This is SiliconANGLE.DV's exclusive continuous coverage of VMworld Day 2. We're here excited to have the new CEO of VMware, a long time, seven time CUBE alumni, when he was a lowly president at EMC, Pat Gelsinger, with my co-host, Dave Lump. Welcome back to theCUBE. Thank you very much, guys. Great to be here. Pleasure to see you again. First time as CEO. So first of all, how do you feel? Tell us what it's like. Obviously, just for the folks who haven't watched the EMC World interview, I asked you a point in question. I said, Pat, if you were running VMware, what would you work on? So we'll get to that later, but it turned out to be true. Turned out, once again, once again, the CUBE got it nailed, I like all of this, right? Yeah, absolutely. So how do you feel? Just give us some personal color around the transition. Obviously, you know, Paul, you guys have great rapport. Obviously, on stage yesterday, you got a standing ovation. Who's being called the king on Twitter. He's got a huge respect. You guys work together. Just take us through emotionally, the Pat Gelsinger inside Pat. What went down there? How did it feel? And the way he said, handing over the custodianship of the community to Pat Gelsinger, that was really, I think, a great way to put it. Well, first thing, Paul and I are just great friends. Over 30 years, we've worked together. It's like a great pick and roll team in basketball, right? He knows when to pick. I know when to roll. We've really learned how to work together over the years, and just great respect for each other's talents. And to have Paul embrace me, and really endorse me to the VM world and the community in that sense is powerful. But it also is intimidating. A bit of a responsibility as well. And I had dinner with Tom Jorgens last night.  My new best friend. So it is this very rapidly shifting role as well as we laid out a pretty bold vision this week. And you at Intel too, you understand the whole partnership dynamic. We talked to us in the queue of the ecosystem, VMWare, at the beginning of this massive opportunity of extending beyond the VMWare look. I mean, you announced, as an example, people who know VMworld, it's always been about VMWare. They've been dominant in the enterprise. But yesterday you announced change to the pricing. I mean, you guys are thinking bigger now. Is that part of the plan to think bigger beyond VMWare and extend to other vendors? Obviously, great love fest on the CEO panel yesterday, and also the demos up on stage. So talk about that mindset and what you plan to do to take it beyond just VMWare. Well, it is very much a community. And when you think about what we're doing with Software Defined Data Center, right, really it's touching everything as Paul said. It's virtualizing the data center. And to do that, you know, it's the networking guys, the security guys, the storage guys, the management guys, the new application vendors. Right, it really is this ever broadening community. And as part of that is both a great opportunity, right, as well as a great responsibility to all of those community players and how we innovate together collectively to bring about this next layer, right, of fundamental innovation, right, agility and speed for the Software Defined Data Center of the future. So we're going to get to that in a second. I want to ask you about Paul Moritz again, just to kind of come back to the policy. He has yet to be on theCUBE, so we're trying to get him on theCUBE and say it's a safe place. Does he not like you? I mean, what you do? Have you offended him? I don't know. People want to know about him. He made some really kind of cool tongue-in-cheek comments just say about Facebook's valuation and VMWare where everyone kind of good chuckle out. But talk about Paul Moritz as a person. He's rarely doing public appearance. He's a total tech geek. He's a cool guy. So share with the folks out there what he like. Well, I think of Paul as sort of the Michael Jordan of strategy and technology, right? You know, he is just, you know, well, I don't think of myself as a bad strategist. You know, this is like the best strategist operating in the industry today around technology and somebody who's deep, right, in the technology but also strategically very, very broad. And in that sense, his new role is really to allow him to really go focus on what he truly loves, his long-term strategy, understanding the technology trends and really going deep in that area. And the technology, right? He's actually a huge technologist. Oh, yeah. Right, you know, he's sort of like tops and bottoms, right?  Well, you said it's somewhat intimidating and you're a lifelong hardware guy now taking over a software company. How do you think about that and how do you think you might change the way you approach your leadership? Well, I think in some ways, I've always thought of myself as an infrastructure guy, right? And, you know, most of Silicon is done in software these days. So in that sense, I don't see it as that radical in that regard. But I have had the opportunity to really build the hardware infrastructure that every aspect of cloud is built on and now to be able to put tops on bottoms, right? To be able to layer that software on top of it. To me, it's just a great opportunity, right? To take on this next piece of finishing that overall portfolio. How does he fit with Joe Tucci? Because I just love the dynamic Joe was on there yesterday. You know, and we've had a chance, he's Joe's been on theCUBE and we've talked to him in person, great guy. He's just such a great executive CEO. And he's been around the block. Paul's like his sidekick now and those two guys are going to cause some trouble. What's your prediction on the Joe Tucci-Paul-Marist dynamic? Because you've got a strategist that no one's ever seen before in the tech of business in Maritz. Now with a canvas, painting a new canvas. He's done VMware. He's got that thing kicked off, laid out the roadmap in 2010. It's all feeling it nicely. It's all going great. You're going to take it from there and ride that ship and sail on the good waters. But now he's now painting a new canvas. What is Joe and Paul talking about? What's that next canvas? Well, if you sort of think about Joe, right? He's really become at this point of his career, I'd say, the elder statesman of the industry, right? Where everybody likes Joe, right? He makes everybody comfortable with them. And there's just this comfort, right? That Joe really brings to any situation, right? So here you have the big brains of Paul being combined with the experience, the relationships of Joe. And to me, I expect it to be a really powerful combination. You know, I was commenting to Dave on a lot of different things yesterday and tying in some kind of trendy stuff like Apple's market share value and looking at that percentage of market share. And then also when you guys were up on the panel, one of the observations was you got the elder statesmen in Tucci and the senior experience of Joe with Pat, you and Paul. And a lot of the companies like Facebook are run by people under the age of 35. So there's a generation of kids out there running big companies that have market caps of a billion dollars. So that's now coming onto the scene. How do you see that all playing out? Is there a trend towards business value?  You made a comment about that. But is it shifting to business value? Is that kind of what you guys are trying to get there? What do you say to those young leaders out there? And also what's happening in that market? Well, I do think that there is this aspect of, you know, building infrastructure, data centers, right?  You have to, you know, to transition people over time. Your customers are CIOs, right? You know, there is a level of security, confidence, et cetera that needs to occur on that side. And then you have the dynamism of the consumer trends, right? And you know, to cook at Apple, right? Clearly is the elder statesman of the consumer social side, right, of the world as well. And you know, he's not a teenager anymore, right? In that sense, but clearly is this ability to generate extraordinary growth, extraordinary new valuation, as you've seen with Google and with Facebook. And how all of that matures for social to become a sustained monetization model in the industry? Is it really proven yet? You know, I was really liking Michael Dell on stage, trying to really make his point, I'm not going away. Yeah, we did a direct business model. We're the PC guys, and then he's advocating and it's good to see him back in the game like that. Yeah, me too. I was, you know, I think Michael, over the last two years, you know, he has a tough job, you know, HP has a tough job to really transform those companies and you have to say, okay, Michael, he's really made it better. Well, a lot of those CEOs in that PC era that put a lot of, you know, East Coast mini-computer companies out of business, I think, don't want to see that happen to themselves. Absolutely.  Yeah, yeah, and Michael, I think, has clearly said, I'm up for this challenge and I'm going to take my namesake company through that challenge. So I got to ask you a hardware question, because, you know, you know that business, now you're going to be moving more into the different kind of, that is with virtualization and apps, but HP and Dell are classic PC vendors, they've innovated, they're part of the whole wind-tell generational shift. They have huge market shares still. Margins, yeah, are tied with the market's changing. You guys point about that in a new way. Apple has huge market value and they have single-digit share and growing in hardware, yet they're so valuable. So the logic is, if you connect the dots, small single-digit share, you get huge profits. Really great, good products, obviously, but they're wrapping services and other business models around the hardware. What's your take on that if you were at Dell and HP and saying, hey, you know, don't give up that PC business, just move fast, don't become driftwood, but what kind of services are they going to have to wrap around these products? Because the end user computing world, yes, it is changing multiple devices, but Apple has demonstrated that you can have a very strong hardware business and wrap around it. So what's your advice to those guys? Well, I don't think of Apple as a hardware business. In that sense, I think Apple has been focused on a user experience that happens to be embodied in hardware and services. And in that sense, they have owned the user experience. They're maniacal about industrial design. They're maniacal about that whole experience and have really innovated in how consumers buy, utilize their products. And I think any aspect of things that touch the user, they have to have that in mind. It's all about the user experience and they've done it well. And they've said, it's not hardware, it's not software, it's that integrated platform and experience. And my advice to anybody in that space, whether it's Dell, HP, Lenovo, RAM, Nokia, Microsoft, you have to really take that very aggressively in mind. So you put your man on the moon moment up on your keynote. You said, let's get to, virtually 100% of applications in first place. I think you said 90%. That's intimidating. I have a reminder of the climber who's climbing to the top of the mountain and it's like this false summit, right? So my question is, to get there, you're going to have to lick the complexity problem. And over the years in IT, we think we've got that problem solved. And then you peel the onion and oh boy, there's more complexity there. To get to that 90%, you're going to have to solve that complexity problem. Are we, have we solved it? Are we on that path? Well, I think we're beginning to lay the foundation for it. And I think some of the software defined data center pieces. Okay, you know, we got to attack management and orchestration. We got to attack the network and security. So clearly those are elements of it. You know, we have to make storage easy and available. But we also have to attack some of the higher level problems as well. And some of the cloud foundry, the PAS layers as well, because it's not just about modernizing the old, right? With things like Gemfire and data fabric and, you know, rebuilding the database environment. But it's also enabling the new and enabling those across the multi-cloud environments. And you know, so it's a lot of work to go do, but I think we've laid out the core pieces of the vision. And now my job is really to refine, execute, and accelerate that end game. Pat, I got to ask you about disruption and change. Joe Tucci made a comment that I thought was pretty Joe Tucci-like when asked about the trends. And he said, the horizontal's getting shorter and the vertical's getting steeper in terms of the time, the change in the disruption. And he's hyper-focused on that. I know you are too. And you tend to move fast and executive in watching your career. So let's take this software defined networking trend. I know we reported that you were in, when you took over AMC Ventures and looked at that, and you guys moved on some of those deals. So that's really key success. And we talked about it on theCUBE. But that's a game changer for VM, where like spring source was acquired, acquisition changed the developer landscape. Now you got the necessary deal. Is a game-changing statement. But you have existing stuff going on like VCE, which is pioneering a lot of the V-block stuff, right? So you got VCE out there. And now you got the software defined data center at the emerging side. So how do you sort that out? I know you're first week on the job or first second day in the job.  