So welcome everyone. I'm Betsy Koh and I'm also in orange wiki tree orange is Aowyn Walker and we're we're so happy you're here tonight. This is the second of a monthly series for people who are new to wiki tree and I I still consider myself new to wiki tree and it's been almost two years that I've been at very active on the site and I do feel like there's there's a steep learning curve so we're here to to answer questions that that are coming up for you. What seemed to be a popular idea last month was that everybody thought it would be helpful to watch me create a profile in just sort of you know I'll screen share and we'll walk through the steps. So does that sound good to everybody? Yes. Yes. Great great and you know we'll leave time at the at the end for for questions that are related or unrelated. So I'm gonna go ahead and share my screen with you. Okay can everybody see my my screen? I should say Edward Edward Tudor Edward George Tudor. Okay great and Aowyn since I disabled that extension I'll have if I just reload. Yeah it should. There we go. Okay so this is my my great grand uncle and what we're gonna do tonight is we're going to add his wife. So I mean whenever you're gonna create a profile just to I hope just state the obvious I mean you have to be connecting to somebody who's already there. Maybe it's you and maybe you're you know adding a sibling or a parent something like that. So we're gonna add his spouse. The easiest way to do it is click on spouse. We're gonna we're gonna assume and hope that this person is not already on wiki tree. So her name is Emily her maiden name last name at birth and you will all hear the LNAB people use that little acronym a lot Emily Francis married name Tudor. We're gonna I backed up all these things that I'm entering in here with sources. So she was born in 1864 estimated she died 1935 I guess I would say estimated. And then you're in most cases you're going to see a list of what the system thinks are potential matches. Okay I can rule out same name but Australia different different county in England. So I feel confident that that there's no no it's act match. I'm gonna go ahead and I'm going to check the two that were the closest and just to show that I I examine those and that I am passing those over on purpose. So then she doesn't have a middle name that I am aware of her birth location. I love this name is fish guard Pembrokeshire death location La Morgan. I've got the right does everybody see the date range. She died in 1935 so I'm being careful to to click the right date range marriage 1888. I have a marriage record so that's certain actually I even know that it was December. So I'll do that married in Cardiff. I'm not sure exactly what they're doing. Do people people please feel welcome to ask questions as I'm going along. Should we stop and take some questions. This is a the form that comes up first when I went on a person's an existing profile and said I want to add this person's spouse and then this is the form that comes up. Does that make sense. I guess she's just I guess she's just explaining what is going on. Yeah yeah. And when I've always wondered about this I can't always see like the full line is there a way to see like the full of the of the because like this is wrong this is the wrong date range but yeah I as far as I know there's not yeah not sure why it's like but yeah I'm gonna go with that marriage and date when she passed away. No email address and so now here sources you have to enter one sort when you create a profile. So what I've done for tonight is I went ahead and and created a list of the sources. So I'm gonna go ahead and I'm going to enter the 1911 census as my my initial spouse. Okay all you do is you just copy it in there. Hi this is Denise can I just ask a question there about sources. Of course Denise. Okay so when you're adding sources if I don't have any source but I knew that person and I the source I can say he is my uncle he was known to me. Yeah yeah you can put first-hand knowledge. Okay yeah and but but it would be good to add on to that some sources if you can. Okay or you might know somebody in your family like a generation or so beyond me you know previous to me may have known that person and told me about that person so how do you reference that?  Yes okay. And if your mother a nice way to do it I think is if your mother's on wiki tree has a profile you can first-hand knowledge from and then link her her wiki tree profile. So it shows the connection. Okay perfect thank you. Sure of course. Betsy I have a question about sources. Yes. Okay so I understand you know they don't want us to you know put sources down that require someone to have a paid subscription somewhere and I'm I'm really passionate about making sure my rabbit trails or whatever I leave behind is like that. If I find a document through a paid site like ancestry and like a census record and I see the citation on it am I breaking any rules if I mean I'm using that for my own research but am I breaking any rules if I want to say here's a census record and here's a citation you know ancestry ancestry did the the work and made it available family search doesn't have it available but but I found it