Let's do this. Good morning, everybody. Just wanted to get things started here. My name's Brandon Kennedy. I'm a P.J.Y.3 here. I'll be moderating today for a couple of great cases. First up, we have Dr. Nana Makari presenting Representation and Ophthalmology. Fun fact about Nana Makari is he's been exposed to a concerning amount of new foods here in Utah and he's now considered to have a distinguished palate. I once heard a rumor that the first time he had pancakes was here on a camping trip with Dr. Petty. I don't know if that's true, but possibly so. All right, here you go, Nana. All righty, good morning, everyone. Thank you for the fantastic introduction, Brandon. So today I'll be talking to you guys about retreat I went to about a month ago called Pillar, which was about Representation and Ophthalmology, specifically academic ophthalmology. That didn't work. Can you use the mouse? So this is just a picture from the conference. It was hosted at Byers Eye Institute, Stanford. This is Mubarak and I took as many pictures as possible with Mubarak, he's incredibly photogenic. Here's some additional photos and a photo with Dr. Singh, one of the glaucoma attendings at Stanford, who's there. So Pillar stands for Program and Lasting Leadership in Academic Representation. And why is this important? So there was a paper published by a group called, headed by Miller and Katz, who are, they had a consulting company that deals with Fortune 500 companies, work with companies globally to elevate the quality of interactions, leverage people's differences and really transform workplaces to make it more conclusive in really an environment where you can prosper. And so these were several quotes that were from employees from these organizations, includes the following. Inclusion challenges our thinking, brings in fresh perspectives, raises the bar for our practices and strength as a gene pool. Inclusion fosters engagement and engagement itself increases efficiency. Our decision making is enhanced when people feel included. And so I just wanted to quickly glance at the demographics of the US population. This is from 2018 by race and ethnicity. So about 60% white, 18% Hispanic slash Latino, 13% black, 6% Asian, about 2% identified as multicultural or multiracial. 1% American Indian and about half a percent or less than half a percent native Hawaiian. And then in the child population represented by the bar below, it just shows that there's more diversity amongst that total population. And this is the profile published by the SF match last year from the years 2017-2022 showing residency demographics. And I wanted to draw your attention specifically to the years prior to 2021, whereby black and African Americans were represented one to 3% of the time, about 5% identified as multiracial, 7% Hispanic slash Latino. Many declined to state what they represented as and around 25% Asian and then the rest 45 to 55% white. Then there's a similar representation amongst fellowship demographics as well. So there's a study by Dr. Hanoff Valentine that looked at how the NIH could take a scientific approach to inclusive environments in general. So specifically they analyzed biological and biomedical sciences and medicine amongst medical schools in the year 2017 to 2018. I wanted to draw your attention to the light yellow light blue graph parts of the graph that show underrepresented women and men respectively. And you can see as you advance from associate's degree kind of work your way up all the way up to department chair representation declines. And so one of the first thoughts that I think I have and perhaps many people have is implicit bias at work. And so a group at Stanford, Dr. Pershing Stell and Dr. Caroline Fisher kind of analyze this amongst residency applicants. They redacted name, sex, gender to see if bias was involved in there in the way in which they recruit applicants. And the result of their quality improvement study showed that that was not the case. And so that brings me to one of the questions of, this is a quote by Dr. Caroline Fisher during the pillar conference that really stuck with me. It was, it's one thing to ask for help and another to have the language to ask for it. And oftentimes as physicians we're kind of challenged to really answer questions that patients have before they even know they have it. And it's not to say that a certain group needs help more than another, but perhaps there are many ways in which we need to deeply analyze representation in the way in which we can best represent our patients to provide the best care possible. And so pillar was hosted by the Byers Eye Institute at Stanford, Rad Venable Excellence in Ophthalmology Program and the National Medical Association of Ophthalmology. It targeted underrepresented minorities in medicine, specifically with preference to PGY-2s amongst ophthalmology residents. And once again, it took place last month, September 24th and 25th. The National Medical Association was founded in 1895. It's the largest and oldest organization representing African American physicians and healthcare professionals in the United States. It focuses on health issues related to minorities disadvantaged and medically underserved populations. It's one of the leading voices for parity and disparity amongst, or parities in health and justice medicine and with the goals of elimination disparities in health. The Rad Venable Excellence in Ophthalmology Program was named for Dr. Maurice Rad, Drs. Maurice Rad and Dr. Howard P. Venable, both of whom were nationally recognized amongst their respective fields but also for what they did in terms of how they helped the next man forward. They both combated the inequities of their time by selling as a, almost as a form of protest. The Rad Venable Excellence in Ophthalmology Program was founded in 2000 as a research competition in Washington, D.C. by 2007, gained national recognition by the NEI and NIH. And then as a result of COVID, kind of had a migration to a more virtual format. That helped third and fourth year medical students who were interested in ophthalmology kind of provide an opportunity for career development, mentorship, navigating the application process. And this was just a random photo from the Pillar Conference last month. And then I wanted to draw your attention to the article listed below. This was analyzing the contributions of Rad Venable over the years, specifically with attention to the year 2020 to 2021 and how Rad Venable has contributed to some of the changes that we've experienced in the demographics of ophthalmology. And so I wanted to take another look at this graph here again, a little bit closer of a look here. I have no comments for this, but you've been closer than that. From the year 2020 to 2021, black, and people who identify as black and African-American, there was a substantial increase from 1.3 to 5.4%, which is about a 300% increase. And that was sustained for increase even further to 7% in the subsequent year. Upnoted, Hispanic and Latino represented by the dark green did decline during that period from 7.4 to 5% and then back up to 8%. And so the Rad Venable program saw this as a resounding success. So that was a really pivotal year in the way in which they combated how they can help students of color really get into ophthalmology and succeed in it. And so this was a group of us at the pillar or retreat last month. And really, this was a lot of our first times meeting each other in person. We've been through so many conferences together, so many virtual formats, and it was really, really awesome to be able to see one another in person and really share our unique experiences together again. And I just wanted to draw some attention to George from the class of 2021. And then of course, my co-resident, Mubarak, who's also part of the Rad Venable organization. And so Pillar had several different main components, many of which are listed here, but it's not an exhaustive list. The year was the career paths in ophthalmology. There was talking about grants and research funding, fellowships, navigating academic careers, inclusion and diversity, sharing their shared experiences, mentorship and then work-life integration. It was formatted in a way that it had seven different big sessions. There was presentations on each specific topic followed by Q and A and then four 20 minute table sessions afterwards. One of these sessions was career paths in academic ophthalmology, whereby Dr. Amar Ross from UPAN discussed laboratory research as a career path in ophthalmology. Specifically, she shared her joys of lab research, ways in which you can find support, mentorship and institution and really choosing an institution to best promote that path if that's something you're interested in. Then Dr. Nicholas Volpe from Chicago kind of showed a different, I guess a contrasting career path whereby he highlighted a master clinician as a career path that one can pursue and it's important role in academic departments. And then Dr. Roretta from Wilmer discussed residency PD as a career path in ophthalmology and how she has the opportunity to have significant impacts on the lives of others and really a career of mentorship. She discussed scholarship and the creation of knowledge amongst so many as well as the various ways you can take paths to that ultimate goal. Dr. Paul Lee from Michigan