So VCE obviously is a flagship offering. It's V-block. How does that fit into this change? I mean, it's quickly, the disruption's positive, but they got to react. So a lot of the moving parts have to kind of get tweaked. What do you see there for VCE? Well, and clearly, you know, we have on the SDN side, before I answer the VCE piece of it, you know, we have two incredible assets, right? We have the whole V-shield VX LAN, right? Capability, which you'd say inside of the VMware environment was already well down the path of SDN. And now we have the NYSERA assets and MVP and open V-switch, et cetera. Right, so now, you know, job one for us is bring those together as the most complete offering for the SDN space, right? In the industry. You know, we got two great teams, bring those together and unquestionably, we got the top talent in the world. So we got to make that happen. And then we have to make that available for our partners, right? To be able to innovate with us, underneath us and on top of us. We announced Cisco partnership yesterday, right? You know, around how we're going to work together on that hardware software boundary. And then with VCE, it's used them as the world-class delivery vehicle for converged infrastructure. But now from the VMware role, hey, it's, guess what? You know, HP just did a great integrated demo, right? If they're converged integrated, you know, how are they going to participate with our SDN assets and how do we enable them? How do we enable Dell? How do we enable the rest of the industry? And VCE now, is that going to, how's that relationship, that's a separate company, but it's well-funded and they've knocked down some good deployments, it's pretty solid. Is it a high-end offering? Is it more of, I mean, how do you sort that out product-wise? Well, you know, VCE vBlock has always been a higher-end offering, you know, that's where UCS is positioned, right? You know, it really is the premier platform in the industry, right? And we expect to continue to invest in that and partner with them. And, you know, VCE is doing well, hitting a billion-dollar run rate, so we're happy with them. But, right, as I'm quickly, you know, learning, you know, I got other great partners as well. So ecosystems obviously are organic, they're ever-changing. How do these acquisitions that you make change the balance of the ecosystem? Well, every one of them is, right, aimed at, you know, can we do it through partnership or should we do it as an integrated offering? And where that line is is never the same, right? And we might make a decision that, hey, it's better done in the ecosystem today in two years from now, and it's time to integrate it into the core operating system of VMware, right? That's just the nature of how software and operating systems are built over time. Now, that said, hey, we're gonna be an ecosystem-friendly company, and even where we choose to integrate, we'll always have open APIs that enable industry innovation around us because there's more bright people outside of VMware than there are inside of VMware. And if we don't allow people to innovate with us, well, yeah, they're gonna go innovate somewhere else. Well, you have to move fast.  That's right. Something like Nesero's start of 2007.  And there are three primary pools of innovation, what we do organically inside of an enterprise like VMware, what happens in the university community and what happens in the startup community. And we believe that we effectively have to participate in all three of those. You know, we have our roots from Stanford, right? And that community, right? Nesero comes from Stanford and Berkeley, so clearly we see the university piece of it, right? We see the inorganic piece of acquisitions and obviously organic, cool things that we're doing like the excellent inside of the company. You've done a great job. I mean, we can honestly say, in tracking you from the original interview, you did those things. And every year we ask you, we'll ask you at the end of this interview, what's your plan for the next 12 months? So congratulations on that. Question I want to ask you is, yesterday we heard abstract pool automate. Yep. Which kind of is like code words for operating system. You know, you got to abstract away complexities, have resource management and then automate and make all that link and load together. You're pretty smart, that's good. I had to look that up this morning at Wikipedia. So that's cool. And you've also talked about your historical experience at Hintel, cadence of Moore's Law. So the question I want to ask you is, as you take over the helm at VMware, you have a different kind of OS cadence going on. That's very rapid, as Joe Tucci pointed out. What's your Moore's Law for applications look like? Cause now you have an enabling infrastructure in the VMware products and technologies as well as the ecosystem. And you got to foster that enabling technology. So what is the cadence of the app market? Yeah, and you know, first I'll say, you know, at the operating system level, right with VMware, we'd say, boy, you know, we like this yearly cadence, right? And it's nice that it sort of matches with TikTok model at Intel, which I helped create. Right, and sort of the major, minor releases of VMware are sort of in lockstep with that. And you know, cause what sets a cadence? You know, why shouldn't it be three or four years? Right, you know, what should be the right thing? And hey, you know, we sort of set, you know, we build on a firm foundation of Silicon and we're going to align heavily on that. So to me, this TikTok through the stack. And then if I look to the next level of the stack, clearly, you know, Agile and Sprints and so on have allowed app development to occur, I'll say in a social, right, crowd source model and in an effective way. But I think fundamentally you got to say, what is your foundation? And I'd say, boy, you know, a yearly kind of major release cycle, right? I think there's good solid, right, technical foundations for that. And then making sure that you have an effective ability to continue to do continuous innovation. So Pat, for the last five or seven years this industry obviously is focused on doing more with less operational efficiencies, obviously the converged infrastructure trend. John talked about, you know, abstracting, automating, pooling and automating, all of those things really driving efficiencies. And you know the story with IT spending, it's flat, it's been down. But there's a thinking out there with big data and with new flash architectures that we can have major impacts on productivity. When John asked you at EMC World, what would you do if you were running VMworld, you answered, part of your answer was more tighter storage integration. I want to ask you specifically about a top-down storage integration. In other words, bringing flash really managed from the server level, doing atomic rights and driving new levels of productivity for organizations that go beyond just sort of cutting cost and better TCO. Can you talk about just the vision of is that the right place to do it? In other words, controlling the metadata from fast servers versus slow storage. You know, interesting transition from a storage company now to where you are as the head of VMware. Yeah, unquestionably. You know, we have to do a better job at VMware, of taking advantage of flash on the server side. Right, you know, the performance capabilities of that, the IO gap that's opened up, right, in-memory data, right, applications. But, you know, at the same time, we're seeing the polar extremes become more polar. Right, the size of big data, right, you know, will forever drive these larger and larger pools of scale-out data on the one end. Right, and now with in-memory and flash technology in the server side, the things that you can do, right, with extreme performance characteristics at the server or at the application level, and VMware has to do a better job of making that available and some of the things that Steve talked about with V Flash is an example of that. Right, and we are going to do a lot better job of enabling those high-performance in-memory characteristic applications on this end while an agent with larger and larger pools of shared storage on the other end. And embracing Hadoop, you want to infer that you're going to bring big data analytic applications and actually potentially feed those transaction applications that you're virtualizing in near real time. Yeah. Is that direction? Oh yeah, absolutely. But, you know, to me the phenomenal thing is the extremes that are emerging here, where everything used to be just in a shared storage array, you know, we're now sort of blown apart, right? You know, now we have high-performance in-memory on one end, right, and these massive scale platforms, the multi-pedabytes on the other end, you know, it's pretty spectacular. And I said, you know, I said you want to operate on both of them in essentially real time. What's interesting, Pat, when we were at EMC where I asked you, can there be a red hat for Hadoop and you said, and you, you know, editorialized that you don't think it could be. Well, we recently had that debate on SiliconANGLE and pretty much the crowd is weighing in that there is no red hat for Hadoop, mainly because then just the market conditions are different, so just, I want to share that with you and that we're going to continue to do that. You made some good- I'm glad they agree with me. I like that. You made some good calls on big data. The question I want to ask you is, though, is in the major presentation, yes, that you guys laid out the new experiences and you talked about old way, new way, access, it was access, app and infrastructure, PC users to mobile users, existing apps and new apps in big data, service to cloud. So I want to ask you about converged infrastructure because that's the old way. So a lot of the definitions around converged infrastructure has been defined as part of that old side, that side of the street that's old. Yet, in the new operating system future that we talked to everyone about, data is now a key kernel part of the design. So I want to ask you, data infrastructure, define what data infrastructure is as it relates to the new converged infrastructure, not replacing converged infrastructure, how has converged infrastructure changed from old to modern with data at the center of the value proposition?  