and here's a citation for it. Yeah that's totally fine. Yeah we encourage to try to not use the pay sites if you can but if the only source citation that you have is from a paid site it's we definitely want to have that there. That's totally fine. Ancestry doesn't own the data they just point you to it so you should be putting down enough information to point yourself or have somebody else be able to go find the data at the census site. Right so basically like with ancestry it'll put ancestry but it also has NARA there and they are for the National Archives and you copy from NARA on and you have the census number of the the old labels when we used to have to use the reels the real number and all that and that's what you copy you leave off ancestry. Yeah and you can even see if we if we examine this citation which I you know is a census that I got off family search but if you look at a little more closely it does say find my past which is which is a paid site but then of course the original records are at the National Archives. Right and the same with death records you put the actual state that it came from not ancestry's name. So drumroll at that point now I'm ready to officially create okay so as you can see we've got I can't see the profile oh she's going to be Francis 9 6 7 5 is the new new profile. So up at the top you can see all the information that I entered in birth year and place that she's the wife of Charles Henry Tudor she's got some children that could be added they had children who could be added in you would become you would be the profile manager and the system does automatically generate just like this very very simplistic biography from from what you've entered above and then as I mentioned to you I really I feel strongly that I want to back up everything that I that I put in like the birth year in the birth place so I'm going to also now now I'm going to go to my citations we we use the census but of course as we all know women are are tricky in genealogy and so someone could come to me and say well how do you know that her maiden name was Francis and so I was able to define the marriage record so let's put that in so now when I go to edit I'll do an inline citation so I can add to the bio she married now I'm going to go ahead and hyperlink her husband's so the way you do that if in in case you don't already know is the profile single line Henry Tudor in December of 1888 and then I just come back and I do site your source now I'm going to just drop that in I'm actually going to get rid of that asterisk don't need that okay and now if I preview we'll see you see that I've hyperlinked her her spouse and now I've documented the record and in finding this record I will say brought up a really nice example of wiki trees collaborate the collaborative nature of the community because when I found the marriage record initially it said it was just an index and it said for Charles Henry Tudor that the possible spouse was Cecilia Watkins and everything else was correct but I thought oh no so I know somebody in the wiki tree community who's in Wales and I was pretty sure that she was on find my past so I messaged her and I said could you look up this record for me or give me any ideas on how I can verify this and she wrote back pretty much in about 15 minutes and she sent me this from free BMD which birth marriage death in the UK and so you can see there are my two people and so I felt much reassured that I had the right record there Cecilia Watkins was on the same page underneath but you know so so it's really really nice when you know you have this big community where you could just reach out and people will help you like that to feel more confident about things so and then you can see that the other source that we initially put in that's just hanging out at the bottom it's not an inline citation yet the other two things that I like to add are a birth record birth registration so and I'll do that it's an inline for for the birth statement it was born about in Fishguard and now I'll cite my source preview and so you can see that now this is number one in the marriage registration is just automatically become number two and then death record away there now I've created three three inline citations now the other thing we touch on in those sources there I noticed that the first few have numbers beside them and then that last one you put in just has a dot right that's because well let's look at it up here the first three are inline citations so I I appended them to a statement that I made in the biography whereas this last one is just hanging out underneath sources okay so so eventually yeah yeah is it better to have them all one way or the other it's inline citations are preferred but you know you sometimes I will just have some sources down below that I haven't had time to weave into a full biography okay thank you yeah probably go back and catch that up into the narrative later thank you yep any other questions let's see I see a question in the chat box yeah from Sally who says if you had found Emily in that list when you first started to add her how would you add her to the new profile well if I if I had found my match then I wouldn't have to have