this conversation, right? So I don't know, I don't, you know, we're in one program of Domestic Violence Action Center. Domestic Violence Action Center does, you know, spearheaded by our wonderful ED, Nancy Creedman, you know, really assesses what issues in the legislature they will kind of stump for, for lack of a better word, or just support. And so, but I do think that, you know, there is kind of this movement happening right now, not just amongst young adults, but of youth and minors, that are saying, you know, we don't not have a voice just because we can't vote yet, right? And so it's time to listen to us, and it's also time for you to actually be the adults and be examples for us. So one of the issues with teen dating violence is that they are emulating or imitating the things that they are seeing around them. And so if they don't have examples of healthy relationships, they won't know how to have a healthy relationship. And that's just a reality. And so I think it's important for young people in high school, in intermediate school, in elementary school to say, these are the examples that we want to see, and this is what you owe us. This is your responsibility as an adult.  I love what's happening. I love it. That is a great narrative, and that's what I want to see, too, is kids rising up and saying, wait a minute, no more. If the parents can't get it right, let's let those kids have a voice to say no more, because if they can learn it in the schools, do you guys go to the elementary schools, too, or do you just go to the high schools? We work in intermediate schools sometimes, so we work at King Intermediate a lot, as well as others, and so, like we said, we'll go to anyone that invites us. So it is really cool to see that there's a statistic. I think it's in the 20s of middle schoolers in Hawaii are experiencing, have experienced, emotional abuse in the past 12 months. So middle schoolers are dating, right? So we also will try to go to as many intermediate schools as possible, and we really appreciate those conversations, because a lot of the time, by the time they're graduating or they're in college, it's not too late. That's kind of a pessimistic way of looking at it. So at Cache, you only go with it. No, that's realistic. In a way, it's realistic, right? So if we can start that conversation as young as possible, we run at that opportunity. And I would like to plug, if people would like to see the actual statistics for intermediate students, they can Google Hawaii Youth Risk Behavior Survey, and they can read, this is a survey given every other year by the Department of Health that is available to the public that people can track how intermediate and high schoolers in the state of Hawaii, they have a state one and as well as one for every county, how they are experiencing teen dating violence. Oh, well, what's that site again? So just go to Google and type in Hawaii Youth Risk Behavior Survey. Hawaii Youth Risk Behavior Survey. You'll hear people call it YRBS for sure. YRBS? Okay. It's easy to remember YRBS. If you can remember with the letters. Exactly. Can't just put that in the Google search though anyway. Oh, it might come up. I don't know. Give it a try, let us know. Hey, great. So I used to go out to grammar schools and to intermediate schools and I only went to a couple of high schools, but I worked with a lot of high school kids as a United Methodist minister for many years and I would go out and this is back in the 80s, okay? And nobody talked about it back then really. There was so much shame involved and I think that the Me Too movement has really removed the shame from survivors being able to talk about what's happened to them or to be able to have the rest of the world look at it without shaming the victim. So how do you guys do that? I know that shaming the victim is such a big issue that needs to be broken up and kicked out. I think, well, we talk a lot about shame in that we discuss why people stay in abusive or unhealthy relationships, why it's really difficult for them to leave, why it may take more than one time for them to leave. I think part of, in stepping away from particular movements oftentimes the shame still lies with certain groups of people. So we know one of the intersections is the more marginalized you are, the more difficult it is to not feel that shame or to come out and speak about your truth. So for instance, in the adult realm of DV, right, we know this narrative of one of the reasons why many women stay in their abusive relationships with husbands or male partners is because oftentimes they have not been able to establish themselves financially, right? So financial abuse is a very common type of abuse. If I don't have those financial resources, then it may do even more to keep me in that relationship. So we have to do a better job in society with restructuring our systems so that they support victims and survivors in getting out. And one of those systems is the education system, right? Our students, our youth have to feel comfortable coming forward and telling their stories and not feeling like they're going to be victim-blamed, which we talk about, not feeling like they're going to be shamed or feel like, you know, this is just another re-traumatization. Right, which it so often is. I call it the one-day-I'll-be-good-enough syndrome. A lot of times it'll keep women there or even kids there. It's like, well, one day I'll be good enough and she'll stop. I mean, one day I'll be good enough and she'll stop when they need to learn that they're already good enough. Absolutely. Well, the problem doesn't belong to them. The problem belongs to the abuser. Absolutely. And until we can kind of help that narrative get established out in the greater community, which is what I think you guys are so important doing because you're establishing that for the next generation that comes out. They're not going to come out with that shame-the-victim stuff that's been present for so long. And I think that's what perpetuates that shame. I know it was as a victim of domestic violence to come out about it in the early 80s was like there were no services, there was none of that. For sure. And I'm happy to see it all. I'm no longer a lone voice crying in the wilderness. There's everybody out here with me crying along too. Absolutely. And I love it because there's power in numbers. There's strength in numbers and there's healing in the telling. Absolutely. So when we can do that, right, we can make some progress.  