So today, converged infrastructure, you'd say, what's at the center of a V block, right? You know, you say, well, it's sort of, you know, the UCS servers because that's where the apps run, right? And I think increasingly in the future, the center of converged infrastructure is more around the storage infrastructure because VMs are so mobile in light and comparison, right? But the idea of collapsing the boundaries between server network and storage, I think it's still a very fundamental concept.  It's this array of infrastructure, right? That is agilely available for their different applications and I think that's fundamentally the right model, right? And a cloud-scale version of converged infrastructure makes a lot of sense as well. And highly homogeneous and many have observed obviously the advances that Amazon and Google have and you're clearly the software defined data centers moving toward a homogeneous environment. Right, one common software layer across a set of services, right, that are embodied in converged infrastructure hardware. And historically, homogeneous is meant you don't get best of breed, but so how do you achieve best of breed? Is that through the ecosystem? I wonder if you could elaborate on that a little bit. Well, I think, you know, in this case, the scale operation characteristics swamp, right? The individual characteristics of best of breed, right? In that sense, right? And they become enabled through this layer. But that hardware software boundary is always a point of innovation, right? When virtualization and VMware first emerged, right, you know, Mendel had this paranoia we will rely on no hardware, right? Right, it will make it work on anything. And then over time, the hardware got better at doing things like, you know, page table mapping, memory breakthroughs, et cetera, for virtualization. And all of a sudden, it's sort of like, oh, the hardware is enabling better virtualization and you took advantage of it. And the same thing will emerge as you go think about converged infrastructure for networking and storage as well. The hardware will continue to evolve to better enable this virtualization layer of software and automation above it. We're starting to get the hook, but we know we want to go, you got multi-core, high megahertz clock speed right now at PAV, got a couple of minutes left. I have two questions. One is around the future of virtualization. We're following on siliconangle.com, some of the new advances around large data centers that have commodity gear. So you obviously, you know, the usual suspects are Google, Facebook and whatnot, having a lot of commodity machines. And low level virtual machines is a really big trend now looking at how to deploy VMs at a programmatic layer. I don't know if you're following that. So I want you to comment on what you're following relative to some of the new trends around VMs. Obviously, down at the low level, low level virtual machines and how they're playing up the stack. And then my final question after that would be, you know, next 12 months, what's on your to-do list? Yeah, well, you know, I think, you know, part of our task is sort of the, you know, the, today the leader in virtualization has continued to leading the trends, right? In that sense, you know, continuing to reduce the overhead of virtual machines. You know, IO stack improvements, right? You know, the flash example that we gave before is a big piece of that, continuing to enable, right, better app affinity. You saw the Hadoop work. You know, some of the big VM work around databases as well, right? And saying, how does, you know, because in many ways, databases, right, you know, VMs operate on under provision hardware, right? And be able to over provision, right? And databases are over provisioning a memory, right? You know, for an under provisioned resource of the database, it's almost the inverse. So how do we address that? You know, the Serengeti Hadoop work is another example of that. So there's lots of things, right, to continue to innovate, right, at the virtualization layer, both as you look down toward the hardware, as well as as you look up toward the application, right? And I think in that sense- Is that where the software kind of tie in? That's why you're not saying more software-defined networking, more software-defined data centers. Do you have some ranges there? Is that the- Oh, that's a big piece of it, yeah, right. And you want to, that's all become policy-based, right?  So that, you know, the virtualization, the networking, the security elements, all of those become embodied in that as a set of services to the VM or this virtual data center. Next 12 months, you know, obviously, job one is make the transition smooth.  And then, you know, some of the key agendas are those we already talked about, you know, operate on the SDN, right? We just did 1.3 billion. I better make a good use of that. You know, figure out our storage and security virtualization strategies, our management stack. And some of the horizon things today are really pretty thrilling, you know, for that next generation end user experience. Pat Gelsinger, always a blast on theCUBE now as officially the CEO. Great to have you on. Well, actually I'm not officially, I'm at T-minus three days. Three days. September 1st. Okay, September 1st. Congratulations on me. Pat Gelsinger. Thank you very much. CUBE alumni, great guy and tech athlete for sure. This is theCUBE, silkenangle.com's flagship coverage of all the events extracting the signal from the noise. We'll be right back with our next guest after this short break.


A sizable part of what makes a standout entrance theme is that signature sting. You know what I'm talking about. It's that unique sound effect played right at the beginning of the song to pop everyone huge before the music even kicks in. Now, sometimes these not-so-subtle noises can turn what's considered to be a decent tune for a good character or characters into a massive calling card turning them into wrestling gods. That being said, I'm Kevin Callis from Wrestling Behind The Themes and don't forget to subscribe because here are the Top 10 Best Opening Sound Effects in Entrance Theme Song History. After failing to connect with wrestling audiences at the onset of his career, Brad Shaw found decent mid-card success as a member of the APA along with Ron Simmons. But he didn't truly grab Vince McMahon's brass ring and break into the main event scene until he rebranded himself. As John Bradshaw Layfield, a wealthy big-mouth modern-day million-dollar businessman arriving in a long white stretched limousine, JBL's entrance combined his Texas roots and his real-life accomplishments as a New York stock market investor. The opening ringing bell sound effect in his theme called Longhorn is symbolic in that it represents what occurs at the start of a regular trading session. But what the sound really represents in wrestling is JBL's overall stock rising as he bullied his way to a Hall of Fame career. Being the only tag team featured on this list says something about the impact that Bubba Ray and Devon made during their illustrious careers. One of the most decorated of all time, the Dudley boys have been tag team champions 18 times. Oh, and they had some hot theme music too. Thanks to Jim Johnston and the song We're Coming Down, the missile-style pyro bomb flying from the arena roof onto the entrance ramp accompanied by an incoming bomb whistle-like sound effect was like shouting a gigantic wassup.  With WCW on top of the wrestling world and thriving because of the success of the New World Order, an interesting decision was made to split the group into two separate factions and allow Kevin Nash to lead the NWO Wolfpack. Now everyone thought that the NWO was cool already, but this angle provided the ideal scenario of a face group of the NWO feuding with the heel NWO Hollywood. To differentiate between these two groups, the Wolfpack developed a sort of hip-hop style, and the reactions they got showed just how over the red and black were. But what really helped them was the Wolfpack's insanely catchy theme produced by the mouth of the South Jimmy Hart with a simple hip-hop beat and opening howling wolf sound effect that was just too sweet. Speaking of Kevin Nash, given the name of Diesel as suggested by Shane O'Mac, Shane McMahon, based on the fact that Nash was from the Motor City of Detroit, Michigan, Big Kev's initial entrance theme was a sample of semi-truck engines revving and loud horns beeping, extremely annoying to say the least. Thankfully, soon after winning the WWF championship from Bob Backlin at Madison Square Garden in 8 seconds, these noises were layered with more bluesy, harmonica-driven music that fueled Diesel's assent to the top. But if you need more proof about this sweet sound effect, just go back and watch the 2011 Royal Rumble match and listen to the reaction Big Daddy Cool Kits when this song begins. Now you can't talk about Kevin Nash without mentioning his best friend Scott Hall, aka Razor Ramon, becoming the stylish Cuban American bully and one of the greatest Intercontinental Champions of all time Chico. With squealing tires announcing his arrival, the bad guy oozed machismo as he strolled down the aisle to a much more relaxed tempo and percussion cowbell beat, reminiscent of the song Lowrider by the group War. The Hall of Fame career of Mick Foley was no accident. He was one of the toughest performers to ever lace up a pair of boots and his pain tolerance for taking crazy, high-impact bumps night after night after night cemented his legacy as the true hardcore legend.  The car crash sound effect at the beginning of this theme pretty much sums up what it must have been like to wrestle Mrs. Foley's baby boy. Throughout your life, there are only a few precious moments in time that you'll remember exactly when, where, and what you were doing when a life-changing event occurs, such as laying eyes on your first crush, the birth of a child, or when CM Punk made his iconic return to pro wrestling on August 20th, 2021. Now, whether you love him or you loathe him, you can't argue that this was a goose bump-inducing moment that made grown men openly weep tears of joy. The crowd that summer night in Punk's hometown of Chicago was white-hot and welcomed him back with one of the loudest, most sustained pops ever. As soon as that infamous static scratch gave way into Vernon Reed's legendary guitar riff.  In what is possibly the greatest entrance music opening sound effect outside the traditional mainstream wrestling promotions, Kazuchika Okada's metallic coin flippy flip simplistically lets everyone know that the Rainmaker is in the building. What follows next is Godlike and Grand, befitting the man who makes a point of having the best entrances in the industry every single year. Now, this song brilliantly conveys the idea that the new age star Okada is a generational talent and the unquestioned ace of new Japan pro wrestling. Much like his legendary main event career, this track proceeds with a series of thumping impactful bursts before galloping into a vast deluge of flamboyant licks tailor-made for a classic video game-like fighter.  Over his 30-year career, Taker's theme consistently evolved from a haunting graveyard symphony to the rap rock of limp biscuit and kid rock and back to a more refined, more triumphant culmination of his debut theme from 1990. In short, it's everything the Deadman should be and so much more. Legendary former WWE composer Jim Johnston's ode to the Phantom of the Opera, the ominous bells that toll in the beginning signal the Undertaker's arrival and lead into the most breathtaking, all-inspiring entrance in the world of sports entertainment. From the second you hear the sound of glass breaking, you know and I know that Stone Cold Steve Austin is about to make his way to that ring, hand out a few stunners, and open up a can of whoop-ass. Never one to suddenly enter a room, the rattlesnake worked closely with Jim Johnston to create his signature song that he wanted patterned after the rage against the machine hit Bulls on Parade. Capturing the attitude of the Stone Cold character and song, Johnston produced the opening sound effect by layering together the sounds of multiple pieces of glass breaking, a massive explosion and a crazy car crash.