discussed negotiating and accepting the first job, what one should prioritize like family and benefits with regards to contractual negotiations. He also discussed sources of assistance, choosing a lawyer, things I didn't even think about with regards to navigating that process. Dr. Dolly Chang discussed industry and academia and how there's kind of hybrid fellowships that exist out there and ongoing collaboration between industry and academia. And then Dr. Mildred Olivier discussed DEI leadership as a career path, specifically Rabbi Venable where she serves as the president and local department school leadership opportunities, importance of representation, increasing recognition for career advancement and promotions. And so along those lines, I thought deeply about diversity, equity, inclusion and ways in which we can really tackle that. Dr. Olivier brought up this paper, Passing the Leaks, Revitalizing and Reimagining the STEM Pipeline. And in summary, it's about early exposure, early and often exposure. So there's exposures to research, exposures to internships, work experiences, et cetera, et cetera. And then that got me thinking a lot about my own personal journey. From when I was 13, I've had the opportunity to be a part of various different pipeline experiences. I think specifically to my very first one, it was called the White Foundation. It's a program for individuals in Newark, New Jersey who specifically underrepresented individuals in Newark, New Jersey, who there's a ton of research supporting the fact that there are plenty of people qualified but didn't necessarily get the, I guess opportunity to obtain college scholarships. And this program started really, really young. I actually had us going to class after school, every Wednesday and Friday and then on Saturdays as well. So it was exhausting, it was exhausting and really, really rewarding because it ultimately provided a pathway for us to obtain scholarships to boarding schools at the time and then actually assisted us with college as well. So it was a really transformative experience for me and so many of my peers who were fortunate enough to be a part of this program with me and I listed some other programs that have helped me along the way as well. And that brings me to some of my most rewarding experiences, kind of things I've been a part of or founded that have similarly looked at goals of influencing others along the way. And of course, I'd be remiss if I didn't discuss possible challenges that exist when you're kind of thrusting these environments whereby maybe not everyone looks like you or comes from environments with which you came from. Some of the challenges of that include, you know, like you have to be more than competent to do the job, you know, like you have to be able to fit into the organization and its culture, willingness to accept the spotlight and being the only one of your kind, able to represent an entire identity group sometimes on your own, capable of disproving colleagues preconceptions about members of your identity group, able to deal with constant questioning as to whether the job was obtained as a result of your merits or your differences, serving on committees, task forces, public appearances related to your identity, none of which is necessarily your job responsibility or considered in your performance appraisal. And then of course assisting as needed with recruiting and outreach. And this is also listed in the article I previously mentioned from Miller and Katz. And so what can we do? In addition to the just generalized support that we do a great job of here, there's a variety of different programs that we can kind of expose students underrepresented in medicine too, if they have an interest specifically with ophthalmology. That includes the aforementioned RAV-Venable program, but also the Minority in Ophthalmology Mentorship Program, which is a similar program that helps students become ophthalmology applicants and competitive ones at that. It's headed by the AO, provides a similar one-on-one mentorship, another opportunity for networking and educational resources as well. And then more recently, I've been exposed to a group called the Black Physicians of Utah, which is really, really fascinating because they target high school and as early as middle school students in the Utah area, get them exposure to medicine in general. I know the other day they helped introduce how to put in IVs and they're asking for some medical health and honestly, I wasn't very much help at all, but I thought it was really cool to at least show these individuals, get them some type of exposure to that health pathway. And for me, the most rewarding aspect is both the exposure that we can assist with, but also the sense of community that exists here because being underrepresented in medicine is kind of a US issue, but also more prominent in the state of Utah as well. It's one of my good friends and longtime mentors from high school, Dr. Mike Quiss. He's an ophthalmologist at Cleveland Clinic now. He was at the Polar Conference and he stayed this quote that has really, really stuck with me and I think it's just a fantastic quote. It's actually originally from his father, but kind of passed along the way. And he said that when life gives you the opportunity to take the stairs out, make sure you send the elevator back down. And it's something I personally wanna continue to live by and promote the rest of my life, but also I'm hoping to inspire others to do so as well. So I wanted to give a quick thank you to the Buyer's Eye Institute for hosting as well as the RAP Venable and NMA program. To Dr. Petty for letting us, me and Mubarak know of this retreat. And then my colleagues at Iowa, Dr. Sy Lewis and Arnaful Garza who helped me with the collaboration of this presentation. And then here are some pictures from our own mini retreat about a month ago as well. We went camping at Buckeye Lake and it was an awesome experience. And in addition to my distinguished palette, I now have a distinguished sense of sight. We used binoculars, it was really fun and really cool. Unique experience for me and super rewarding. So I now will take any questions, comments, ideas, happy to entertain. Thank you so much for your attention. I think when people are first coming and looking at the underrepresentation of medicine, it just looks like a pipeline problem entirely, right? Although what could we do if there's just not enough medical students in the pipeline? And while those are essential and fundamental, over time you start to see the challenges of the graph you showed with the trends in biology, right? So as you've come in much more diverse and by the time you're getting down to full professor, it's really push those underrepresented groups to a significant minority in the group. And so that's the part that to me seems less just simple, right? It's like, okay, we can put more effort in the pipeline. But this kind of systemic structural challenge, how would you assess this? I mean, how much of this is mentorship? How much is this culture? You were to advise a department, a school, what would you recommend to address this particular issue of attrition? Yeah, thank you for the question. So I think I'm clear in my experience first and foremost with that. There were so many things I was just really oblivious to before that retreat in general. So Dr. Roretta talked about the path of GD, for instance, had no idea what was the typical, same with associate deans at the typical pathway to that or a whole variety of different mechanisms to do that. Really it's both explaining that course but also promoting excellence. So it's one thing to kind of rush people into positions they're not ready for. It's another thing to prepare them for it. And so I really think it does start really with pipeline and getting more and more people interested in medicine in general first and foremost, and then eventually ophthalmology as well. But we really have to make sure that the people who do come through, become the best they can be. And that's the only way that this would be a sustainable habit between if we were to, both of these people, it's a variety of different positions. It really needs to excel. I look back at, from, like you used to do some of the, Dr. Roretta, and so many other different people. And you really have to excel in positions to inspire people that want to continue that and put those people forward in the future. Thank you. Thank you. Question. So I just had a couple of thoughts and I was curious to hear your perspective about a lot of the programs that you were involved in early on. I'm familiar with a couple and I know it's still an application process that is overall somewhat competitive. And amongst the under-representative students are still unequal distribution, like allocated resources. So how do you think we can better tackle the individuals who aren't even aware of these programs early on or those who do apply and don't get into these pipeline programs maybe because they don't have similar backgrounds or access to resources as others that are considered under-representative? Yeah, and that's another fantastic question. So a lot of people in RAV Venable did not obtain this admission to the Minority Alphamology Mentorship Program, like the AEO. They just had such a limited supply of resources. They