Thank you. We just have another minute left here. Okay. So I would love it if you guys have one last thing you would like to say to the people out there. Well, I think the only thing I want to leave everyone with and Lydia knows I love quotes, right? That's true. So one of my favorite actresses is Viola Davis and something that she said that goes with what you were just saying is I was born worthy, right? You don't have to earn your worthiness. And so I think what I would want to leave with all of society but especially our youth is you don't have to keep proving how worthy you are to yourself or to others. You are already, you were born worthy. And so please reach out to us if you need to. Give us, give us the contact. Yeah, definitely. Our Instagram is at Tina Lertt program. So definitely Instagram has DM us if you have questions or if you're like Simon, you know, whatever. So also our website is www.top808.org. If you want to request a presentation, you can go through that or our email which is teen at stoptheviolence.org. So yeah, definitely reach out to us. Let us know if you have any questions. If you have friends who are experiencing violence or if you're a parent who's like, how do I talk to my kid about this? We definitely want to provide as many resources as possible to the community. Awesome. I want to thank you guys so much for what you do. Thank you. Yeah, thanks so much for bringing us on. For coming out.  I want to thank everybody out there for joining us today. At the bottom of the screen with all of those numbers and things that you guys saw, there's a website here to or an email that you guys, survivorcentralatthinktechcovid.com. This is a safe place for survivors to come and tell their stories and a place for advocates to come out and share important resources just like this one here. Today's episode was stop, tap out, sorry, tap out dating violence. And I love that. The tap is the teen alert program and we need to tap out dating violence without a doubt. This has been Finding Respect in the Chaos on Think Tech, Hawaii, and I am Cynthia Lee Sinclair and I hope you will join us here next time, week from Friday. No, sorry, every other Friday. Every other Friday at three o'clock. Come back again.


I mean, is it 12th gen I-5? Okay, right.  Is it ideal?  If you run an I-5, you're probably not even gonna be able to participate in our system.  If you're doing multiple instruments, and you're gonna try to keep multiple instruments times five.  So if you got five time frames, which is what, that's our general out-of-the-box layout, you're gonna have five charts, five time frames, times four instruments, that's gonna be 20 charts.  Oh, you had an update of no problem Pablo, no worries. I have an I-5 fortune getting wrecked with that. Yeah, so Athero is, you know, he's telling you right there. But on a normal day, right? Athero, have you been using our system for a while? Your I-5, it's been keeping up, right? George said he's doing an I-7 as long as he's only on two instruments, right?  Can you do it? Yes. Can you go down to one chart? Yeah, in fact, like you, if you get into our advanced training, you'll see I've got some strategies where you can narrow this whole thing down to single chart, especially now we've got Mac V Ultimate, you know, you can trade single chart. Especially if you've got the enigma, I mean, well, we just want to go like this. I mean, we could do this. I could take off Alpha Omega. Don't really have to have that. It's just nice to have. I could technically take off the double crosses here, but and it's just purely enigma if you wanted. Yeah, we have the, you know, we got the Delta flagging down here too as well. But you can basically narrow down your space. I tend to tell people that you, you add on the Algo matrix up here at the top left. If you don't know what that is, go type in YouTube and search for Vinny E. Mini Algo matrix, the Algo matrix indicator. You'll see that will go right up there. I actually created that originally for some doctors that had said, Hey Vinny, when I'm trading at the operating room, they're not in the operating rooms, but they, these are operating room. They go over to one of their side rooms and they've got their little tablets and they were like, you know, can I trade from a tablet? I'm like, you know, originally it was, you know, not really, but I kept the noodling on what they had said and asked, I'm like, well, how would I show them high time frames and all of that? So I actually have it right here. You guys can see here is the Algo matrix up here. So I know it's pretty small here because the 4k, 4k screen, all right. About this one more time. Did I get it? Yes. Okay. So there's your Algo matrix right there that tells you the highest time frames right now is on the green, right? So I want to wait until my layout here coincides and you can basically read this on a single chart. You know, you basically learn that in training if you would like. You know, we use it in correlation and combination with everything else. I could take this off here, technically speaking, but it's nice to have if you need to reference it. There's a lot of ways to adjust and adapt our system to whatever situation you're in.