created a new pro I wouldn't have to create a new profile in the first place so sometimes that happens and then you can just say oh yes this is my person and then it's just a matter of linking the Emily that you found to the husband that was already and hopefully you don't have to go and delete the other husband okay so yeah sometimes that happens that usually not in my experience but occasionally and then that's really exciting because then you just connected two parts of the tree that should be connected that word previously let me just show one other thing so we touched on this last time research notes so if I want to create that heading it's just the two equal signs whatever and then the two equal signs and what I'm going to say is Emily's birthplace in the 1901 census is listed at Fishguard however her birth record lists what is that have her have her heard West and that's just something that I found a little bit disconcerting I think from the minimal research that I did that that Fishguard is the small little town it's about 15 miles north of Haverford West and that Haverford West was probably like the central location where the registrations births and deaths were done and so that's why there's that discrepancy but I want to make a note of that and then if you want to sign off on it so someone knows that it's you who's saying that you do four of those little pearly cute things and on the upper left side of your keyboard that's kind of like putting a signature on it I don't think it's strictly necessary on a profile where you're the profile manager but I always do that if I'm on somebody else's profile and I'm adding in a research note just sort of red flagging something or calling attention to something so that it's kind of well it's just your signature so having done that now we have to say what we've done we've added sources we improve the bio and we did research shouldn't I be able to manage oh there okay okay all right and now let's see so there you can see the sort of signature that you get in the research note what those little curly cues create so if anyone wants to look at this on their own computer without me scrolling up and down just go to Francis 9 6 7 5 so questions we can we can move on to completely different topics we can show how to add a photo we can show how to do fun things like italics and bold and indenting and bullet points in a profile if that would be of interest to people I have another question if you're if you can hear me I can Georgia go ahead okay there's two guys with the same name okay one has the profile in which tree one does not have it yet the wife that belongs to the second guy has been wrongly assigned to the first guy once I create the new profile for the new guy how do I move the wife over so that's a great question so let's let's we're not going to save anything but I'll show you okay so if we go edit within Emily and you see over here on the right shows she's married to Charles Henry we could edit that marriage and then what you can do is remove the marriage so that that's what I think is that makes sense Georgia yes thank you thank you but first you should make sure it actually is a different person yes yeah of course I'm absolutely sure it's a different person I've an half an inch thick file on the second guy not the same same name but not the same guy anyway how do I how do I get out can I just close this and I'll be well nothing will be saved yeah okay cool and then the ever helpful all the way at the bottom return to profile without saving what you need to open the door wall a little we have I can't see the chat do we try to be real quiet about it well she's pretending to be she's one you're going thank you and now is John looking at the chat yeah if you don't John this is how do you upload pictures okay I have an example of that so let's see okay we go to another tutor and so okay I've got God there's my photo all right so we go under images and it says would you like to upload a source image click to upload it and I have it all set to go here on my my desktop so what's the matter sorry there we go okay so now I've got my my JPEG now this is a photo that I found on an ancestry tree follow them up I'll just step over here and steal a kiss so what we can see you be careful I don't want to see sorry do these people know that they are not thanks everyone so I made sure that I email the or sent a message to the ancestry user and asked for permission I said you know I explained what wiki tree was I gave him the link of the profile and asked if he minded if I uploaded it to wiki tree it took a little while sometimes people are slow to respond but eventually happily he did so what I'm going to say is used with permission of ancestry user and then I'm just going to use his his ancestry user name David at words 203 and then I don't I don't have anything more elaborate than that it's Edward yeah Edward George Tudor seated with brother I don't have a specific location or date and then this is definitely a photo of the individual now upload and there we go and I think by default it becomes the profile picture yes if you don't want it to be the profile picture like like sometimes it's just my personal preference