couldn't accept everyone into that program. And then there's another half of people who just never heard of it. Despite having interested alphamology for four years of medical school for a longer. The resource thing is a top endeavor. I guess we can obviously put more resources into it, but I don't know, I couldn't tell you from that standpoint of what we really can afford and can't afford. But in terms of the exposure, I think it's almost a shame if someone was in medical school and from an underserved background and didn't hear about it. Because it's such a nationally recognized, a lot of these programs were very nationally recognized. So someone just needs to show that care to really bring it to their attention. But then also it's, you don't have to necessarily tell them these programs just invoke curiosity. So there's, in my opinion, there's minimal excuse to not know what things are out there if you're interested enough for it. And sometimes it's just asking them how bad they want or putting forward the question of what have they done to seek or obtain that goal that they're assigned for. Because there are many ways that we live in the world of Google whereby a lot of these things will pop up. So we just have to be curious enough to find them. Thank you. Yeah, thank you. Not just one more question, comment, talking about systemic structural issues related to this. I remember applying to medical school and if you didn't have a certain amount of volunteer hours, you wouldn't even get an interview at certain medical schools. And in hindsight, we are trying to move more toward what's called holistic review and look at this thing called distance travel. And seeing someone who worked full time as a waiter or waitress through all four years of undergrad, my goodness, like what is showing more grid and commitment than that, even if they didn't have the financial freedom to volunteer or research is the same way research volunteers positions are largely volunteer. And that, you know, this doesn't necessarily directly correlate with race, but you know those with resources and ability to volunteer for a summer and not worry about, you know, making ends meet. Again, that structurally just keeps this pipeline of privilege into medicine. It's something that we need to acknowledge as well in the process. I think very much related to that is the application process itself doesn't allow you to highlight something like that. So if you look at some of the application, they'll be, you know, like previous career experience, one bar and a waiter. There's really nowhere else for them to highlight, like unless they choose to talk about in their personal statement. So I think structurally it's recognizing that that's an issue, but then also changing the rubric by which you're evaluating people in a much, you're thinking much more outside of the box and allowing people to highlight that as a part of the standardized application instead of recognizing that we as reviewers need to, you know, need to dig for it, it should be able to be much more, you know, I think it should be able to highlight it much easier. And I think that's interesting, one, because it's a college application that you would have not to list how many hours you put in or are dedicated to a certain activity or work. So I do think it would be more ideal to be able to expose just how burdensome a certain job might have been for you or how passionate you are about certain activities with the hours you put in. One of the things that I think speaks to what Brand was talking about was the outreach in middle school and elementary school. And that's a lot of the middle school students being introduced to STEM and coming up to the university. If it isn't even an idea, then you won't go looking, Googling for how do I be a doctor? If it doesn't even cross your consciousness, that could be possible. It relies so much on your teachers, your counselors, saying, hey, you know, there's this career you could do because I think that people are aware of the things that are around them. Yeah, I think that's one of the more important points, too, as well, I think about where I came from and how really medicine was not in the courage pathway just because no one around us were really in that. And I was fortunate enough to have a carriage to pursue it during my own pursuit as well. But there are so many individuals who are kind of pushed towards other things as a result of the lack of role models to really think about medicine or STEM in general. So it really is something that we have to be more dedicated for attacking early. And I see so many, even the paper I showed, it started at the undergraduate level. It really starts far earlier than that. I think at the undergraduate level, it's almost too late to make a significant impact because especially nowadays with the minerals, we have to have such a robust application. Some of you were working experiences, volunteering, opportunities like that, that you talked about, and it starts early. And you have to do a better job at attacking them. Thank you, Mr. President. Thank you very much. You're a great presentation and really a topic that I think we can agree on that we had all discussed for over 30 minutes. So we have Dr. Ashley Polsky. She comes to us from the great, great, great state of Michigan.  And a fun fact about Dr. Polsky is she wants to do a Seabird Ecology Research on a Protected Island in Puget, us, Phil and Sarah, near Seattle, for summers and college shows. Now she knows an unusual amount of seals. So welcome back. I have a pigeon at the sea. Hi, good morning, everyone. I'm Ashley, and we need you to answer the question. As many of you know, part of our responsibilities as an intern in this program is to run the Ophthalmology Walk-In Clinic at the VA Hospital. And the case that I'll be presenting today is actually one of the first patients that I saw in that intern clinic last year. So I'm really excited to share it with you. There we go. I have no conflicts of interest to disclose. And this case begins with a 74-year-old man who presented to our VA Walk-In Clinic with painless generalized blurry vision that developed in his left eye about five hours earlier. He denied any flashes or floaters in his vision and he had no recent history of eye trauma, prior eye surgery or any history of anticoagulant use. His past medical history included hypertension, which was reportedly well-controlled on amlodipine and his ocular history was significant for a branch retinal vein occlusion of the left eye that occurred in 2013 and was complicated by neovascularization of the iris and retina. He did undergo intravitral Avastin injections for that in 2013, as well as PRP treatment in 2015 and 2017. He briefly followed with our VA glaucoma service for neovascular glaucoma, but this had remained quiescent since 2017. For his ocular medications, he was using Bremonidine drops daily in his left eye. He had no relevant family or social history and specifically he had no personal or family history of bleeding disorders. His visual acuity on initial presentation was 2025-2 in the right eye and 2020 in the left eye. He had full color vision, normal pupillary responses and full extraocular motility and visual fields to confrontation. His intraocular pressure was 14 in the right eye and slightly elevated at 22 in the left eye. His anterior segment examination of the right eye was within normal limits, aside from an age-related cataract and his left eye demonstrated diffuse conjunctival injection. And before I kind of further discuss his slit lamp examination, I'd like to show you a few examples of what we saw in clinic. So this is what I saw on my very initial external examination of the left eye. You can imagine that my heart started racing a little bit when I saw this as a brand new ophthalmology intern. I think I called Brandon like two seconds after seeing this. And then this video hopefully will play here. This is what we saw on slit lamp exam. Yeah, very cool video. Thank you to Brandon for taking this. Okay, so that was what we saw on slit lamp exam. So as you can see in that video, this patient had a four millimeter layering hyphaema inferiorly in the left eye that was being fed by this continuous philiform hemorrhage originating from what appeared to be a small vascular tuft at around one o'clock on the pupillary margin. There was no observable neovascularization of the anterior surface of the iris. However, we did see very subtle vessels suggestive of NBA temporally in the ear to corneal angle on gonoscopy. Dilated examination was unremarkable in the right eye and in the left eye demonstrated findings consistent with this patient's prior known BRVO including some superior shunt vessels and a sclerotic vessel that was branching from the superior arcade. There was no neovascularization of the disc or the retina and he had stable dense PRP scars superiorly consistent with his prior laser treatments. We did obtain a blood pressure measurement while the patient was in our clinic as well and that measured 141 over 83. So this list represents some of the major differential diagnoses that we were considering for the etiology of this patient's hyphaema. Some sort of iris vascular lesion was really at the top of our list given that the bleed appeared to be originating from a tuft-like structure at the