All right, hello everyone. Thanks for joining the Automotive Linux Summit Europe. Our next talk will be Ishisan from Panasonic Automotive Systems. Welcome, Ishisan. And enjoy the talk, debugging tools and techniques for virtualized automotive systems. Take it away. Thank you. Hi, hello, everyone. Thank you for joining this session. My name is Hiroyuki Ishii. I'm working at Panasonic and also being a member of the Azure Project. Today, I will talk about debugging tools and techniques for virtualized automotive systems. Firstly, I'd like to apologize for minor change in my talk's title. I have removed the contentization part from today's topic for making my talk fit into the time frame. And I have already uploaded this slide to Sketch so you can download it anytime if interested. So here's the agenda for today's topic. First, I will provide a brief introduction. Next, we quickly explore various debugging tools useful for virtualized systems. Then we'll deep dive into a practical example where we'll analyze the VHOSnet, which is a typical component in virtualized environment. Finally, I'll wrap up the talk. Now let's get started with the introduction. So let me introduce myself again. My name is Hiroyuki Ishii. I have been working at Panasonic automotive systems for more than 15 years and have experiments in Linux-based software development for in-pico infotainment products and also cockpit domain control products. My primary areas of expertise are Linux scanner, performance engineering, virtualization, and cloud-native technologies. And in 2021, I joined the Azure project where I serve on the steering committee and system architect and also contributing in various roles such as virtual resources expert. So let's take a look at some background trends in automotive software. In recent years, there are various requirements arising related to software-defined vehicles, such as high-performance computing, hardware scalability, and workload distribution, mixed criticality, and many more. And in response to these needs, there has been a growing demand and initiatives for virtualization as a key technology for each of these requirements. For example, Azure project has been actively worked on virtual machine-based demo integration using KBM to address these needs. And other projects such as Sophie, Eclipse-CDV, and Android automotive are also actively contributing the virtualization solutions for automotive use cases. However, there are big challenges associated with the complexity of virtualized systems. These include complex interactions between host and guest components, increased system footprint, or complicated integration, and limited capabilities, and visibility within guest environments. As a result, debugging and performance engineering becomes increasingly difficult, and complications arise in understanding the overall system behavior. And to address these challenges, there is a growing need for specialized tools and techniques for virtualized systems. All right, so let's proceed to the next section. In this section, we'll review various tools available for virtualized systems, including Perf, Trace Command, BCC, Frame Graph, and Divak InfoD. These tools can help you analyzing, debugging, and optimizing your virtualized systems. So the first tool is Perf, which is Perf profiling and tracing tool for Linux systems, as many of you may already know. Perf acts as a front end for various tracing technologies in Linux, such as Perf events, Ftrace, and Kprobs. And it's developed within the Linux kernel source tree, which ensures it is stable and reliable at a certain level. However, this also means that Perf has a strong dependency on the kernel version, which may impact its compatibility across systems. And additionally, some hardware events supported by Perf are platform-dependent, which may limit its usability in certain cases, for example, on a platform. The next tool is Trace Command, which is the front end tool for Ftrace and developed by Steven Lodestad. Trace Command provides features quite similar to Perf, but with a simpler and more user-friendly interface in my opinion. And one notable thing is that some recent updates in Trace Command is designed for embedded and portrait use cases, including Trace Command agent and Trace Command recent. Unfortunately, I haven't been able to test these features this time, but I plan to turn them out soon. And next is VCC, which is a BPF-based tracing tool designed for performance analysis and debugging. VCC offers a rich set of features, including Python support and various practical example scripts, and I really do to simplify the creation of the custom tools really to a point. However, there are also some drawbacks to using VCC, including its relatively large dependency, for example, on LLVM and Python, which may not be ideal for some embedded use cases. Additionally, VCC has limited support for the ARM platform. Unfortunately, we were unable to use some good scripts in VCC, such as KVM exit and many more at this time, due to platform dependencies. And next is FrameGraph, or framegraph.pl, which is the batchization tool for performance data samples. This tool helps users understand the workload overview and identifying bottlenecks within the system as shown in this picture. And the last tool is Devak InfoD, which is a bit different type of tool than the other I mentioned. It's a host demo for handling and managing Devak Info files. Devak InfoD is developed as a part of the LFU2 project, and it's compatible with numerous popular Devakin tools, including GDB, Perf, Trace Command, VCC, and many others. Devak InfoD is especially beneficial for embedded systems, I think, as it allows for offloading Devak Info files from the target system, which solves storage limitations. And additionally, Devak InfoD resolves past conflicts of Devak Info files within virtualized systems. And a big advantage of Devak InfoD is its CMS integration with the yokt build system, which