Good afternoon, ladies and gentlemen, and welcome to this very happy occasion, the swearing in of Ms. Helene Van Damme as the United States Ambassador to Austria. We're very privileged today to have with us the President, Vice President, Judge Clarke, who will administer the oath, the Ambassador of Austria, and distinguished members of the Cabinet and the Congress. Accompanying Helene, her husband, Mr. Barron Leeds, their son, Michael Leeds, and their niece, oh, Ms. Greed too. And now the oath of office will be administered by Judge Clarke and Mr. Leeds will hold the Bible. Helene, if you'll raise your right hand and repeat after me. I, Helene Van Damme. I, Helene Van Damme. Do solemnly swear. Do solemnly swear. I will support and defend the Constitution of the United States. I will bear true faith and allegiance to the Constitution. I take this obligation freely and without reservation for a purpose of evasion. I will well and faithfully Discharge the duties of the office upon which I'm about to enter. So help me God. We're applauding for her. Fine.  I think this room kind of tells the story. And I decided that maybe the best thing if I could would be to relate a little personal experience that has gone on for a great many years on 16 of them so far. And all of you here are testimony to what I'm going to tell you and what I'm going to say. There was a young girl in Austria living in Vienna during the time of the Soviet occupation of that city and all the tragedy that went with it. And then she made her way to the United States. And I've been very proud for a lot of years that she read something. She had a job in Chicago and she left the job, made her way to California when I ran for governor, and went to the headquarters in San Francisco, wanted to work in the campaign, needed a job, and she was hired and she worked in the campaign. And then I became governor. Judge Clark came with us to Sacramento, decided this young lady from what he had seen in the headquarters and her work should be a part of the administration. And there came a moment when there was someone needed my office and he said there was only one person he knew in the capital that should be the governor's secretary. And Helene became my secretary. And I became acquainted with a very quiet, modest young lady who was absolutely, totally dependable and who did everything the way it was supposed to be but who was also the most American human being I have ever met. She made all of us admire the people of Austria with this as an example for us to see. But she was more American than Patrick Henry. And the few times that I saw her bristle was when some American was criticizing this country or what it has to offer. And she would even stomp her foot in times about them. And then the years continued and now here. And then, as you well know, into a very important position in our administration. And then one day our ambassador to Austria came home desperately ill and with the knowledge that he possibly would never be able to return there. And came to me and told me that the one person, if he couldn't return, who should be the ambassador to Austria was Helene Pandem. Now, I greeted this with mixed emotions. I greet this day with mixed emotions. How do you say goodbye to someone who has been so important in your life for 16 years? But in the other hand, the joy of knowing that from the prime minister on, they are looking forward to their former citizen returning to be the ambassador in their country. And I know that she will be a great diplomat. She has, as I say, great dependability. Certainly there in her own homeland, I have complete confidence she will represent this, her adopted land for so many years, faithfully and as well as it could be represented. There is one thing also that does add to my joy in this assignment, in spite of my sorrow at her going. And that is that she will have a chauffeur to drive her wherever she goes. The only American thing she didn't master well was traffic. She has a couple of totaled porches to testify to that. But I want to thank you so very much for all that this has meant and for what you are going to do because we still have a string on you. I hope so.  It's OK for an ambassador to show emotion because if not, I think I just flunked my first test. Mr. President, dear friends, thank you very much for sharing this very special day in my life. It is a little bit overwhelming to think that in less than a quarter of a century, a humble immigrant can progress to become assistant to the president. And now sworn in as the United States Ambassador to her native country. I hope Mrs. Reagan will forgive me for stealing a line. But my life, too, began with Ronald Reagan. That's, of course, not literally true. But it is in the sense of my knowing what it means to be an American, what it means to be dedicated to the principles that are the hallmark of our nation. Individual freedom, personal dignity, equal opportunity. In this sense, it all began, as the president said, one day in 1965 when an address he made so moved me that I followed him halfway across the country, determined to get on his team. Well, since then, my life has been very rich on goals, satisfaction, personal growth, through eight years of the governorship, the disappointment and heartache of 76, the triumph of 80, and now, of course, the continuing challenge of the presidency. During this time, I also found my wonderful husband, Byron, whose love and understanding has been an immeasurable source of strength and happiness to me, and whose support I know I will need as I meet my new responsibilities. In looking back, what I treasure most, I should say cherished most, about the American people is their incredible generosity. With all the initial handicaps of a new immigrant, I never felt anything but total acceptance and support as I tried to make my way as a citizen here in the United States. Whenever there was a bridge to cross, there were outstretched hands helping me across. That was particularly true with the Reagan family. Nancy Reynolds, Lynn Nafsiger, Mike Diva, Ed Meese, and, of course, Bill Clark, who initially brought me into the Reagan administration. Not only became my friends, but became my mentors as well. This is true of all of you, my friends, colleagues, associates, and, of course, most of all, the president, who always found it perfectly normal to hear an Austrian voice on the intercom. Mr. President, I cherish the memories. I feel very privileged to have been a part of this magnificent adventure. Nothing has been quite as inspiring and illuminating than getting to know the president and being at his side. While history books may record him as a strong leader, as a principal president, I feel very fortunate having known him as a human being, whom I so much admire and respect. To say that I'm grateful to you, Mr. President, to my adopted country, and that I understand, in a very personal way, the meaning of the phrase only in America barely begins to express the emotions I feel today. It sometimes is difficult for those who have always experienced freedom to really appreciate how very lucky we are here and how people around the world who are so much less fortunate in suffering do look to America as a shining beacon for hope and encouragement. When I was a young girl, experienced war, occupation, uncertainty, I too saw that beacon. And now, I'm more than ever how important it is that we have men like the president who make sure that America continues to live up to the responsibilities that go along with all our many blessings. You honor me deeply by disappointment, Mr. President, and I hope you know you can count on me.


Hubble has also revisited the famous Eagle Nebula, capturing the multi-colored glow of gas clouds and wispy treadmills of dark cosmic dust. With these new images come better contrast and clearer views of the region. In addition to this new visible light image, Hubble has also produced an infrared image. The infrared penetrates much of the obscuring dust and gas and unveils newborn stars hidden in the visible light view.


Our folks, this is the Tiger Financial News Network, 11 AM market update on the 8th of December. The Dow is down 96,000 at 35,622 after making new recovery hybrids and anticipated from the low of the 200-period exponential moving average made at 34,022 on the 1st of December that after four days of running strongly, the fifth day should see either a little tiny doji candle and a reversal the following day or today would see some kind of turn around to negative. So spectacular moves, you have to expect some kind of digestive phase, now it's a 35,619 that makes the 35,500 area key support, the close under that says, now you've got to start assessing whether or not we can go much higher or whether we've done everything for the moment and we have to wait for better news. The S&P at this particular point is trading at 46,75 down 11, also made a new recovery high, very strong move, it needs to hold the 46 on the short term basis, 46,68 area if it closes under that we'll have to reassess to see how much upside there is still left because the magnate did not close positive and that's kind of important in the daily chart. QQ is pulling back a little bit here, just down one at 39,679, very good move, there's a lot going on, you can see that the isolated stocks that are spiring to the upside, apple still looks good, it's also in the down, but at the same time there are a lot of stocks that have been beaten down, so how the close comes in on Friday at four for the weekly chart on the QQQ, NDX100 is going to import the small caps, meanwhile try to rally earlier on, they're still actually holding the gains up one to play and catch up, but at 225 they're reading to get to the 227, 228 level to say hey we've got further to go on the upside, gold is just kind of meandering, it's down two at 1783, just hasn't been able to find upside action, it's good all that we're going to be watching closely because it's had a fabulous move, it's even holding now up 11 cents at 1716, if good all is able to get to the 7380, 7380, 7425 area in the next two days, that says you know what the low that was made just recently, that could be a pretty good low for now and we're looking at the TLT which was pulling back earlier on, now it's pulling back much more, it's down to $1.70, that means bonds are pulling back, yields are going higher, so stay tuned, you've got Larry Percivento coming up, wonderful show of course, we've got Think or Swim, that's with Kevin Hanks, you've got Steve Rose, Dave White and Tom O'Brien, just fabulous shows coming up, stay tuned for a really good market day and what a day it's going to be, a very interesting session, stay tuned, I'll see you again tomorrow, have a great day, thanks a bit.