I don't I don't necessarily like to use a tombstone as as the profile picture but I might want that photo on the profile you can you can come down you can come down here and uncheck that and that will that will still keep it on the profile but it won't it won't be the the one of the upper left corner so you can upload more than one picture then right yeah absolutely also down at the bottom page and this is this is see his his brother is in there in the photo as well if I I don't have his brother's number his wiki tree number on here but if I did I could just type it in here and then the photo would also be attached to his brother yeah so we can wiki tree tries really hard not to have people uploading the same photo you know like five places you know it's much better to to just link it and if you wanted to remove the picture how would you do that if I wanted to remove it there's got to be a it's down the bottom it's done where you were it's right don't come back up you're right there where you add the person right above it see where it says people and things on the image I say it yeah so if you want the image removed from just this profile he'd remove right there but say you have like four or five profiles linked if you want the picture completely gone you have to remove it from each profile okay so if you just remove it from one it's going to stay on the other one still okay thank you what what type of I know you use jpeg but are there other women are there limitations on what kind of pictures yeah and you know I think just about anything I know JPEG PNG's work you can upload a PDF yeah I think most most file types there's a help page that's the it's photo FAQ and that helps answer a lot of the photo questions too well does does anyone have want to be our our guinea pig and give us a profile ID that they're working on and maybe having trouble making cooperate then we can look at it as a group I had a question yes so I'm new to wiki and I'm new to all the intricacies of wiki so the other day I got an invitation to join discord now I'm starting to get unsolicited emails from discord saying hey you've got a message replied messages when I go to discord I can't really find them so what's what's the point of discord and how does it help me advance what I'm doing inside wiki well so this court is just a really handy way for the smaller subgroups on wiki tree like this you know the Scotland project or or the ambassadors they all have their own channels and it's just a very handy way to communicate and everybody is on there with their wiki tree ID number so it's sort of clear to know who's who like I'm co-31 which is the same as my profile ID I don't I don't remember getting a lot of when I joined these discord I don't remember getting a lot of emails about it a when do you know why that would be um it just depends maybe on was it with a specific project John yeah tonight so am I also and you're understanding you're right that the discord lane of traffic that I'm in is that I'm involved in the Scotland project so all the people that are in there are also likewise in the Scotland project as opposed to like the greater yeah yeah so there there are a few projects that have their own discord server and Scotland is one of those so just based on how they set it up you you probably would get a variety of messages from the different groups that they have in there yeah so so John I'm in the Scotland project so I'll see you on the discord yeah it takes it takes a little while to get used to you can also mute certain things so that you don't get an alert like every time somebody says something in the Scotland channel you can just mute so you only get certain types of alerts you know one of the things I'm the project administrator for clan McTavish so I get like 20 or 30 emails a day sometimes so I'm trying to dial down the air traffic I'm getting from some of these sites so I can actually do some work yeah let's see I have a profile that you could possibly have a look at when I when I go into my unconnected profiles on watch list I've got two one of them is it's Arthur trim bath so he's trim bath dash 207 okay hang on a second how do you spell the last name t-r-e-m b-a-t-h okay and it's dash 207 and it's got a little icon next to it saying unconnected branch table now this is this is not a profile I created but I've taken over managing it was obviously created by Richard Bell and I just I'm not quite sure it says it's unconnected I'm not quite sure what I have to do or because it he's got children he doesn't have any ancestors but he's very early so I really can't do anything too much with him I know he needs tidying up but there are some sources there even though they're not correctly formed or anything yet I could go in and do some stuff with them but when it says unconnected branch table what what what sorry where is that I'm looking oh that's that's when I go into unconnected people in my my shortcuts it's it's um you know I go find and it says unconnected people and it says two unconnected profiles on my on my watch list and he's one of them and it's got this funny little icon I could share my screen with you if I'm allowed to so you can see that or not um what do