enables you to utilize it with a single command. So let's deep dive into practical examples using these tools. The goal of this section is to gain knowledge of Devakin tools, usage, and techniques in virtualized environment through practical examples. And as the example, we'll investigate the behavior of the B-host net, which is an acceleration for standard battery net by comparison with standard one. Then we'll explore how and why it can improve performance, as well as any potential side effects that could exist. Now, let's look at the difference overview between standard battery net and B-host net. The key difference lies in the implementation of the battery net device emulation. When B-host net is enabled, the emulation shifts from the QMU user space to the dedicated B-host net kernel thread. This change can result in improved performance and reduced overhead. But I will not go into too much detail here, as we'll analyze it by tools later in this section. OK, so before we dive into the analysis, let's quickly go over the preconditions. First, I'm using the AGL KBM demo platform, which is built from the AGL UCB master branch as a base image. And I have installed additional tools, including B-host net support and IPAV3, SSH, and Burst Devakin tool to the base image. If you need more details, please refer to the appendix of this slide without loading it. And my test environment is running on AGL reference hardware here, which has Renaissance Alka H3 SoC with eight physical CPU cores. And it hosts a single guest VM using QMU with set SNP equal 4, which means that guest VM has four virtual CPU cores. And during the analysis, I'm generating the network traffic between the host environment and the guest environment by IPAV3 to load the network virtualization systems. And to ensure the accurate result, I have halted all other workloads prior to the investigation. And I will be comparing the metrics and traces between B-host net and standard battery in other words, with and without this B-host net support by utilizing tools such as perf, trace command, and PCC. So let's begin with the simple bitrate measurement using IPAV3. With standard battery, the bitrate was 1.66 gigabit per sec. While with B-host net, it reaches 3.26. This shows that B-host net is about two times faster than the standard battery net, which clearly highlighting the benefits of using battery net. No, no, B-host net. Now let's start deep analysis with KVM event statics using the path set. Please note that we are limiting the number of packets here to 100 megas to provide the same load to the different environments. We can see various events recorded here, but key observation here are the significant reduction in the WFX events, which is a CPU standby event for on the AMP platform. And also, B-CPU wake-up event occurrence are same on guest B-CPUs. From this, we can guess that this may have some relation to the performance improvement in B-host net. Next, let's focus on the VMXGT events using path KVM stat. Interestingly, while we've also observed the decrease of WFX events, events again, but VMXGT events themselves have actually increasing in B-host net, mainly due to the data about event and IRQ event. The common belief is that a higher number of the VMXGT events leads to poor performance in virtual resistance, but this may not be always true. And here, we can guess that WFX could be more costly than other VMXGT events. Now, let's change the approach for focusing on monitoring IO operations on battery using. Battery stat, it's from BCC. Now, note that we have to learn this command from the guest side instead of the host side. The buffer length handled by battery net is shown here, here and here. And the left side is in buffer length, and the right side is out buffer length. And as a result, we can observe that the traffic handled by battery net is almost consistent between standard battery and B-host net, which implies the behavior of guest side should not be changed, at least on the interface level. And next, let's try to take performance sampling across host and guest using Perf K VM record. Before starting, it's necessary to mount the guest file system from the host using SSHFS like this. Afterward, we can pass the mount point to the Perf command like this. So this showed the result of Perf K VM record in standard battery or environment. By using the Show CPU Utilization option, you can visualize whether the workload belongs to the host or the guest, such as these rows, no, these rows are guest side and these rows are host side. For example, the top line of this indicates that the guest kernel function named and received Perf consumes about 20% of CPU in guest-conter guest. And please note that the process name starting with a column like this represents child threads of another process. In this case, all of them are a virtual CPU, vCPU thread of QMU process. From this, we can observe that two out of four vCPUs are working in this use case. As shown here, you can analyze high load functions in detail across both host and guest at once. However, this function level of detail might be too much in this analysis. So let's summarize the previous result using Perf K VM report sort option. This is showing the result summarized by processes. In this view, you may gain better understanding standing than before. However, it's important to note that the overhead metrics in this view includes idle functions. Thus, you need to identify the idle functions and manually exclude them from each process. The result, after exclusion, is shown at the bottom. As you can see, the overall CPU consumption has significantly decreased in the V-host-net environment on each processes. This clearly indicates the efficiency of V-host-net. OK, then let us try to look at function level workload again using frame graph. The basic usage of frame graph is outlined here. If you're interested in, please take a look later. And here, we present some tips and tricks for