So the inspiration for this presentation came about a month ago, a month or two ago when I was reminded of a story from medical school. Early on in my first year, there was an older student who had come to be friends with who I really thought was an intelligent, fun, easygoing guy. And I was not with some of his friends one night and was sort of taken aback by them telling me that they felt like he had what they called a darkness about them. They said they used to hear him audibly berating himself in the shower or other times. And I remember thinking to myself that that was crazy, that I needed to make sure that I never got to that point. But by the end of my first year, I literally caught myself berating myself in the shower. And it had taken the voice in my head becoming audible to realize how much of a toll that first year had taken. Over the subsequent years, I've had a fair bit of success with becoming more aware of that voice, recognizing it and quieting it. But it still pops up from time to time. And although it might not be quite as audible for everyone, I think this is something that many people, especially in medicine, experience to one degree or another. So there were several things during that same time period that initially brought that story to mind. We had two excellent and thought-provoking Taco Tuesday sessions, one on imposter syndrome and the other on wellness and cognitive distortions. I happened into a number of conversations with colleagues about the discomfort we feel in the face of uncertainty, either in front of colleagues or in front of patients. And then I came across a few podcasts by one of my favorite podcasters, physician Peter Atia, who talks a lot about negative self-talk and how it is particularly prevalent in medical trainees and about self-compassion as a potent antidote and even a more effective motivator than self-criticism. So I wanted to try to get to the root of whatever these problems are. And the problem goes by many different names, cognitive distortions, imposter syndrome, negative self-talk. And we know it's especially bad in medicine, just calling to mind the issue of physician suicide makes this abundantly clear. One of our very own here, Dr. Catherine, who refined these ideas and built a conceptual framework for how medical students, but also presumably how all practitioners get caught in a self-perpetuating cycle of shame, depression, anxiety, wherein dysfunctional thoughts lead to negative feelings, which themselves lead to emotional distress, which itself provides fertile ground for those distorted narratives to continue to grow. And there's several solutions that we've recently discussed as a residency, more of that seemed to be more widely discussed these days. Numerous wellness initiatives over the past several years have had measurable positive impacts on many of the residents. We discussed self-compassion practices in one of our sessions on Taco Tuesday sessions. And meditation is something that's fortunately becoming much more mainstream than it probably was in the past. But the idea of narratives being at the heart of the issue was something that kept coming up, and it brought to mind the idea of narrative medicine as an antidote to burnout and emotional fatigue. The topic of narrative medicine is something that had a bit less exposure to. I somehow committed myself to giving a grand round on the idea of narratives, and it was at about that time that I figured out I ought to do some research on the topic. So I borrowed a copy of Lindsey De Nino's The Principles, sorry, Lindsey De Nino's copy of The Principles and Practice of Narrative Medicine by Rita Chiron et al. and I worked through it over the past month or so. Lindsey had previously recommended this book to me based on discussion that we had, and so it's something I've had a peripheral interest in for some time and thought I'd take a deeper dive into it. And right off the bat, I was struck by this concept of thin stories that I immediately identified as what I felt was the foundational issue, the thing underlying so many of those issues that I just mentioned, and we can pinpoint exactly which type of distortion is present in a dysfunctional narrative and recognize that our negative self-talk comes in innumerable flavors and textures, but all of them are thin. They lack context, insight, reflection, and compassion. And the idea of a thin story comes from psychologist Michael White, who describes them as generally negatively charged, frequently characterized by conclusions that one is hopeless, a failure, incompetent, unworthy, hateful, inadequate, and so on. Now in this context, the word story being applied specifically to a personal narrative, but I think it's more helpful for reasons that will be clear in a minute to think of a story a bit more broadly encompassing the narratives that were told by patients, friends, colleagues, and even the narratives that we read. So the opposite of a thin story is, of course, a thickened story. It adds the context, it adds compassion, and in so doing, it creates a richer narrative and reveals insights to the speaker and the listener that exist far below the surface of a thin story.  So the authors say to narrativize and thicken a story is to tell it in a new way to a responsive listener, not to change the events of the story, but to discover novel significance in them, so that the thin conclusion no longer appears fixed and essentialized. And so then the question is, how do we thicken our own stories? And the practice of narrative medicine proposes to be a means of doing just that. The authors call close reading the signature tool of narrative medicine. And the term itself, they say, they talk about at length and it's been used in circles of literary criticism, starting around a century ago and was adopted as a foundational method of narrative medicine's teaching and practice. But as with anything that's been hanging around circles of literary criticism, the term is a bit esoteric and obscure. The authors do a fairly good job, though, of breaking it down into something tangible. They describe that close reading is not for the purpose of cultivating novelists or poets. On the other hand, it is for increasing one's capacity to notice things, to be curious about words, to gain insight into one's own biases and interpreting stories. And they propose that a method for teaching close reading by reading non-medical literary fiction with an eye toward the author's use of time, space, voice, and metaphor. But that's still something that's a little hard for me to wrap my head around. I feel like I need a teacher to guide me through it. I think an idea that might be more palatable or comprehensible to a lot of people is just that of engaging with art and creative works on whatever level that might be for an individual. It could be literary fiction, poetry, film, music, visual art, or any other creative work. And this talk actually initially included a brief history of how Western medicine came to be so focused on the biological sciences, often to the exclusion of the humanities. And while the reasons for that may seem obvious and the resultant benefits of scientific advancements over the past century undeniable, there's a reason to think and increasingly evidence to suggest that it might come at a cost. So, Ken Costano in 2016 published a study in science showing that reading literary fiction as opposed to nonfiction, popular fiction, or nothing improves theory of mind, which is the ability to understand other people's mental states. Manjion et al. in 2018 showed that exposure to the humanities during medical school correlated with increased empathy, tolerance for ambiguity, wisdom, emotional appraisal, self-efficacy, and spatial skills was inversely correlated with burnout. Winkle et al. in 2016 reported on the results of a one-year narrative medicine seminar where OB-GYN residents from three programs would meet once a month for an hour. And over that year, those with higher narrative medicine session attendance had a decrease in emotional exhaustion compared to those with low attendance who had an increase. And all these studies seem to suggest in one way or another that engaging with creative works and cultivating creativity can be beneficial, either to the well-being of medical trainees or to patient care. But there's an additional consideration, I think, in the author's posit that the medical field has a particularly tense relationship with creativity. Most patients probably don't want a doctor known for her creativity. But the authors propose that this is a flawed view of creativity, that the very act of listening to a patient's story, examining a patient, and putting all of that information and data together into a unifying diagnosis is itself a creative act on the part of the practitioner. Just the other day, Dr. Shakur told me I had to stand back and look at an ICG like the work of art in order to appreciate a subtle core ioditis. So I think, again, that there's reason to believe that the idea of exposing oneself to and fostering one's creativity is not just a boon for the individual, but also potentially beneficial to patient care. And I want to go into some more tangible examples of what this actually looks like in practice, but I wanted to pause here first and ask if anyone has any thoughts on this personal experiences or anecdotes about how exposure to the humanities has either improved personal well-being or their patient care. Or maybe even people have other creative outlets that I haven't mentioned. It occurred to me last night that the culinary arts might deserve to be included among things like literature and music. So you can feel free to ask to be unmuted or just put ideas in the comments if you'd like. Give a few moments here if anyone would like to. I can unmute myself quickly. So I feel like Randy always gets to brag that he's a math major and I never get to brag that I'm a humanities major. So that's my first time ever in medicine. Thank you for that. It seems like you're trying to connect the dots between, I'll just say, engaging in a creative opportunity with improved mental well-being. And just a comment for consideration. So often we talk about all the self care, right? All right, residents, you're unwell. Do more yoga, get more sleep, et cetera. And yet we have a system that doesn't allow that. We've really worked hard to address that in the residency with your admin half days and different things. And so one of the questions I have, the skeptical side of me is, is it just a matter of giving people more time to engage in the things that make them well? Or is there something unique to this creative humanities outlet that you feel is fundamentally important for this issue? I do think that there is something unique about the exposure to the humanities to creative expressions. And I think I'll sort of get into some of the examples of that. But I absolutely agree. And something that Dr. Dredgeen talks about all the time is the irony in making things mandatory in the name of wellness, adding things to residents' schedules in the name of wellness. And that's certainly not what I'm proposing. But I do think that many people, and this may not apply to everyone, probably find some outlet in engaging with creative works in humanities, but may feel that that is sort of removed from their practice of medicine. And I think that some of this evidence and some of the things in the idea behind literary medicine supports an idea that it actually contributes to building your medical practice. Yes, it contributes to your wellness, but also has potential to create a better physician in the room with the patient. Thank you, John. Looks like there's just two other questions. I'll just kind of read up while you're here. Again, you may need to move on. But Griffin just noted, I've often found playing the piano or listening to instrumental music be very therapeutic, especially when stress is high. So nature, this is from Dr. Olson. So nature and appreciation of finite status has been great to give me perspective and humility, especially that it is not about you. I also love well-done biographies to show how ordinary people really were capable of extraordinary things with an emphasis to their very humanity from Dr. Olson. And then Chris Keith, I come to my technical field via creative work, film production of fine art photography, love everything about the way I think to creative work and the forms of angle I take and the problem-solving can serve me well. So no specific questions there, Sean, but want to do at least let you know of those comments at this point. Dr. Olson is muted. Hey, listen, if I could just go ahead and comment a little. I think what you're saying here is great. And that is is that because medicine can be so stressful and so all-consuming, I think we sometimes get ourselves cocooned in that. And because, sadly, if you make a mistake and maybe your sentence isn't quite right or your painting isn't quite right, we make a mistake and our patients can pay a price. That's a heavy burden. And so I think that we have to learn how to cut ourselves some real slack. And we have to learn to appreciate that you can't change the past. You want to learn from it, you got to move on. That's why I think it's important to have balance. And I think that's what you're talking about here, really. And all of these things help give balance. And to the point that we don't allow balance in our life. And I've seen people like that.  