you uh Aowyn is that that's let me see if we can yeah I don't see way to do that the other thing I'm just curious because you're right he has children yeah yeah but are the children so unconnected means that he's not connected to the main part of the tree yet I guess if we feel it to his kids it's like oh maybe maybe there isn't the link down okay okay so so I need to I need to get his descendants linked into my tree that's what that's what it requires yeah okay okay that's fine I can I can certainly do that I probably haven't he's not my ancestry's my husband's but um yeah I can I can certainly I possibly haven't got that far because I'm I started out really really excited adding people and then realized I had to put a lot more effort into each person I was adding and so some of those branches I haven't taken back as far as I have in my own records yet yeah yeah one chance to get he's far enough back that you'll probably go to add someone at some point and they'll already exist on the key tree and then yeah let's just connect right in sure thank you right right so I mean sometimes it's it's just a matter of like plugging in spouses and like magic they're connected so thank you thank you it just confused me because it said he was unconnected and I'm thinking well you know he's got he's gone family right right I guess it really is that it's a branch it's a yeah yeah that it is a multi-generation branch that's just kind of floating out there okay thank you thank you that it that makes sense and I shall do something about that good luck keep us thank you when you get somebody that wants to merge or you're gonna merge two different profiles and some of the information is not correct or what you think is not correct how do you go about merging and who merges into which profile right okay you understand yes yes I do I've only been involved in a few merges in my two years there is there's a process and there's a button somewhere I anyone where the bottom oh yeah so I mean initiate a merge supposing I decided that there was another Arthur Trembath and he was Trembath 180 and I wanted to merge them so you always you would be in touch with the other profile manager they would they would get it once you initiate a merge they would get a message about it and then there be some communication you always the the profile I want to correct me if I'm wrong but it goes to the the earlier profile number right yeah it merged the higher profile merges into the lower number profile right so whatever was created first becomes the one composite and there is an opportunity to to compare side by side and I guess if there were disagreements anyone what happened I mean well and that's a little bit of the tricky part with merges is it's going to be one or the other view that's going to be able to go through and click what you know what dates stay and things like that so I just always go back to check and make sure you know what stayed and that the sources are still there if there's some kind of dispute about the information like you can talk to the profile manager about that or make sure there's good notes in the profile that just talk about you know any discrepancies in the dates or places or names like the research notes that Betsy was doing you know sometimes you'll see people put like disputed section about whatever there's issues about I would say overall merges tend to go pretty smoothly but sometimes there are you know some conflicts and well my concern was on one of my merges that I went into it was a different profile manager that ended up with it but I had done a lot of the research and so I think what I'll do with what Betsy did is to go in and do research notes and then they'll know that and I can change that in an edit. You can also make a request to be a co like a shared profile manager. And who do I do that to with with the person who's already the the the profile manager. OK, I think I did send a message but I never heard back. Yeah, there's a process called the unresponsive profile manager process. So if you're having a hard time getting an act of profile manager to respond, you can go through that and it's it's not hard. It's basically just to the comment, try and contact them. And if you don't hear from them, you can let us know at info at wiki tree dot com and then we try to contact them. At what? Let me find the help page or Betsy. Can you find the help page? Did you want to? Did you want to do a suggested merge? Because I've just found it found that I do have Arthur in my tree and this other profile is is actually a duplicate. So so Trembath 207 is the same as Trembath 20. Oh, oh, nice. Interesting. Hang on. I'm very I'm let's let's look at Trembath 20. Let's look at them side by side. Aowyn, I'm sorry, I don't know where to find the help page. Aowyn, I don't know where to find the help page that you were saying asking me to find. Stuart in the chat now. Stuart, yeah, he's doing a good job adding help pages to the chat. Trembath 20. Yeah, you've got photo and stuff in there to the moment in the URL. Oh, I see. Yes, you're right. That's why it's not working. OK. 1663 to 1731. Yeah, I see the same birthplace. And now do you know Joseph Perry? No, that's not something I know. And Chris, right? You don't know. You also you don't know. That's me. That's for me. See, I took over that profile because it was an orphan. I see. Got it. So you need to be in touch with Joseph Perry. Yeah, yeah.  