virtual systems. First, you can record samples on both the host and guest systems at once using SSH command like this. Second, you can merge the two outputs into a single SVC file like this. This makes it easier to compare and analyze the data. But please note that these procedures are designed for convenience and may not be strictly correct. And these are the results. All those, the font might be small, will zoom into each part later. Frame graph allows you to analyze system-wise stack traces. In other words, the function called hierarchy. The horizontal axis, this axis represents the total duration of the function across all samples. And the stacks are displayed from bottom to top with the bottom most element indicating the process name. Yeah, too small. And this visualization makes it easy to understand the performance bottleneck and its flow of execution at once. Now, let's take a look at each part. First, guest side has a nearly similar shape of workload between host standard and virtual and vhost.net. As same, IPerf3 on host has quite similar workload. Regarding swap case-rate on the host, the workload appears somewhat similar. But the idle time is slightly longer in the vhost.net environment. And finally, we can observe that primary difference lies in QMU and vhost case-rate on host. We can also see that the same function load, which is target user, appears in different contexts, such as QMU and vhost.net, which clearly visualizes the shift of network device emulation from QMU to vhost.case-rate. Additionally, we can identify an important difference here, which is the usage of the system course. In the case of standard Bataio, as QMU is a user process, it must utilize system course specifically widely to invoke kernel functions like target user. In contrast, in case of Bataio.net, there is no need for system course because vhost is a kernel thread. And this results in the difference in overhead. In the case of standard Bataio, we can see that many intermediate function course functions are being called until reaching to the target user. This leads to the loss of CPU time, as shown by the time difference between this bottom most coder function and the actual load function. And in conclusion, we can say that QMU generates significant overhead during network packet transfer, primarily due to use of system course. All right, so let's move on to the final exercise. We will try to trace interactions between the host and the guest using trace command record. To effectively analyze the context switches between the host and the guest, I recommend tracing both KVM and SCAT events at once like this. Additionally, K-Proofs can be utilized to trace almost all kernel functions. This is an example of creating and tracing K-Proof event for target user function. And here is the result of such tracing in standard Bataio. I know that this may look too complicated, so let me explain it step by step. First, let's focus on that two CPU cores are working here. One is the guest VCPU, and one is the QMU's main thread, which is also known as IO thread. Then let's examine the sequence. The starting point of the sequence is this MMIO event initiated by the guest VCPU. This prompts the host, in other words, emulator of the network device to transfer the next packet. As a result, the QMU IO thread awakens. Afterward, the guest VCPU enters the sweep set using WFX, and it awaits the next event, which is the compression of the network transfer. Then the QMU IO thread invokes target user function. Next, QMU handles the IO queue event to inform the compression network transfer for the guest. And then the guest VCPU gets woke up again from the sweep set. And finally, the next MMIO event is invoked, which means the end of single sequence. So let's evaluate the durations here. The total duration during one sequence in standard battery was 411 microseconds. And we can infer that the root cause of this duration is likely due to the VCPU's sweep and wake up, as well as the use of system calls. And finally, the sequence becomes obviously shorter than standard battery. So let's take a look at the sequence as well. As you can see, it's essentially not so different with standard battery. But there are two notable differences, such as there are the VHOST case-rate running and VCPU doesn't invoke WX. And the total duration during the one sequence in VHOST net environment become 187 microseconds. So in conclusion, we have observed over two times time efficiency in VHOST net, as seen in the sequence trace. And these results are highly consistent with the bitrate measurement observed using IPer 3. Essential reasons for this improvement would likely include the removal of QMU user space, which utilizes system calls from the critical pass, and also the minimization of VCPU sweep and wake up occurrences. So let me wrap up this talk. In summary, during this presentation, we have confirmed the value of VHOST net by the behavior analysis using specialized tools for virtualized environment. VHOST net is twice as fast as the standard battery net, with no significant side effects observed, especially in terms of CPU utilization. Additionally, various methodologies and tools covered in this talk. And I believe they can be applied to a wide range of development scenarios for virtualized systems. These include analyzing performance improvements and regressions, as well as debugging or walking through virtualized systems. And next steps, I will contribute materials to AGL, which likely includes some debugging tools. As well as VHOST net support. And I will also explore some additional tools, such as porting BCC script to AIQ 64 architecture or developing custom tools using BCC or trying to trace command agent and reason. And also, I will investigate on containerized environment and cloud environment. So that's all of today's my talk. Thank you. Any questions? If you have questions, please wait for the microphone. So thank you again. All right, thank you.