And so I'm a big believer that that balance is critical. And I don't know. For me, I've loved getting way away back up in some of the wildest areas in the Wind Rivers, for instance. There's just a sense of both appreciation of the grandeur and a sense a little bit of your own significance in a certain way where it's not all about you. You're part of what's going on. And so you can't take it so personal. You've got to be thinking more of others and yourself. And then it seems to me like a lot less of a problem. Anyway, those are just some things that, for my long career, have been very helpful. If I don't get time out, exercise is another way for me to think about things in a different way. If I don't have time for that, I can feel the stress building. You've got to work to be able to find a creative outlet to release that. Absolutely. Absolutely. And I think those times in nature or whatever it is in our creative outlets are times when we were able to be so much more aware of all the nuance in our surrounding. And that's what narrative medicine tries to get at as well. So let me try and make it even a little bit more tangible in terms of what the practice of narrative medicine looks like. So that last study I mentioned there, and thanks to everyone who shared. I also want to be clear that the Murray and I Center in particular in this residency program has done a phenomenal job, especially with some of the wellness initiatives. And like I said, I think that a lot of residents have experienced measurable benefits from them. And this is just one thing that I'm sort of adding to the list of things for consideration. So in any event, that last paper by Winkle et al. showing that residents with the highest attendance at narrative medicine seminars had decreased emotional exhaustion after one year. It happens that the book contains specific excerpts from some of the sessions that were part of this study. And I want to share one of those. Basically, they had 15 session curriculum designed to run over a two-year period of time. And each session had a theme. So calling, why do you do what you do, work-life balance, making mistakes, so on and so forth. And each had a reading assigned to it. And the reading often was not obviously tied to the theme. One of those, I believe it was session five on managing expectations. In that session, the OB-GYN residents were asked to write a definition for some of the ACGME core competencies. And the idea was to somehow make these competencies meaningful in a way that the residents could appreciate. Now, the ACGME defines practice-based learning and improvement as the ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine. So one of the fourth-year residents at the start of the seminar or the start of the session gave this definition, using experiences in daily care of patients to guide further decision-making. Now, I think that's a perfectly good definition. But after writing that definition, they read Jamaica Kincaid's Girl, which is a short story, and they were then asked to write instructions to themselves in a similar style. And this is what one of the fourth year residents wrote. Don't wear scrubs outside the hospital. If you want to have scrubs your size, you're going to have to bring them home. Make sure to eat breakfast. If you skip breakfast, you'll be grumpy by noon. Don't be grumpy. Not in smile while I yell at you. I'm not yelling at you. Why did you do that? Present the list of grand rounds. Tell the story so I know what you were thinking. Why did you think that? Do it this way. Wait, I have something else to tell you. Hold on a second. There's something else. Don't be late. Try to move a little more quickly. There are a lot of patients on the labor floor right now. You should really check that the junior resident checked that lab. I'm going to need to use a scarf for this case. Teach your intern to do this another way. Why did you do it that way last Tuesday? Stick around.  Why'd you go over work hours?  So this student chose to write instructions to herself about medicine, about life at the hospital. Other students chose to write things completely separate, unrelated to medicine. And then at the end, they were asked to revisit the practice based learning and improvement competency. And of course, whether or not this is better is highly subjective. But to me, it seems richer. So the definition before is using experiences and daily care of patients to guide further decision making. And the same fourth year student's definition afterwards was incorporating the lessons of the day's work and the experiences around me with the technical and cognitive knowledge I've gained into a more whole image of a doctor. So that is one example. It may be compelling to some, maybe not to others. Another example I wanted to share, and I think I'm coming up on my time here, but this won't take too much longer, was this one. I know this slide violates everything you're not supposed to do in a PowerPoint presentation. But I just love this example of a creative piece a student wrote after a six-week seminar about a patient encounter. So the student wrote, what I wrote was the patient has a prior history of falling when trying to cross the street. What I wanted to write was Ms. W, who's 90, was jaywalking in NYC while returning to her apartment from the liquor store. She, quote, must not have seen an indentation in the road, end quote, when she tripped and fell into the street as her newly purchased bottle of Chardonnay rolled away from her.  The wine bottle remained miraculously intact, untarnished, and ready to drink. Ms. W laughed at the irony of the situation in telling the story and noted that she had retrieved the bottle before returning to her apartment. What I wrote was, patients MSE was significant for zero out of three objects recalled after three minutes. What happened was I asked Ms. W if it would be all right to test her memory, given that she'd noticed difficulty finding words over the past year. She replied, I know one of them is going to be soldier, right? Sure, it can be. I replied, grinning, falling into her infectious rhythm. Let's make it soldier, apple, and pen. She repeated the three words. She thought hard about them, but when it came time to remember, she could not. Do you remember that you suggested one of them to me, I asked, rooting for her? Soldier, she said triumphantly. What I wrote was the problem list, an assessment and abbreviated adulterated formulaic version of the rich encounter I'd had. I was schooled numerous times by this way fish comedic, lovably difficult woman, but here I was leisurely breaking her down to finger arm, eye, head, from a lofty spot miles away, deleting the character, leaving the complaints. I know this patient, but who else will? Now there's an impracticality here, of course, and I'm all for brief and to the point documentation, but it calls to mind a particular patient encounter that's actually been ongoing for me recently. That's quite sad and that several people here are involved in. And it's an interesting and perplexing case from an academic standpoint. And often the discussion with someone unfamiliar with case starts with the medical facts, but where the story really evolves and where people's expressions and investment in the story changed dramatically is in little things I picked up along the way. A photo of the patient riding a horse years back that he keeps as his background, his sister's account of how much faith he's put in his healthcare providers over the past several months, the way he tried to communicate that he was scared through a trade or conversations with his wife who's unable to be in Salt Lake with him. I know I personally find that it's a chore to go and re-examine his eye, but those little nuggets that thicken his story are really revitalized for me. And I can see that they are for others who hear his story as well. Now, you may never recall at this point that this started off as an inquiry into our own dysfunctional personal narratives and what we can do about them. And at the risk of becoming a bit difficult to follow, I think it's essential to realize the knowledge that our own stories and the stories of our patients sufficiently thickened are incontrovertibly intertwined. I know that personally, when I find myself in either a particularly good or bad mood, it's easy to track that feeling back through a chain of interactions with colleagues, patients, friends, family, and strangers. Philosopher Alastair McIntyre provides a caricature of the chain of events that unfold in such a situation like this. What I feel is in large part a response to what I take others to feel or not to feel.  And our ability, therefore, to understand our own emotional state, our own narrative is contingent on our ability to do the same for others. So I have this last quote here. I won't read it in its entirety in the interest of time, but in order to bring this full circle, essentially, Rita Sharon says that through close reading, and I think we can substitute any sort of creative outlet for close reading, the close reader is accompanied on the readerly journey not necessarily by another person who will actually say things back by similarly attentive presence, the self-increasingly known. And ultimately, the first step I think in changing negative personal narratives is recognizing them, getting closer to them, investigating their origins and thickening them. And it may be a bit of a leap, but I believe engaging with creativity, whether in literary fiction, painting, piece of music, or anything else, and learning to appreciate the subtleties and nuance contained within it is an invaluable tool for cultivating the skills that allow us to thicken the story, whether told to us by a patient or by ourselves. And that's all I have. I want to go down to Lindsay Dunino who gave me the initial inspiration, let me the book, and whose office I'm borrowing right now. Griffin Jardine who advised me very helpfully on this presentation yesterday. Any shortcomings are my own. And Eric Hansen who was encouraging of this topic. Here are my sources. I'd love to hear any comments. Your presentation is very well thought out and very thought provoking, I appreciate it. There's some excellent comments in the chat box. If you'd like to review those, in the interest of time, we will unfortunately have to keep moving and we'll move on next to Dr. Simpson. Dr. Simpson is some quick things about her. She's an award-winning baker. She won the Iowa State Fair. And also an effort to embarrass her. Her birthday was earlier this week, so happy birthday. And she will be presenting a case of a two-year-old with ptosis. Dr. Simpson, please take it away. Thanks Abigail. She's cute up. All right, so we're gonna switch gears and talk about a case presentation that I saw in a two-year-old with ptosis. So she presented to the PCHED at the beginning of August last year with her dad with the complaint of right eyelid droop. HPI was about a week prior. She had nausea, vomiting, and poor pio intake and was overall fussy. And then about five days later started to develop right eyelid droop in which she was intermittently rubbing her eye in her head and dad was unsure if it was painful or if the ptosis was just bothering her. Past medical history is really unremarkable. Normal birth, normal development, no past ocular surgeries. No medications or allergies. Her family history was a negative for inherited eye disease, amblyopia, glaucoma, headache and migraine. And she currently lives in Utah with her dad. On exam, unfortunately with the ptosis we were really unreliably able to get a vision because she was not tolerating manipulation of that right lid. Hey, I saw your message. I wanted to take some call. In the left eye, she had an unreactive pupil on the right side. And from the best that I could tell, a right exotropial and hypotropia on the right side with adduction and superduction deficits. The rest of her exam was notable for ptosis on the right side around a non-reactive pupil on the right. And her DFE was just with an elevated cup-to-disc ratio of 0.8 in both eyes, otherwise normal. And so now, now what do I do? Do I panic? Do I leave the ED and have PCH consult pediatric neurology? Or do I call my friendly neighborhood a neuro-ophthalmology fellow? I ended up doing the latter after considering and probably doing the first and second. But I knew that this new neuro-ophthalmology fellow was going to expect a differential diagnosis for me for what seemed to be a cranial nerve three palsy. And at this point in time, I have an extreme amount of experience in exactly one month of PGY2 year under my belt. But what I remember from being a VA intern was that if a cranial nerve three palsy was pupil sparing, it was ischemic, microvascular. And if there's pupil involving, it was aneurysm and I should send them to the ER. However, I knew she'd probably expect a little bit more from me. So I came up with this list, which of course still has ischemia and aneurysm, but also has other ideologies like infection, demyelination, lesions, that sort of thing. The problem I had with this list and the problem I had with this case to start was that she was two years old. And so I had to look up what were the common causes of cranial nerve palsies in children. And this was the data that I found for cranial nerve three or three, six or four palsies in children and congenital and trauma being the most common. However, her history didn't really fit with that. So I knew that that probably wasn't gonna be a good differential for my neuro-ophthalmology fellow.  