I'm going to guess he hasn't been active for a while. And he let's see. He was last active in February of 2019. But he did show up to do a merge, so he might propose the merge and he might. Yeah. OK, so maybe I propose a merge to him and and then we can work on it. Because because the one of these profiles was created, his one was created in 2011 and the one I managed was created in 2014. So they're both fairly old. Right, right. Yes. So then it would the the remain once the merge happens, you'll have Arthur as Trembath 20. Yeah. OK, so so can you show us all sort of the steps that we should take to propose this merge? Would that would that help other people? I think that's a good topic. Oh, do you want to do that as a separate webinar? Sure. I just I'm not sure how to do this because I don't want to. You want to propose the merge? I do. Yeah. Yeah, but seeing you don't have to go all the way through the process. OK, we can just go to the point to a certain point. And then I can turn back and then you can stop. OK, so do I on Chris's profile? Yeah, so you'll want to start from the higher one. Yep. And then. And then you should emerge. Ah, OK. And then this is where you. But Trembath 20. Right. Yeah. And then if you scroll down a bit, don't click merge because then you'll. Right. But when you're ready to do that, you just click merge and then let us do the merge. It should it should pop up a screen where you give a reason why you think they're the same person. Sure. So just put that note in. And then they'll be like a next button or something. And that will initiate the merge. It'll send an email to Joseph just saying that the merge is there. Hopefully he pops up in response. If not, after 30 days, you'll be able to go ahead and do the merge. Massive. Yeah. It defaults after 30 days if there's no response. Oh, yeah, I got it ready. Oh, great. Thank you so much. That's really good. I like to compare when I'm looking at. You know, I just you could do that. But if you want to compare, um, it's it really is easy. Because there are some little differences in there. I can see that, you know, the date of death. But given given that time frame, that's not a terribly surprising. Um, and that would and he's not given as a song. Yeah, it's that'd be good. That'll connect that whole branch thing, if that works. Yeah. And this is this is yours on the right. Yes. This is on the left. Months on the left. So yeah, I noticed that we have a spouse over here. Yes. And that spouse is correct. Yep. Petronelle Davey. Yes. Mm hmm. That's that's a spouse. And on the right, it's got parents and everything. So yeah, that's and those are correct. And the biography for Chris has the info of the spouse. Uh huh. Uh huh. I have a feeling Arthur is not going to be unconnected that much longer. Good. Can I just say that there is a discrepancy with the mother because the baptism gives the name is Jane and the one of the profiles gives the name is Cheston. So there is a discrepancy and those sort of things may need to be looked at. Of course, yes. There may be. Although there's only one in the OPC, but I've only just looked for full name. So I haven't done any wildcards or anything like that. Mm hmm. Did I understand that correctly that if you request a merge and you don't get a response within 30 days that you can just go ahead and do it? Yeah, the system will default it. And at that point, anybody can complete the merge, not even just the profile managers after 30 days. Now, sometimes there's something that resets that. I don't remember exactly what that is right now. But most of the time, just after 30 days, it will be followed. I had one about six months ago when I tried to contact the guy a couple of times and didn't get a response. And I just kind of walked away because that was the part of my family I needed to tie into there. So OK, this is. Yeah, you should be able to. To put that through. OK, thank you. So you guys all sound like you're really savvy with wiki tree. So I'm real excited and I'm going to have to play with it more. I have some real basic questions. OK, so first of all, I mean, I know there's a lot of stuff in help for people like me and Stuart, wherever you are, thank you, because I've been putting questions in the chat. And then you guys just like bang out those links. So thank you, helpful. OK, it's very helpful. So, you know, well, little stickers for Stuart. So or whatever, you know, the thing that points or whatever. So OK, the first thing is if I if I put my tree on here, can my family, if they or other people that are trying to find out about this, can they see can other people see my tree? Because that's what I'd like to be able to do. Yeah, yeah. So it's. So let's see. Arthur's not too well connected. Let me go to to Emily. Actually, let me go to her husband's. And then if you go to Family Tree up here. On any profile. You'll see that little branch. OK. Now, supposing I want to see, you know, and then I can switch to the pivotal