pupillary margin. Iris neovascularization was also a very important consideration given this patient's prior history of a BRVO and previous need for anti-vegeta therapy. However, he did not have obvious NVI and the NVA that we saw on gonoscopy was not actively bleeding. Traumatic hyphaema and UG syndrome seemed less likely in this case given his lack of previous eye trauma or any prior surgeries. And systemically he had no history of constitutional symptoms or easy bleeding or bruising to suggest a systemic coagulopathy. So at this point in our workup a bleeding iris vascular tuft was our leading diagnosis. Throughout our slit lamp and dilated exam the iris continued to bleed just like what you saw in that video. So our primary goal at this point was to stop this bleeding and hopefully prevent any adverse sequelae such as corneal blood staining or prolonged increases in this patient's intraocular pressure. Given our concern for possible subtle NVA on gonoscopy and given this patient's previous success with anti-vegeta therapy we did decide to proceed with in a bastion injection in his left eye. We monitored this patient's intraocular pressure very closely after this injection and measured a pressure of 48 immediately after the procedure followed by a pressure of 35, about 10 minutes later. We had hoped that this pressure elevation that occurred as a result of the intravitral injection would have a tamponade like effect to promote hemostasis of that iris bleed. Unfortunately on re-evaluation of the slit lamp that hemorrhage continued to really steadily flow into the anterior chamber. So our next course of action was to pressure patch the eye. And as illustrated in these photographs here we developed a pressure patch by placing two iPads over his closed left eye and applying tape really firmly over the patches to hold them in place. We kept that pressure patch on for 30 minutes and when the patch was removed the active hemorrhage had completely resolved. After achieving hemostasis we discussed standard hyphema precautions with the patient and sent him home on pred forte, atropine and cosop drops in the left eye. The patient returned to clinic the following day and was found to have a visual acuity of 20, 30 minus one in the left eye with an intraocular pressure of 10. And as you can see here that inferior layering hyphema had decreased in height to about one millimeter. And that arrow there is pointing to a quiescent vascular tuft that was noted at the location of the previous hemorrhage on the pupillary margin. It's a little tough to see I think but it's kind of a whitish tuft-like structure there. We followed this patient really closely over the following weeks and by week three his hyphema had completely resolved. His intraocular pressure remained normal on cosopt and he had no recurrent episodes of bleeding. So we were able to discontinue his atropine and taper off the prednisolone. At one month after his initial presentation we were able to obtain an iris fluorescein angiogram here at the Moran Eye Center. And interestingly we saw irregular hyper fluorescence and staining bilaterally at the pupillary margins consistent with the presence of bilateral iris vascular tufts. And there in the close up of the left eye where the arrow is pointing you can see the culprit of this patient's previous hemorrhage with that little tuft-like structure there. As of two weeks ago this patient has had no recurrence of an iris vascular tuft bleed or hyphema. He was able to actually successfully undergo cataract surgery in both eyes last month with Dr. Swiston, Dr. Petty and Dr. Laura Shell and he is now seeing 2020 in both eyes. So for the rest of this talk I'd like to just further discuss iris vascular tufts as well as some of the various approaches to their management. Iris vascular tufts also known as cob tufts or iris microhemigieomatosis are relatively rare benign vascular lesions that form along the pupillary border just like we saw in our patient. These small tufts can range anywhere from 15 to 150 microns in size and they account for less than 5% of all iris vascular tumors. They're typically found in elderly patients and they have no known sex or racial predisposition. Interestingly for largely unknown reasons they are found at an increased frequency in patients with myotonic dystrophy and diabetes. And in terms of clinical presentation typically patients with iris vascular tufts are actually completely asymptomatic. And so I think it's very possible that these go unrecognized a majority of the time. Often the initial presenting symptom is a sudden onset of blurry vision due to the development of a high fever similar to what we saw in our patient. And this bleeding often occurs in the absence of any preceding ocular trauma or systemic vasculopathic conditions. Iris vascular tufts are generally considered an idiopathic acquired vascular anomaly. In our patient the fact that he had bilateral iris vascular tufts really suggests against any sort of causal relationship between his previous BRVO and his iris vascular tuft development. However, interestingly some papers have suggested that the ischemic and hemodynamic changes promoted by vascular occlusions might actually contribute to alterations in vascular tufts structure making them more prone to spontaneous bleeding. So one question that we had regarding our patient was whether his prior BRVO may have somehow contributed to a heightened bleeding risk in that eye through maybe up regulation of VEGF or through some other mechanism that led to increased vascular permeability. And that was partly why we had a low threshold to treat him with intravitral avastin on that day. The diagnosis of iris vascular tufts is primarily made by slit lamp examination along with fluorescing angiography of the iris. And as you can see in these photos here the classic appearance of vascular tufts on an iris FA is rapid hyper fluorescence along the pupillary margin along with often late staining or leakage at the margin there. And in these patients it's actually common for iris FA to identify multiple additional small vascular tufts that were not readily visible on slit lamp exam alone. The Shields group at Wills Eye Institute also suggested anterior segment optical coherence tomography and geography or OCTA as a potential imaging modality to further characterize these tufts. On OCTA the appearance of iris microhenangiomatosis consists of non dilated normal appearing iris vessels that then coalesce into these tightly coiled vascular tufts at the pupillary margin. When they used cross sectional anterior segment OCT with an angio overlay which is pictured at the bottom of this figure they were able to localize these vascular tufts to the posterior iris stroma rather than superficially on the iris where neobascularization typically occurs. Additionally studies of OCTA and iris vascular lesions are somewhat limited. And so at the moment anterior segment FA really remains the supplemental imaging modality of choice for iris vascular tufts. Most commonly iris vascular tufts can be observed without any additional intervention. Topical steroids and atropine with or without IOP lowering drops can be initiated in the event of a high FEMA. And for more definitive management argon laser photo coagulation has been described for the treatment of iris vascular tufts. In this approach the laser is directed often both at the tuft itself as well as the feeder vessel leading to that tuft in order to either stop or prevent active bleeding. And I've just listed here some of the laser settings that have been reported in previous studies that used argon laser to treat actively bleeding iris vascular tufts. This table is from a 2010 literature review of laser photo coagulation for iris vascular tufts. Of the eight cases included here five patients were treated with laser photo coagulation either for an active iris vascular tufts bleed or for a history of recurrent high FEMA. Two patients with a history of recurrent high FEMA were actually treated prophylactically prior to cataract surgery in order to reduce the risk of intraoperative bleeding. And one patient required repeated treatment with argon laser due to recurrent bleeding. But as you can see in the outcome column to the right, the majority of patients had no additional bleeding episodes within their follow-up period. Here's an example of a case from 2013 in which a patient had active bleeding from an iris vascular tuft that was treated with argon laser photo coagulation. This particular iris was treated with just a single spot of argon laser at the pupillary margin. And hemostasis was successfully achieved immediately afterwards. Due to the rarity of iris vascular tufts, there is somewhat sparse literature regarding its treatment, particularly as it relates to actively bleeding tufts. And while argon laser has been shown to successfully arrest active hemorrhage just like what we saw on the previous slide, it does entail its own set of risks, including damage to the iris or other ocular structures, further exacerbating anterior chamber bleeding or causing corneal endothelial decompensation. So because of these potential risks, argon laser is typically reserved for patients who have had recurrent hemorrhage from vascular tufts or as a prophylactic measure to prevent bleeding during intraocular surgery like