And overall, she had a really unremarkable workup. She had an LP with normal constituents, no bands, no meningitis encephalitis. Her autoimmune demyelinating panel was negative and her infectious workup by lab work but through serum was also unremarkable. The only things that came back positive was a slightly elevated ESR and EBV-IGM and IGT that were both elevated. On her imaging, so this is a T1 with contrast image that shows that she had enhancement of the root entry zone of the right cranial nerve three exclusively, very isolated, the rest of her MRI was normal. And on her MRI, unfortunately, the cuts didn't really lend itself well to this presentation but she had a right fetal PCA that was read as kind of displacing the right cranial nerve three root posterior laterally. So her hospital core, she was admitted for a couple of days. They ended up consulting ID to help kind of manage and interpret the multiple infectious labs that were taken, which they thought that there was evidence that she had mono likely within the past six weeks and that her current presentation was most consistent with just biogastroenteritis. Neurosurgery was also consulted given this fetal PCA that could have been pressing on the cranial nerve three. And they felt that there was no need to do an angiogram and that cranial nerve three compression is case reportable and that there was other causes that were much more likely than her fetal PCA causing any problems. So now what? I found that getting more history is never the wrong answer but in this case, I am kind of leaving some key things out that I'll fill you in on. So about one year prior to your presentation, she had right eyelid ptosis and a turned out right eye that resolved over the course of about six months. And dad was told that imaging at the time was done, he wasn't with her, she was with her mom but they were told that she had an abnormal cranial nerve three and she was told by a neurologist that this may happen again. She then was seen in our clinics on the fifth, or in May, excuse me, where she was noted to have an intermittent exotropia but no pupil or ptosis abnormalities. And then the day prior to her ED presentation, she actually came to clinic where she was noted to have a constant right exotropia, complete ptosis and a poorly reactive pupil. And there was concern for cranial nerve three positive issues she was sent urgently to the emergency room. So a few weeks after she discharged from the hospital, she was seen in follow-up, which her ptosis had improved some but was not completely resolved. She was able to fix and follow in the right eyes. She still had some anisocorrhea and she still had a superduction and adduction deficits and a large right exotropia and hypotropia. So patching was started for her. A few months later, this was last month now, she was seen in clinic, ptosis had resolved, her anisocorrhea was resolved, her EOMs were full but she was still having a right exotropia with concern for development of dense amblyopia in the right eye. So patching was continued but very heavily considering stirbismus surgery. Her neurology team brought her back in November for a repeat MRI, which showed improved enhancement of that area that was previously enhancing that had a result and there was no evidence of a remaining tumor. So what we have is a two year old girl with what sounds like two attacks of cranial nerve, three palsy, which seemed like they had resolved mostly entirely and this reversible enhancement on MRI and imaging. And all that put together came up with us for the diagnosis of recurrent painful ophthalmopolegic neuropathy or ophthalmopolegic migraine is what it was formerly known as. And so the epidemiology is very rare as about 0.7 per million people and it's largely a pediatric disease, typically less than 10 years old with the onset usually being around eight years old. There is slight female predominance. Earlier studies suggested that there was male predominance but I think that as more studies have been looked at there there's actually more females affected and a large majority of these patients have a personal or family history of migraine. So what is recurrent painful ophthalmopolegic neuropathy? It is characterized by an ipsilateral headache followed by a palsy of one or more cranial nerves. The headache does not have to be a migraine but in a large majority of the animal about 60% that there is migraine or migraine features. The palsy typically starts between zero and 14 days after the headache onset which can be difficult if you have a headache and then two weeks later have cranial nerve palsy to kind of correlate the two. By and large it's usually the cranial nerve three that's affected about 70% and there have been reports of cranial nerve six and four being affected. The ophthalmopolegia usually lasts around a few weeks but can persist up to months and unfortunately the repeat attacks are really poorly predicted. Sometimes it's a week, sometimes it's five years before they'll have another attack of RPON. So as I mentioned before this was formerly known as ophthalmoplegic migraine as it was felt to be related to a migraine phenomenon. However, in 2013 it renamed it and felt that it was actually more related to a painful cranial neuropathy. And so it falls under the category of painful cranial neuropathy and facial pain in the ICHD diagnostic criteria now. And what I wanna point out is that it is a clinical diagnosis but that we need to exclude kind of getting to criterion C and D other causes of cranial nerve three palsy. So a lot of times these people are getting to work up to rule out other causes. And we get a lot of aid in this from our imaging findings. And the imaging findings that I discussed before are actually part of the reason why it was recategorized from a migraine to a neuropathy. The pathophysiology is really difficult for us to kind of get a handle on. It's based basically on case reports and radiographic finding. Initially it was felt that it was possibly compressive and related to migraine, which caused compression of the cranial nerve root. However, it didn't really explain pupil sparing palsies and why the palsy would be so persistent even after the headache resolves. Some have felt that this is related to ischemia and that perhaps vasospasm causes breakdown of the blood-brain barrier, which would allow us to see those MRI findings of enhancement and that they've drawn correlations between the time course of resolution between a diabetic third and RPON. The last one that they've kind of entertained is denomyelinating or inflammatory condition. And this is because of those MRI findings of enhancement of the cranial nerve and thickening. They thought perhaps this is post-viral or related to a condition, something like CIDP or Guillain-Barre syndrome. But again, and a lot of these people, they're work up with serum lab work and with CSF is negative. So maybe a mix of all three, it's really been difficult to kind of parse out what is actually causing RPON. So these are the very classic imaging findings. This is a photo from one of the case studies, but I could have easily put our patients' images up here. And what they have found that there is enhancement and or nerve thickening, typically in the cisternal portion of the cranial nerve or in the root entry zone. And this is present in about 75% of patients who have been diagnosed with RPON. And typically this enhancement, like in our patient resolves over the course of weeks, kind of as the cranial nerve palsy gets better. And in a study that they looked at that they had also gotten vessel imaging, it was normal in 93% of patients, which called in a couple of big questions for me for this case. And the first one was, what is the significance of her fetal PCA? As suggested before, the overlap, there's only maybe 7% of patients that have abnormal vasculature when they're being worked up for RPON. But there is a few rare documented cases of concurrent RPON and vascular abnormalities. And they've suggested that the proposed mechanisms either be direct compression of this vascular abnormality or perhaps an altered trigeminal vascular response and that the proximal portion of the PCA has a lot of density of receptors. And so edema in that area can trigger the cranial nerve palsy as well as the headache. And I kind of wondered about the clinical relevance of this since neurosurgery said, this is a very rare case reportable. And it's true, there's just a few handful of cases largely in people who are old or 50 to 70 or so years old in which they had cranial nerve three palsy that they felt was related to vascular compression and they decompressed them. These patients, all of them got better or completely resolved in some sort of way. But they also noted that in 70% of people who they managed conservatively also got better. And so they recognize that there's a great overlap between RPON and these people that they're decompressing and that even it's a really difficult diagnosis to make even with imaging. So fetal PCA probably incidental, definitely not the full story with RPON. The next question I had is why did we repeat the MRI in November? We have two clear attacks. We have the classic MRI finding of that nerve root enhancement. Why do we need to repeat? I mean, if she had a cranial nerve palsy and got nearly completely resolved, it's unlikely to be a tumor, right? That's kind of what I was thinking, but actually there are a decent amount of case reports in which they've had schwannomas mimic RPON. And there are a couple reasons why they think that this could be the mechanism. And one is that perhaps these initial attacks of RPON are actually schwannoma in which the tumor is just too small to be seen in an MRI. The other thought is perhaps these repeated attacks of inflammation and demyelination actually cause cellular transformation and eventually will cause a schwannoma to develop so that RPON is actually a risk factor for the development of a schwannoma. The main takeaway, again, this is just a small percentage of people who have been diagnosed with RPON and it's likely not the full story. But what I gathered from looking into this was that we need to repeat the MRI at each attack. And there's a couple of reasons. One, if there's no, just because someone has RPON doesn't mean they can't develop an aneurysm or something you would hate to miss. And two, they could have also developed a schwannoma that maybe is now more evident on imaging. Some have suggested repeating imaging at a more regular interval in between attacks, but that's really poorly described. So the treatment, as you probably gathered, we're working on a handful of people, fractions of percents to kind of gather what we should do and how we should treat these patients. So there are no controlled studies. The biggest body of data that we have