If there can't be abstinence from the Surgeon General, there should be other means you, do you agree? I don't quarrel with that. I've been lacking in much of the education. But the Surgeon General says that there has to be specific sex education about the needs for sex education at a very young age. I said that that education was accompanied by values. But one of the things that's been wrong with too much of our education is that no kind of values are right and wrong are being taught. In the educational process, I think that young people expect to hear from adults ideas of what is right or wrong. What do you have to give away to win the highway veto over? What are you going to do to Terry Sanford? It's still up in the air there. I'm waiting for it to get straightened out. Are you really spending enough money on AIDS, a lot of people? We have increased the spend budget. Just Congress has doubled what you've proposed. President of the United States, accompanied by Secretary Bowen and Dr. Corrielle. President, I'm Lou Corrielle, President of the College of Positions of Philadelphia. And it is a great pleasure to welcome you to the college. The audience consists of fellows of the college and some of the staff. Mr. President and Secretary Bowen, the college is the oldest medical organization of its kind in the United States. It was founded in 1787 by 24 physicians who were concerned about the quality of healthcare being delivered. Philadelphia at that time was the largest city in the nation, the capital, the center of commerce, and became the cradle of medicine in America, largely due to the actions of this college fellows. The college fellows were the prime movers in founding the first medical school in the United States, the first medical journal, the first pharmacopeia, the first nursing center, all of the Philadelphia hospitals, the free library, even the American Philosophical Society. And I could go on, but to get on, the college today is a dynamic part of the medical community. Most importantly, the college is a nonprofit academy or collegium of the leading minds in medicine in the region. For 200 years, they've gathered here to discuss how is the best way to deliver healthcare. We can call on the expertise of 2,000 physicians and various doctrines. So we are proud of our heritage and of our continuing commitment to healthcare policy. The motto of the founders was not for oneself, but for all, and we've been doing that. This is sufficient introduction. We are delighted to welcome you, Mr. President, to College Hall. No greater tribute could be imagined than to have the President of the United States visit the college on the occasion of its 200th anniversary. Now, to do our part in this exchange, I have asked Bill Blumly, President of Thomas Jefferson University and past President of this college to organize and moderate an exchange. But before that, Mr. President, again, thank you, and if you wish to... Well, I thank you all for coming here today, and I'm looking forward to what this distinguished panel has to say. Medicine today is saving lives and raising the life expectancy of all Americans. I know what that means firsthand. I've already lived some 23 years beyond my life expectancy when I was born. That's a source of annoyance to a number of people. And as you know, I've had a few stays in the hospital over the last six years. The surgeons were so skillful, I'm thinking of having them work on the budget. But I've seen the life-saving power of modern medicine. And I know that we have here in America a medical community that's the best in the world. Not only is medical care here the best, it's also more widely available than anywhere else in the world. As we prepare for the 21st century, our goal is to make sure that in the year 2000, that is still the case. This is why I've come here today. I'm ready to listen and learn. What are the challenges ahead for keeping America healthy, for developing the science and the art of medicine, for making sure that good health care remains available to all our people? So that's what I've come to hear about and the floor is yours. Thank you very much, Dr. Blumling. Mr. President, I'd like to begin by introducing the members of our panel. On my immediate left and going around the room clockwise is Dr. Robert Ostrin, who is president of the elect of this college and professor and chairman emeritus of the Department of Research Medicine at the University of Pennsylvania. Next to him is Dr. Paul Brucker, professor and chairman department of family medicine of Jefferson Medical College, Thomas Jefferson University, and an officer of the American Board of Family Practice. Dr. Edith Levitt is president emeritus of the National Board of Medical Examiners and a member of the Council of this college. Next to her is Dr. Maurice Clifford, obstetrician, gynecologist and recently retired president of the Medical College of Pennsylvania, now commissioner of health of the city of Philadelphia. And on the other side of the room is Dr. Richard Rothman, chief of orthopedic surgery at both the Pennsylvania Hospital and Thomas Jefferson University. He's also the founding director of the Rothman Institute. Next to him is Dr. William Kissick, professor of research medicine and healthcare systems also at the University of Pennsylvania. Additionally, Bill directs the Center for Health Policy of the Leonard Davis Institute of Medical Economics. Next to