person is. And the center. And what are good ways to see like a lot? Like, I guess there's fans or apps. Yeah, it's a little beyond just the basics. There's different apps where you can look, you know, but I'm more like, try the dynamic review. See the button right up there? Keep going up a little bit. No. Oh, yeah. Got it. Oh, it makes it does make you just log into a tree. So there's just there's a lot of different ways that you can look. At your tree. Another thing to know is we work really hard to be really well indexed in Google. So like, say somebody's searching and they put in your great, great grandfather's name, your wiki tree profile is likely to be one of the first things that would come up for that. So it's really great for cousin bait in that way. Let's try it. Charles Edward. My heart always stops when I tell us because someone always wants to try it. And then I'm always afraid it won't actually work. It'll be like the one that doesn't. That's going to be a hard one because his name is. Getting some. We're coming in this tree. There he is. Boom. That's right. He's right there. Yeah. Boom. Yeah. All right. And and this the second out of two questions. OK, because I am so green at this, I know enough to be dangerous. I've created my profile. I'm getting messages. I had no idea what to do with that. So thank you for sharing that part. But like, OK, if if the people that I've been researching already have a profile and I have more information to add, where is it on the screen? Do you do you try to contact the profile manager? Can you I know everybody's like so much further than I am. And I apologize. But not at all. It does depend on the privacy level. But mostly I've encountered that I can make changes to a profile. You know, so see this icon over here. That means that that, you know, you could make changes. You could go in to George Tudor and and go ahead and edit. You'll know that it's not possible if it's locked or or if there's no edit button. That's the key clue. We like to say, be bold and be polite. So it's sort of like if you're adding sources or you're adding, you know, to the bio, be bold, like go for it. If you're changed, if you feel like a parent needs to be changed and you're not the profile manager, we would encourage you to just talk to the profile manager, show them why you think it needs to be changed and work with them on that. So, you know, big changes want to be polite. Everything else just be bold. I'm really shocked. Elizabeth Tudor is unlocked. I thought that Elizabeth the first would be like a notable who would be. Well, she's she's project protected, which means she can't just be merged into. Right. That's that's the highest level of protection you really have. Yeah. OK. Yeah. I found it. I found the mistress of. Of my grand grandfather, my great-grandfather, who lived in the same house with my grandmother and so grandpa, great-grandpa divorced great-grandma and married. The mistress and so she had his, you know, she had a maiden name. Then she had a married name. And then after he died, she married again. But she was buried with the man she had a mistress with. And so her her last name on the headstone doesn't match. It took me forever to figure out who she was. And then her sister was buried. So she and her sister were buried with the man that she married after having an affair. Well, Jerry Springer. I'm kind of following you. Yes. That that congrats on on sorting that out. That sounds like a headbanger. So I just I was going to go back to what Betsy said real quick. Some other sites do lock down notable profiles. So like royal profiles and like really famous people, their profiles are locked and can only be edited by a specific group of people. We don't do that. So, you know, anything that's an open profile still can be able to be edited by any wiki genealogist. The only exception to that is when it's project protected and that really only prevents the last name of birth from being changed. And it prevents mergers going their own way. So we had a question from John. Yes, regarding profile pic or any kind of photographs and images. I upload my first image just now as we were doing this. And I had my father's image, but I put them under my profile by mistake. Is there any way I can move him to where he belongs? Yes. So with the best way be to go under, can you give us the your profile, which would you mind? Sure. Is there a number or something? I guess so you put it on your profile, right? Yes. What is your profile? How do I find that out? OK, a minute. Up towards the top in the URL bar, it'll say like rampone dash something. OK, rampone dash nine. Right. OK, sorry. OK, rampone dash nine. OK, that's me. There we go. There we go. Now there's my father's picture there. OK. So just going to click on that. Yeah, you know, go to because it's private private. Oh, but so if you go ahead, I was just going to say, if you do that, if you go to the image like she did, you'll see what we showed you before on the image page where you can add and remove from profiles. You know, I'm going to go back to. Yeah, go back to that one and we can show them on there. 