is on the use of steroids, and particularly in those that have enhancement on their MRI. And what they found is that about 50% of those responded to steroid treatment. And that could have been just a little bit of an improvement in ptosis or medriosis or complete resolution. And they kind of described it as that, of how that we'd use steroids and optic neuritis and that it may hasten the recovery but might not change the overall endpoint of how much function they'll regain after their cranial palsy. And the last thing is that there's no clear evidence for migraine prophylaxis. Back when we thought this was related to migraine, people were being put on calcium channel blockers and beta blockers to help prevent recurrent attacks. And what they found that there's no clear evidence to do this, and that the only reason that they should be on it is if they also have concurrent migraines, which a lot of these folks do. And so the prognosis, it's generally favorable. A lot of these folks will recover, functioning about over the course of a few weeks. But in one study, they found that about half of them do not recover completely. And this kind of was the whole spectrum of patients. Those who had a couple millimeters of ptosis or a little bit of medriosis, this remaining to those who really had virtually no recovery of their cranial nerve palsy. And that they did find that these repeated attacks have worse recovery. And I feel like that's shown really well in this patient that she had a decent recovery, just an intermittent exotropia after her first attack. And now she's having more problems with strabismus after her second attack. And the long-term treatment is really not well described. And so we kind of focus on the symptoms. So things like prism glasses for double vision and strabismus and ptosis surgery for those that still have remaining ptosis and strabismus. And in her, her amblyopia is really a great concern. She kind of has risk for strabismus and deprivational amblyopia in that right eye. So I would suspect that they'll be moving forward with strabismus surgery in the near future. These are my references. I'd like to thank doctors Warner, Redfern, and Bagunta for helping me prepare this presentation. And I'm happy to take any questions now or at the end so we can get on to the next presentation. Ali, we have time for one question. Dr. Petty put one in the chat box. I'll read it for you. With so much variability in the potential presentation, headache or not, migraine or not, up to two weeks before, imaging normal or not, is it just the basket to put any idiopathic cranial nerve palsy, or are we convinced it's directly tied to migraine or is migraine the basket? That's a really great question. I think it kind of gets at what we think this is, which has been difficult to describe. I don't, I'm not convinced based on my study that this is necessarily related to migraine. I think that there must be a correlation between patients that suffer from migraine and develop RPON. But I wish I had a better answer with as to why this cranial nerve enhancement develops. As far as, I'm sorry, what was the second part of the question Abigail? The diagnostic criteria, if it were. Yes, if, because it's so variable, is it, is any idiopathic cranial nerve palsy kind of related to that? Or, yes, Dr. Petty, if you want to chime in. Is it directly tied to migraine or not? Or is the overarching kind of umbrella or basket migraine? I guess. Can we do that correctly? So I think there might be an overarching migraine kind of predisposition in these folks, but I don't know that they're necessarily related to migraine because of the way that kind of natural time course of these. And I don't think that any idiopathic cranial nerve palsy, I guess I could see where that would be the case. I would have to be more convinced of it. And as we've, as the diagnostic criteria suggests, if a person has one attack of a cranial nerve palsy and their workup is otherwise unremarkable, someone might tend to favor that to be ischemic. But it's not until we have a second attack that we're able to comfortably make that diagnosis. Thanks so much, Allie. And thank you for your question, Dr. Petty. We'll move on next to Dr. Twitchel. He is a neurosurgery PGY1 originally from Utah who last year amongst, as all of us did, surviving the pandemic. He had quite a year as he couples matched, graduated medical school, got married, bought a home, got a puppy and started residency. He will be presenting a case of ocular myotonia. Thank you for the introduction. I'm happy to be here to join you and to discuss a little bit of what I've learned and if this will work for me. Start off. So this gentleman was a 54-year-old gentleman who back in 2016 had six months of very non-specific symptoms. He had difficulty ambulating fatigue. He had leg weakness and swelling and sores, blurry vision and was diagnosed with cataracts. And then he had stalking glove numbness and decreased libido and impotence. He has a history of osteoporosis with multiple spine fractures and diabetes. And eventually, through all this workup, he ended up being found to have a pituitary macrodenoma and a planem sphenoidalaminin angioma. So he underwent a transfenoidal resection. Spencer, are you still there? I think your audio went out. Can you hear me? Yes, we can hear you now. You're kind of going... Well, hopefully it holds out, but on the left, we can see a coronal T1 MRI post-contrast demonstrating the planem sphenoidalaminin angioma with the typical dural tails that you see evidenced here that are very pathognemonic of meningioma. And on the right, we have a pre-contrast image demonstrating the pituitary mass as well. So the differential of a cellar mass includes rathkis cleftis, specific pituitary adenomas, pituitary apoplexy, arachnoid cysts, epidermoid cysts, teratoma, and cranioferringioma. In this situation, it was more likely that this was a pituitary adenoma, but any of those are possible until we see pathology. The differential for that skull-based mass, first and foremost, would be meningioma. It could be cranioferringioma, astrocytoma cordoma, chondrosarc, or a giant cell osteosarcoma, or any of these other tumors, but they are less likely due to the review of the imaging. So after surgery, he had a resolution in his visual symptoms, but as he was managed with postoperative chemotherapy, he had worsening of his Cushing's disease. And then in June of 2018, he was seen to have a recurrence of his pituitary macrodenoma in the cavernous sinus. This was treated with radiotherapy. And then in 2018, he had a bilateral adrenalectomy for his Cushing's disease. And then in 2020, he had a new onset of episodic diplopia with MRI that demonstrated his progression. He was treated by radiation oncology with radiotherapy, his second round, and he had no improvement in his visual symptoms. It was only at this point that he was sent to neuroophthalmology for evaluation. Here you can see his Humphrey visual field testing. The top line is prior to surgery. The middle line is just after surgery and the bottom line is most recently. And you can see that he's had resolution of his previous visual deficit there in his right eye. On examination when he presented into the clinic in November, you could see that he had reason for his diplopia with his alternate cover testing. He had exotropia and an isotropia. And then with his Maddox rod testing, you can see that he was having difficulty with aligning his eyes correctly in various positions. His color plate testing though was entirely intact. And then his visual acuity as well was excellent. This is a video of the examination. So in the interest of time, we'll move on, but the differential diagnosis for his presentation included an ocular neuromyotonia, convergent spasm, ocular myestinia gravis, superior oblique myocymia, or a decompensated heterotropia. In the end, it was concluded that he had ocular neuromyotonia. Ocular neuromyotonia is very rare, but it's an involuntary episodic contraction of the muscles supplied by the ocular motor nerve. It's due to nerve hyper excitability resulting in a persistent contraction of one or more of these extraocular muscles controlling their vision. It has been noted to be associated with certain neoplasms such as thymomas, small cell lung cancer and Hodgkin lymphoma. And it's also been noted to be associated with neurovascular compression syndrome. The primary muscles implicated are distributed pretty equally between the vertical and horizontal muscles as noted there. And the episodes have been noted to occur but every 10 to 40 minutes and last seconds to minutes, which you can imagine would be very disturbing to your quality of life and your function. The studies that I read reported that radiation is the most common cause of ocular neuromyotonia. And ocular neuromyotonia is a distinct entity from neuromyotonia because neuromyotonia is a peripheral process involving peripheral nerves, most commonly a perineoplastic syndrome and associated with antibodies. The treatment for ocular neuromyotonia resides in stabilizing the membranes and it is typically carbamazepine, phenytoin, gabapentin or diazepam. And it was about 70% of people reported improvement in their symptoms, though it was not common to have complete resolution. It is also possible that if this is consistent and persists through medical therapy that a binocular fusion surgery or microvascular decompression are potential surgical options to be considered. So that is all that I have. Any questions? Thank you, Spencer, for your presentation. We have some excellent presentations today regarding the humanity side of medicine as well as two excellent neurothemology cases. We have time for maybe one or two questions if there's any or any comments that you might have. Dr. Warner has her hand up. Hi, so it was a great case. I think that it was quite a long video which showed that over time, the spasm of the muscle resolved. And I think it was, it's a rare disorder, quite unusual but absolutely characteristic when it occurs. I don't believe it's associated in a perineoplastic with any of the systemic disorders like lymphoma, et cetera, but very much related to tumors in the cavernous sinus radiation. And it has been also described with thyroid eye disease, although that's really unusual. The nice thing about it is it's extremely responsive to treatment. One of the puzzles in this case was when Spencer and Irina were in there trying to do the measurements, things were fluctuating wildly. And when you have that kind of fluctuation in your measurements, I think we all start thinking myosinia, but in this case, not so much. Just a really great case and video. And I hope that Spencer will put that on our core. It'd be great to have that for everybody to be able to see. Yeah, I'd be happy to. And then Ali, terrific job with your presentation. I think we actually had an eight-year-old boy with his second or third attack of a family-plegic migraine, formerly known as about a year ago. Maybe not even that long, that's quite a run. But I think that some people believe that steroids help the pain resolve, but I think that most people believe that it doesn't help the family-plegia itself resolve. I have a patient who's swore by shark fin cartilage or something crazy like that. But the term migraine came about just because of the generally painful nature of this disorder. And it is a migranous kind of headache in many instances, but I think Tom Carlo, who's a neuro-ophthalmologist, gave a terrific, one of those named lectures at AAO about reclassifying it, basically not calling it a family-plegic migraine anymore because so little of it was really characteristic. And then once MRI came along and started to show those enhancing lesions, that really put the final hung the crepe on that as a title. But it's so much more mellifluous and easy to remember. Thank you, Dr. Warner, for those clinical pearls. And I like the word mellifluous. Dr. Jardine, do you have a comment? I saw your comment in the chat box. I can read it out loud as well. I think we can unmute you too. But I'll just read it quickly since you have a minute left. For Ali's patient, I am monitoring the strabismus and amblyopia and the strabismus cranial nerve three motility deficits are unfortunately not improving as much this time around as predicted. Contributing to her amblyopia, she will likely need strabismus surgery. Thank you everyone for attending this Moran Eye Center Grand Rounds. We will see you next time. We'll end a minute early here. Thank you. Thank you. Thank you, everyone. Excellent job, Abigail. That was well done. Thanks, everyone.