Bill is Dr. Claire Fagan. Dr. Fagan is the dean of the School of Nursing of the University of Pennsylvania. And next to her is Dr. Brooke Roberts, professor emeritus and past chairman of the Department of Surgery at the University of Pennsylvania. Brooke is also a past president of this college. And finally, Dr. Bowen, we'd like to welcome you as the secretary of health and human services and distinguished general practitioner, former governor of the state of Indiana, home of the NCAA champions. May I also present Mr. President, the other members of the council and staff of the college who are in the audience. We welcome you. By way of background for our discussions today, when this college was founded in 1787, medical care was rather primitive. It didn't cost very much and it really wasn't worth very much because it couldn't change the course of many diseases. Today, by contrast, medical care can work miracles, which you know so well. But its costs are fast becoming prohibitive. 200 years ago, those early Americans who were fortunate enough to make it through childhood faced all kinds of communicable diseases which are no longer a threat to us, a serious threat anyway, like tuberculosis, typhoid, fever, yellow fever and the like. Indeed, the early American expectations for health and longevity were quite modest compared to our own, which now tend to border on the unrealistic. Woody Allen spoke for many of us when he said, there are those who seek immortality through their children or their work. I prefer to seek immortality by not dying. And while we want the best care that money can buy when we're sick, when we're well, we tend to think that the hospital and the doctor bills are too high and we wish that somebody else would pay them, like the insurance policy, the employer or the government. Somehow, Mr. President, we've got to build a better connection between the responsibility for financing health care and the individual's responsibility for adopting healthy lifestyles. We must in short find better ways to promote the health of all Americans and to do so economically. Mr. President, our panelists are prepared to expand on these and related issues since our time is very limited. I suggest we proceed around the room. That's all right with you. First, could we hear from Dr. Kessig? Thank you, Dr. Blumlee. Mr. President, after family Thanksgiving dinners on the farm in Massachusetts, my mother-in-law would lean back in her chair and say, I've had a great plenty. Today, despite vast frontiers of biomedical science yet explored, modern medicine must digest a technological great plenty that ranges from a cornucopia of pharmaceutical discoveries to laser surgery to the sonic pulverization of kidney stones. We are challenged to use our technology to achieve cost-effective health care. Health care expenditures totaled $425 billion last year, 10.7% of our gross national product, and two-and-one-half times the total sales of the American auto industry. Organization and management of the delivery of health services is essential if these vast sums are to produce the health care required by 250 million Americans. Otherwise, our great plenty of technology could yield an escalation of health care costs rather than improved health status for the entire population. My quarter of a century in government service and academic medicine, Mr. President, has convinced me that regulatory and institutional reforms combined with health services research and development are imperative to translate our technological great plenty into equity, excellence, and cost-effectiveness in health care. Our society can tolerate no less than health care of appropriate quality for all of its citizens, and we can afford no more. Thank you, Mr. President. Bringing the benefits of all of our knowledge to the public. Nursing is part of the solution to these very pressing problems of access to affordable, could be possible if either of these professions tried to go it alone. We've seen life-and-death differences because of physician-nurse collaboration in intensive care, but nowhere is collaboration more prompt to make it happen, though. We must continue to attract the very best and the brightest to nursing and to medicine as we prepare for the 21st century. The health of Americans requires a new joint venture of nurses andists to occur. Nursing as a national resource and properly used can help to solve the problems that we face today and anticipate tomorrow. Thank you, Mr. President. Thank you, Claire. I'll turn to Dr. Rothman. Mr. President, please allow me to add my personal welcome to the city of Philadelphia. From a surgeon's perspective, I see our country's medicine as the finest in the world. Top quality, readily available, and personalized. The issue of concern is to how to control the cost without impairing these qualities. The principles that I feel we share are threefold. First, health care is a right to be shared by all. Second, physicians must be allowed to continue to focus on quality. Third, government and the health care system must become partners in the care of the aged, the poor, and the chronically ill. I agree with my colleagues that we must accept the reality of finite resources. We cannot compete in the world market when the medical care component in a new Chrysler product is $450. Three facets of the solution seem apparent to me as a surgeon working in the trenches. Number one, maintain