we saw with that previous literature review. Additionally, a really good point that Brandon discussed when this case initially came in is that timely access to an argon laser may be really difficult, especially in settings with limited resources. So what other options might we consider when faced with an actively bleeding iris vascular tuft? And based on our case, we would suggest that a pressure patch is a very accessible minimally invasive first line approach to stop active bleeding of an iris vascular tuft. This approach does require an extended period of observation in the clinic. Like I said, we were patching this patient for 30 minutes and also monitoring him really closely before and afterwards. But the benefit is that it can be performed in a variety of settings, including in really low resource areas without significant risk of damage to intraocular structures. If active bleeding continues despite pressure patching, then additional more invasive modalities such as argon lasers should be considered. And although there's limited literature regarding the benefit of anti-vegeta therapy for iris vascular tufts, intravitral abastin, for example, is another reasonable consideration, particularly in the rare setting of iris vascular tufts and vascular occlusion as we saw in our patient. So in conclusion, iris vascular tufts are a rare but known cause of spontaneous hyphema, particularly in elderly patients. Pressure patching is a safe and very accessible option to successfully achieve hemostasis in the setting of an active tuft bleed. And for the rare scenario of a recurrent or persistent iris vascular tuft bleed, additional modalities such as argon laser treatment can be pursued for more definitive management. I'd like to, again, thank Brandon Kennedy who saw this patient with me at the VA back when he was a PGY2 resident. As you can see here, I repaid him with a free refraction. And also many thanks to Dr. Bear and Dr. Simpson for providing really valuable clinical guidance in managing this case. And we actually recently submitted this case for publication as a case report along with that really cool video. And it's currently undergoing peer review. Here's a list of my references. And I'm happy to take any questions at this time. With the patching, obviously the key thing that we're trying to do with pressure patches raise the pressure high enough to have a lot of bleeding. Where you have a combination where you've already got an active pre-pneum. And you've already got pressures that could be elevated. And then a pressure patch all at the same time just gotta be careful that you could actually raise the pressure above the arterial pressure. And we can do that short term. I mean, that's what's one of the stoppin meetings that plays about 30 minutes could be a problem. And a way that you could do the same thing that I know can be quite effective is that you can sit there and you can actually just kind of put your finger on the eye and you can push it and you push hard enough and you'll watch it stop. You're probably at the arterial pressure at that point. And then hold it there for a couple of minutes and just gently lift off. And often it's in place but you're monitoring it and you're not doing it for a long period of time. So that's just, that's a very simple way. I know with Gonioscopy, they can do the same thing where they know there's bleeding by just by holding the pressure, but you're watching it. And it's not something where you're not sure what that pressure is for how long. Yeah, that's a really, really good point. And I shouldn't mention we tried kind of compression. Gonioscopy as well when we were looking at his AC. And I believe just that persisting. Just the finger up to the upper lip, you're watching it and you hold and you push, push, push. You'll get to a point where it'll stop. I'm sure that's arterial pressure. Yeah. Just give it enough time so that something can start, that little fiber can start to crack when you get that thing started. Yeah. And it would be interesting to see too, with more like limited trials of pressure patching for maybe 10 minutes or something could achieve the same effect as opposed to 30 minutes. But yeah, thank you. That's a really, really good point.


In this video, I'm going to expose three real estate training lies that you believe. What's up everybody, welcome back to another video. My name is Rikki Karuth. If this is your first time seeing me, I'm a 16 year full time real estate agent and for the past year I've been giving away all of my real estate secrets for free on YouTube. So click subscribe and hit the bell so you get notified every Tuesday and Thursday when I post new videos. Every week I'm bringing you the deep strategies of how I made a million dollars last year in GCI as a single agent in Alabama. If there's a certain subject or question that you have that you want me to make a video of, just post it in the comments below and I'll be glad to put it together for you. Today I'm going to cover some of the real estate training lies that most agents believe and the reason I wanted to do this video is because I literally want to reduce the failure rate in the real estate industry by spreading the message of real estate's truths. And just as a disclaimer, I want to say that everything in real estate works. All avenues work. It just depends on what works for you. And at the end of the day, it's all about relationships over transactions. So you have to find that special avenue of business that works for you to create and maintain the relationships that you need to grow your business. The first lie that most agents believe about real estate training is that the only way to get listings is to call for sell-bounders and expires and handle objections. This is not the only way to get listings. I focus my entire business around circle prospecting or farming, picking out a subdivision or complex and targeting those owners with direct mail and phone calls and approaching them in a low pressure approach and creating that lifelong relationship forever. You can get my entire circle prospecting game plan in the link below. The second lie that most real estate agents believe that I'm hearing a lot lately is that cold calling and direct mail is dead. This is something that I feel is absolutely not true. Now what I do think is dead is the high pressure cold call. I think that the high pressure cold call is dead. The low pressure cold call is still very much alive. I believe this. I believe that conversation is the key to all closings, period. There has to be a real conversation in place, further to be even a chance for a transaction. So I don't care where you get your leads from. If you get online leads for sell-bounders, expires, circle prospecting, door knocking, et cetera, et cetera, you're going to have to develop a list of these prospects and you're going to have to call them and follow up or cold call them to create and or maintain the relationship. There has to be the voice to voice at some point for there to be a chance of a transaction. And if you're not calling, then another agent is going to get that deal, someone who is calling. The only way to exponentially grow your business is over the phone. If you want to see exponential growth, make phone calls all day, every day and see what happens. Yeah, you're going to have some people hang up on you. Yeah, you're going to have some bad calls, but most of your calls are going to be great conversations that lead to all kinds of business. I'm going to do a video next week on overcoming your fear of cold calling. And as far as direct mail goes, I think this is something that is still very relevant and becoming more and more relevant as time goes on. As more agents start to pour money into digital marketing, it's leaving the door wide open for agents that want to do direct mail marketing. And especially if you handwrite the letter and handwrite the envelope. They are going to open it. That is a moment that you have their attention. What are you going to do with it? And the third lie about real estate training that most agents believe is that it matters what company you go with. Yes, brand does matter to a certain point. But really in real estate, the brand is more you than anything. I don't think it matters what company you go with in the beginning of your career. Everything is going to be a learning stage at that point. You need to go with a company who you feel like is going to teach you the most, get in there and get your feet wet. And then after a year or two of being in the business, now you can step back and take a breath of fresh air and decide who you want to go with. What brand do you want to line yourself with long term? At the end of the day, it's going to be about you, not necessarily your brand and how you interact and create and maintain those relationships. It doesn't matter where you work. It just matters how you work. So thanks for watching. I hope you got something out of this. And I really hope that I'm helping change your mindset and motivating you to be that number one agent in your area, that top producer that you want to be. If you guys haven't watched the video of me making 84 live cold calls, check that video out. And be sure to check out my free training in the description below. Click Subscribe and hit the bell and we'll talk to you soon.


In this video, we provide the solution to question number 13 for the practice exam number one for math 1060, in which case I'm just gonna read it real quick. To estimate the height of a tree, one person positions himself due south of the tree while another person stands due east of the tree. If the two people are the same distance from the tree and 35 feet from each other, what is the height of the tree if the angle of elevation from the ground at each person's position to the tree, top of the tree is 48 degrees? So there's a lot going on in this story problem. It can be very helpful to try to draw a picture to help us illustrate what's going on here. So think of about the following situation here. So we have these two axes and we're gonna draw a tree which I don't have the color brown available to me. So our tree is just gonna be yellow. That's the closest color I can get to a tree.  There's our tree, great. And so we have a person who walked south of the tree and someone who walked east of the tree. So if we say that this direction is south, therefore this would be north. And this one would, we'll call this one east and this one is west. We feel weird that north isn't at the top. Maybe I'm a dwarf, maybe I just, I just didn't think about it beforehand. It doesn't really matter. This is how our situation is set up. And so our people walked some distance from the tree. We don't know what that distance is, but we do know they went the same distance. So the person who went east and the person who went south, they went the same distance away from the tree. It turns out we don't actually need to know what that is. But what we do know is that the distance between the two people is 35 feet, that we know. And also we know that the angle, the angle of elevation to the top of the tree, that's gonna turn out to be 48 degrees, 48 degrees. I'm gonna draw that triangle right here as well, 48 degrees. And so again, we don't know the distance to the tree, let's call that D. Maybe it is something we wanna figure out at some point, but just, we're kinda drawing this picture right here to kinda get an idea of what do we know, what do we wanna know. So we definitely need to know the height of the tree. So if we were to draw some of these triangles separately, so one of the triangles we have is the follow and there's some distance D, it's a right triangle. There's some distance H, and we have this angle of elevation of 48 degrees. So if we just focus on that, so that's just this triangle right here. If we just focus on that triangle for a moment, just using the tangent ratio, we get H over D is equal to tangent of 48 degrees. Like so, solving for H, we're gonna get H is equal to D times tangent of 48 degrees. Okay, so if we knew the distance, the two people walked away from the tree, we could find the height of the tree. That's often how you do these measurements. But since we don't know the height, excuse me, since we don't know the distance they've walked away, that's the reason why there's two people, we know the distance between them, the 35 feet. How can we utilize that fact whatsoever? Well, it turns out that there is another right triangle right here in play, for which what we know about this is there's 35 feet right here, and we also know there's a distance D and D, like so. So we could solve this using the Pythagorean equation. We could solve for D, we're gonna get D squared plus D squared is equal to 35 squared. In other words, you get two D squared equals 35 squared. D squared is gonna equal 35 squared over two, take the square root, you get D equals 35 over the square root of two. So you could use the Pythagorean equation to do this, but another observation I wanna point out to you is that this triangle here is necessarily the Saucely's right triangle, how do I know that? Well, because this is D, this is D, the two legs are congruent to each other, so that makes it a Saucely's triangle, this has to be a 45 degree angle. And so we could use, we could in fact use the trigonometry of a 45, 45, 90 degree triangle. So in other words, the legs are just gonna be the hypotenuse divided by the square root of two. So D equals 35 over the square root of two. So if you had recognized it was the Saucely's triangle, you could have skipped some of the work necessary to get 35 over the square root of two, but nonetheless, it's gonna be the same answer no matter how you approach it. So putting this information into this equation right here, we're gonna get H equals 35 over the square root of two times the tangent of 48 degrees. Now, when it comes to these problems, you always need to give me an exact answer. Honestly, the approximations I don't really care about. This is the calculator portion of the test, but you'll see that there actually was nothing that required a calculator here. If you wanna do an approximation, that is appropriate, but for full credit, give me the exact answer. The approximation put into your calculator would be 27.486, it doesn't say how many decimal places to put it because it actually doesn't ask for it. So we'll just say that the tree is approximately 27 and a half feet tall.


I am Ulises Olvera Hernandez. I work for Interdigital Communication Europe. And today, we're going to come and show a mechanism that makes IP services both cost-effective and low-latency. This is exactly what we're going to demonstrate. We need to focus on those two nuggets that I gave, low-latency and cost-effective. This is what we're going to do. Right now, I'm going to trigger the deployment of the network. We'll go more into the details of what this network is with the PowerPoint presentation, which should be short. So please bear with me and let's do the deployment. And then we'll go right back into the presentation. Right now, 5G is all about meeting the requirements for KPIs. And if we take a look at the delivery of services that we have today, in some cases, these are pure end-to-end, meaning if you need to deliver a video to a single subscriber, and then you have millions of subscribers that will have to be multiplied accordingly. Of course, real delivery networks don't work necessarily one-to-one. We have content distribution networks, content delivery networks that attempt to mitigate this one-to-one delivery. But even in those cases, we have to configure those networks. We have to, if there are, for example, redirections of where this content is, and even if we have mobilized content delivery networks, they need to be configured for this to work. What we bring here is a possibility to rather than go to the content delivery network that is close to me according to the typology that could be handled based on these constraints, we're not going to the best possible access, which is the next hope. So that's the use of what we're trying to do here. So if we want to deliver content to some of these users, then it would be ideal that we can go directly into the immediate next hope rather than look for content in areas that could be far away from where the user is trying to access that content. So this is the leverage pitch that we have for you. So we're trying to come up with a system that looks like IP, smells like IP, but it works most better than IP. And if you put this into networks, then these networks will work much better than they do today. This is the problem that we're trying to tackle today. So we talk about these content delivery networks that we have today. They are difficult to configure. You can imagine trying to configure different DNS entries. And of course, when we're going to see the mobility, then that becomes even worse. So you end up with an overprovision network, and the cost for these networks is quite high. The solution. In our solution, we introduce an innovative multicast mechanism that takes advantage of ICN. However, what we're trying to bring here is of course not something that will require the operators or whoever deploys this to rip the network upon something new. So there is an important aspect. It has to be something that could be introduced using the technology that we're bringing, but it has to be backwards compatible. You cannot take devices to all of a sudden change just because you introduce new technology. By doing this, we reduce latency. And also, we improve the performance of the network using native multicast with the specific technology that we have. And the technology is based on a very simple idea where you exhort the link identities of those packets that are traversing. There's two aspects. One is the multicast game, and the other one is localizing the content. Now, for this demo, we're only going to show the first aspect, which is the multicast game. The localization of the demo that would be a topic for a different presentation. We're trying to play a video that is fed remotely. The video is fed remotely from Bristol in the UK. And in our lab in the UK, we also have 30 clients that are trying to download the same video that we're going to watch here. The idea here is that you have 30 clients plus us, 31 clients. And if you use current technology, you will have to send this video 31 times. With the technology that we have, we will send a single multicast that would be delivered to the access points where these clients have. So the network access point in Bristol will receive one single video. And