Medicare, but strengthen it by improving its insurance base. Consider a means test so that the well-to-do elderly contribute more, include the younger and healthier workers, and include catastrophic coverage. Two, reallocate our resources. We have too many physicians and too many hospital beds. Let us educate our citizens that good health is their responsibility. Three, limit the waste of defensive medicine by tackling the malpractice crisis. The cost of defensive practice is immense when one adds up the unnecessary x-rays, the extra hospitalizations, and the useless consultations prompted by fear of legal action. These pernicious practices can only be solved with strong federal support of tort reform. Finally, Mr. President, let me reaffirm my faith in our healthcare system and our citizen patients. Together they can and will understand the problem of better uses of our resources. I firmly believe that this country will continue to be the bastion of the world's finest medicine, now and in the 21st century. And finally we'll turn to Dr. Clifford. Thank you, Bill. Mr. President, the paradox of modern medicine is that today we can transplant the human heart, but not transform it. We do well at curing disease, but not very well at correcting behavior. And our behavior is killing us. The things we do to ourselves, smoking and cholesterol and drugs, violence, frenzied striving, and loveless sex, we are careless about our personal health. And we don't care enough about our health as a people. Alone among great nations, America has no plan of universal health care.  In my view, Mr. President, as we approach the 21st century, we need to set ourselves two goals. For the sake of our health as individuals, we must control our habits. For the sake of our health as a nation, we must do better as our brother's keeper. The physician leaders of your administration are on course. Surgeon General Koop with his vigorous campaign against smoking, and Secretary Bowen with his strong advocacy of coverage for catastrophic illness. Moreover, today, a day made memorable by the honor your visit does our college, this auspicious day marks the effective date of national legislation increasing eligibility for Medicaid benefits for millions of Americans. Now let us press on, Mr. President and Mr. Secretary, to put a better, healthier life for each of us and for all of us. Thank you, Mr. President. Mr. President, this completely prepared statements of the panelists. We'd be delighted to hear either questions or comments from you, sir. Well, if I could just say I find myself in great agreement with everything that I have heard here today and being married to a nurse's aide, that includes your statement about their importance. I made great use of that a few weeks ago. But yes, in these last statements, it seems to me that we have a great deal still to do in education in the sense of informing our people of some things. As governor of California and several widely publicized catastrophic family cases that came to view there, we set out and worked out a plan with the private insurance companies in which if we would agree to be compulsory to compel everyone who worked in California to take out catastrophic health insurance at that time, they could have provided that insurance limitless as to cost for $35 a year. And when I say speaking of education or something about this, the frequency of that is not sufficient that everybody thinks it won't happen to them. We couldn't even get a postcard. We were going to make this available to the people to decide. We just couldn't get any attention at all about it and it just died a warning. No one ever thought it would happen to them. And I think here maybe this is a field for us to work harder than we have. Incidentally, Dr. Bowen there may have some comments if I may be so bold. I'm not in charge here, but Dr. Bowen nearly as I have been able to figure out is only the seventh physician to ever serve in a presidential cabinet in the history of the United States. And having been a governor doesn't hurt at all. I had just remarked to him a little while ago, we need more governors in Washington. Otis, do you have something? Thank you, Mr. President. I want to express my gratitude to each member of the panel for expressing their objectives very forthrightly. They have given me added incentives to continue to work for the quality of care, to adequate access to care, and proper methods of the delivery of care. And that includes a lot of things such as the financing which has been mentioned. And especially as Dr. Clifford mentioned, the prevention of the illnesses and the changing of lifestyle. And I'm grateful for the endorsement of the long-term care and the other catastrophic insurance programs. We must learn how to use effectively and economically all of the new technology that is coming out and must not let the cost containment reduce the amount of new technology that is coming out. So I'm grateful, Mr. President, that you asked me to come along. I've learned a lot. Mr. President, I know you are due shortly for another speech. I will turn the program back to Dr. Corriell. Dr. Corriell will say that our time is about up. Your visit, Mr. President, has given the College of Physicians of Philadelphia a new impetus, and I hope perhaps we can work together to do some of these things better than we did in the past. Thank you very much. I hope so. Thank you all very much.