we here will receive a different video. So you can see the video traversing. They're going to the remote place in Bristol and coming all the way here to Geneva. That's the first aspect that we're going to demonstrate today. And this is the topology of the network. The UIs that you see here, the use that we depict here are demonstrated with these UIs that we have here. We only have one. And we have the 30 emulated users that I talk about in Bristol. And in Bristol, we also have this HTTP living streaming video that is going to be played to all these 31 users. What you will see is the first aspect that we handle that we talk about, which is the multicast game. And that's what we're going to demonstrate today. So the second thing talks about, the second aspect would be the local delivery of this content. But as I said, this is not something that's going to be demonstrated today. The way this demo is going to work, I will trigger from the UI a request for a video download. And that request will have two purposes. Number one, to send an HTTP GET to get that video for the client that we have here. And at the same time, that will trigger the other 30 clients in Bristol to try to access that video as well. So what we see here, this is our dashboard where we record the demonstration that we're doing. So on the left-hand side, you can see a graph where we'll just show in time. And of course, we have exactly the time that we have here today. And it will show you how over time the multicast game that we have over a single transmission increases from zero to 3,000%. So let's now start watching the video here. So this should trigger the first HTTP request that you'll see here. Okay, now it's going up. So we can see the first HTTP right here. And how now it's going up to the maximum based on the amount of clients that are connecting to receiving the same amount of video. Of course, what the technology is doing is within a window, it realizes that an X amount of clients are requesting exactly the same content. And the technology knows that the delivery of this content within a window space can be sent to X amount of clients that are expecting that to be played. Of course, we know that within a certain size of that window, the video can be properly played. In this particular example, with the 30 clients that we have, we managed to send the very same video to these 31 clients with only one single multicast. Now, if we keep on playing this over time, you can see that, of course, some of these clients might drop, they might not want to see the video anymore, or there might be some network problems. And in that case, of course, you will see how the game drops. But at the very best, we have exactly the same performance that are, I mean, at the very worst, I would say, that when you go to zero, that would be the same performance that you would get if you were going to send this video with unicast links. You can see how some of the clients miss some of the chunks, but now they are going back to getting the video again. And as I said, this video has been sent from Bristol, delivered to the emulated users in Bristol, and delivered to us right here. This is the video that we're playing.


Staff is quite a horror show. It's also called the Death of SW Climb. We are here using this myself to learn a little bit about what the oldest parts of the rider, which unfortunately is low everything and everything is getting so topical. And that's SW Climb and SW Modified. So, what is SW Climb? Well, SW Climb is a bogey attack observer attack. This is how it's defined with behavior. So, you want to have some way to communicate changes and events. The three things that are usually coupled. One example on the rider probably. You have the day-all engine and the call engine, which is the old stuff. And then you have the human-engined phase on top of it. And you don't want to have that call and trying to go in the human parts. So, you create events in the call. And you have the human part. Listen and register the events at the object's call. And let the hand get events and handle the human-engined phase. So, that you have a good company. The beauty will be the call you don't have for, you know, so much for the theory. You promise? I've stopped counting. I just wait for this in the form of you. And you will find all of you more thoroughly. But in the end, they should be grateful to say that the SW Climb and SW Modified is not particularly needed. For example, the SBT does not broadcast on it. It can't be pretty much the same. It's actually lower in the stack. But I've just started applying it. I've just started modifying it. It can't be much better on it. So, you will find this comment. If you go for XKCD standards. And this is pretty much what happened. So, you draw this and it will try to add a new representation of this super stuff. So, how does SW Modified apply in the world? SW Modified is the stuff that you want to observe. It has events. The example that I gave you is to write a call or an error engine on the one side. That will be the stuff that is in the layer engine. And then you have something that wants to know if things change. For example, new objects. And what that happens if there is an event. You send a message or an event. And you let it be handled by the event. Which is called the functions called Modified or things. And the writer, in particular implementation, Yes, the event is two more items. And two main pointers to provide the implementation. And try it in a double context. So, one of them. This is problematic in many ways. It will show you why in a bit. And this is a motivation to actually move the notification. To observe some other implementation. You don't need to create yet another one. You have enough. And just move it to one of the existing ones. So, one thing that happens is that you have this object. It calls some other. You have to try into it. And notifies about the event. This event triggers the callback there to handle something. Which causes other events. Which again, for example, cause something to happen at the original object. And one of the things that can happen is that there are other objects created that listen to the same object. Which just fire an event. So, you fire an event on an object. Someone else listens to it. Reacts to it and forces another object to be added to the first one. Which is interesting because you're iterating over this list of event headers. And you don't know where the new object is added to sort of. You're notified to a group who will receive the same event that by which it was created. Or if it will not. By the handling of the event. It will remove themselves from this thing to modify it while in the event header. The modifier is a double-edged list. It needs to be aware of that. Because otherwise, it just will have a pointer to the object that it's going to be executed in the event header. So, you can go on the double-edged list. This forces the SW modifier to have a list of all the iterators that are currently iterating over it. And then updating them. For example, one listener to remove sort of one client. So, you see it's already getting very complex objects checking each other. So, you can write almost everything that's not your client. Because the easiest way to get this to use is the limitations. To derive from as not your client or as not your modified not your client. So, and when you set if you want to do anything essentially in writer you have to be derived from some exceptions. But, in general, if you want an object that's available here actually. That's kind of unfortunate that we have this piece of code. I don't know if you can see this. Can you read that? It gets notified. Which our approach is, checks if it gets the message actually from the thing that thinks it's which subject. So, it assumes that the interesting part is this. So, as I said I'm listening to it. One of the things that in my cabinet is that the modifier tells the point I'm actually dying right now. Clients will not kill themselves. But before this they look at if the modifier is itself a client living of everything which again has things in double lists and they are called to the objects registered in you have one big marker have logging or parallelization or anything like that because essentially if you touch everything in writer everything else might fall and that means the only thing that falls is everything. If you drag for it like if you don't know what to be doing it's a toy that makes terms a bit different. It's a charter looks like if you're running around if you're coming past the same piece of code for the 20th time and if that happens because obviously I'm running on servers. So, it's not really deterministic if you run into these cases listening to something and because it's undoubtedly an interesting number of cases it can only listen to one thing which is not great and more so it means that you can actually ask what is the one thing that I'm listening to and that it runs in SW Client that SW Client and if you drag for this I try to remove a lot of those but there are still 96 cases where someone says oh yeah I have this stuff that I'm registered to and after that I'm just doing set a cost because I know I'm just confusing the form behavior that if modified times go to the object that the modifier says that she is listening to so, there is no way that you can assume that you can set a cost once you set a time but we're doing that 5 to 6 times so it's mostly there both the clients manually so they are much sending and managing everything but they actually get the result of everything that is registered and then say, oh yeah what is it that you should have to do and just filter on those things you do so the modifier says, oh yeah I know someone is listening to me that it's of this specific type and I want to get the instance once or now this is essentially and then it's just SW Client pointer so Client set yellow all the functions of the client which cause additional problems to the listener and somehow the listener forgets to he would just turn the thereby causes memory to leave and the wife project of a consultation times all this to be a future not a bug and actually used the SW Client modified thing mostly for memory management you just have a header that listens to the client that the client puts itself to finally we have SW Client or master or 6.1 as I told you the clients are in a double list which means you can only listen to one thing and solution was well if you want to listen to two things the solution was that you have a tiny helper class that is applied and that forwards to the class that you actually want to trigger just what actually is happening and just to add one more or no more story of course because you are dividing from almost everything from client you might actually get a general guidance situation an object that drives from to right objects and then you have two listeners and there is actually a code that somehow is used that there is just one way to be in a list or something so that might actually you can avoid that I'm sure but it is one case where we have to fix issues that are not really obvious what you are going to be most of the obvious so what I'm telling you here is that the client is a wonderful way to create surprises but programming which is not exactly what you want and it intends to actually to be sure that what I have re-implemented all these holes in the same way or it can still migrate away from them safely while we then have a contact code which was there touch that code while we were working the unit in this side gave a lot of confidence to some of the organization they have introduced lexical lexical model findings which you have three objects the stuff that is listening the stuff that is sending events and events for the messages that you are sending them and if you want to migrate away from that the first thing you need to migrate away from is to get the messages in the form of that you can use elsewhere 54 what I mean is lexivodified which is the basic stuff from the SMT listener and you can set those with the old implementation now so that you can migrate off to some point in time should it use the SMT broadcast so that we can listen on both sides so you are essentially breaking with the organization in the internal automation simplifiable thing I told you about how to interact with all of your clients finding the first part of the specific type that was all done with the old tools type thingy which from the tools like which is not very reliable and essentially re-implements the C++ type system so I made that a bit more type-safe with standard classes and also I had some C++ then I created some new broadcasting which is essentially SMT broadcasts so that you can easily use the new stuff when you're going to be migrating away from the old mechanism to move to these new listeners and because the new listeners are not in a double big list they can have a list of multiple parts and multiple objects that means that you don't need to like a heavy work around but then I mostly cleared the new code the SMT broadcast the new code the next thing would be accessibility actually there's no much left there and the fact that we'll start actually migrating the right thing is unfortunately there have been some regressions like to fix this go for immediately finding a bi-wisectic to microsoft fix a few of those we took one of them back 6-1 so I think some of them are not the last one was friday and it's an interesting question so fix the remaining ones here and then the results go on


The plain truth is that technology isn't enslaving our minds or killing the planet. It's an extension of who we are as humans and massive advances in energy creation, food production, computer programming, and industrialization are the reasons why the planet supports billions of people who live more prosperously and peacefully and why global life expectancy keeps growing. Humans actually have been getting better at a lot of things for a long time, in terms of heading off various diseases, poverty, and heading off a lot of things. For the past 60 years, Stuart Brand has been one of the biggest champions of experimenting with technology to solve humanity's biggest problems. You can't count on the past ways of making it better to fix whatever the current problems are. You have to keep discovering new ones. In his early days, he was one of Ken Kesey's merry pranksters, using psychedelics, music, and light shows to expand consciousness. By the late 1960s, he started the Whole Earth Catalog, which quickly became a bible to hippies and techno geeks such as Steve Jobs, who famously quoted its parting message, Stay Hungry, Stay Foolish. Dubbed the intellectual Johnny Apples seed of the counterculture, Brand's ideas and activism helped inspire the first Earth Day, and his early reporting on the personal computer revolution turned machines that were once synonymous with centralized bureaucratic oppression into devices of individual empowerment. His life is the subject of a new documentary film that takes its name from a famous Brand mantra. He had an understanding that humans were on a trajectory towards greater and technical possibilities. And he made an important statement, we are as gods, so we might as well get good at it. His current passion is Revive and Restore, an organization that is leading the de-extinction movement by using biotechnology to bring back extinct plants and animals, including the passenger pigeon, the woolly mammoth, and the once-dominant American chestnut tree. This is what killed five billion American chestnut trees. These trees are functionally extinct because they can't reproduce and make a forest like they used to. But genetically, they're not extinct at all. They've got all the variety they ever had, and they're about to get one more bit of variety, which is one or two genes that will help them add off the diseases that we brought here. Not on purpose, but the cure is on purpose. As the film shows, Brand's techno-optimism isn't without its critics. I would love to see a mammoth. Wouldn't that be cool? That we can do it is so much fun and so fascinating for people who love technology. At the same time, we ought to be asking, should we do this? Is this a good idea? It's a criticism Brand rejects throughout the documentary. Genetically modified organisms were first created. Most environmentalists were just automatically against it, and that actually makes me pretty mad because that's taking ideology more seriously than the ecosystems you're trying to protect. While Brand's vision for de-extinction has struggled with the very environmental movement he helped create, he takes solace in the historic cycles of rejection and acceptance. In vitro fertilization, first came for humans, there was all the usual resistance.   Can I do that to my pet, and it flips? Yeah, it's more about optimism versus pessimism, it's more about the world you want to live in versus the world that you're running from. The co-directors of We Are As Gods, David Alvarado and Jason Susper, whose previous work profiled transhumanists experimenting with immortality, find value in Brand's perspective. Actually what's more interesting is the use of technology, the discussion between whether technology got us to this problem where we have global warming, where we have an economic system in ruin, and whether or not we can use technological tools like Bitcoin or other sort of financial technology to get us out of the current mini-depression that we're in, or using geo-engineering or other technologies to get us out of climate change. I think that it's just really easy to just say it's technology's fault. Well, what's the solution here? What are we talking about? What is the solution that that kind of person would be suggesting? Because I just feel like we need to be working on it together and building better tools, which goes right back to the 60s and what Stuart was talking about. It's been a long, strange trip for Stuart Brand, and the planet he helped us recognize from outer space by goading NASA into releasing images of the whole earth. What has kept him on the forefront of what comes next, from psychedelics to the Internet, to reviving extinct species, is his undying belief that technological progress will help us triumph over our largest problems. Now in his 80s, Brand still believes in progress and the need not just for individuals but whole civilizations to keep experimenting, to keep pushing, to stay hungry and to stay foolish. Try everything. Take nothing off the table.


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