97 there. OK, so this is the one we added earlier tonight. Yeah. OK. And what I would do is I would add your father to the profile and then then remove him from yourself in that box, the empty box blower her mouse is right now. You would put his profile ID, which is probably Ron Pony, 10 or 11, you know, I guess you put that there and add him and then you would remove yourself from it. But I actually have my picture in the right place. It's it's his that needs to be moving to his. But it's on your profile, right? Yes, OK. Oh, I guess. OK. Yes, you're going to add it also to his profile, and then it will show both of your profiles under that section. OK, so that person. So I need his number then. Yeah. Where do I find his number easily? Did he read the beginning of this? I'm just going to quite find his profile. Let's see. OK, he is around each hand. OK, yeah, one each hand. So I have to go back to mine. OK. And then if you scroll down a bit, you'll have to save it. So you have to go back to me. Save changes. Yeah, I can't seem to get back to me. Are you in the section that says edit image details? No, I'm just trying to get back to me. Should be easier this. Oh, there we are. OK, I'm back to me. OK, now. OK, down here. OK, I've got mine on here now. Got to get back to that box where you are. Comments. No, I can't find that spot again. Basically, you want to click on the image. Yeah, you can just get to this sort of page. Oh, here we go. OK, yeah, right here. I'm going to see him. No, scroll down and save that. Save changes. OK. OK, then go back up to the section you're at. And it should show both the profiles there. So which section? Oh, under would be up here. And it would say in this image and it would be you and your dad. OK, yeah, I see. OK, the picture was just too big here. OK. Yeah. OK, yes. OK. So then go back to the section where you can add or remove people and then just click the button under yours for a move from image. OK, which one I should be on then? I should be on. Remove it from you. OK, where's we move? Where's we move that? And it should you see my cursor? Yeah, people and things in the image. See that? OK, here we go. OK, gotcha. OK, remove. Oh, we go and click under yours. Under me. Oh, not his. You want to click under yours? How do I click? OK, I've actually clicked the wrong person. How do I? How do I unclick? Just refresh the screen. OK. And quick question. How do I refresh the screen? Oh, up here in the see where my cursor is next. OK, I'm on a Mac here. I am too. Yeah. OK, OK. So. Oh, I don't see that. Do you see? Oh, here we go. OK. Are you sure you want to send the form again? Yeah, because it'll clear it. OK, OK, there we go. OK, gotcha. OK, I'm removing it from me. Right. OK, so once you click that, just scroll down and say it again. OK. Then you should be set. And now it should only be on your dad's profile. I made it the wrong way. I think I did the wrong way, actually. Well, I don't know where I am here. OK, it's OK. Oh, yeah, it's there. It's on your dad's profile. I'm on your dad's profile. And there is. OK. So now. I have to go and make it this profile or something. Yes. OK, the primary photo. Yeah. Yeah, where was that the primary photo? I remember seeing it. If you go back here, it's on the right. Scroll down. And it's sort of on the other side from where you just were working, set as primary photo. I need to go and edit. I think I'm close. Right. OK, there we go. I'm in the wrong place here. Set as primary photo. Edit image details. I'm under edit data. Sorry, I'm in the wrong way. Under images. Hey, there we go. Hey, and in these details. Yeah, I think I'm. Yeah, right across from there. Right, edit. There we go. Fine. I got it. OK. Hey. Got it. Thank you. Cool. Shall we check? Yeah. See, there's you and your dad. Hey. Thank you very much. You're welcome. We should probably wrap it up for tonight. Exactly. Would you ever be doing anything on DNA? Uh, sure.  Yeah, we can plan to do that. That'd be great. Let's make sure I want to make sure, Aowyn, before we shut out the session, that I want to save the chat because I didn't really get to read the chat and I see questions and, you know. Yes, it stores it. I can send it to you. That'd be awesome. Thank you. So thank you so much, everyone. Thank you. Hope you'll be back next. We'll be back the first Thursday in November. Or if you're really keen, we're going to do another one this Sunday at, let's see, noon Eastern time. Eastern standard time. Yep. And can I ask, how will we be able to access the chat because I didn't have a chance to look at everything? Is there a way to do that? Let me try and figure that out. I probably can do, it saves it for us. I think I can download it and then maybe I can fill a link in the GDG post. Yeah, that's a good idea. OK. I'll try and do that. I think you can send it to your computer. Yeah, I think that was it. Do you guys have the chat button down at the bottom of your Zoom screen? Yeah. If you click that little arrow next to it. Oh, share. Wow. Do you have one that says save chat? I see. Three dots. Let me see. Where's the chat? Oh, save chat. OK, gotcha. So you should have the same show and solder. Yeah, who knows where that went? OK. Oh, it created a folder called Zoom under my documents. OK. OK, gotcha. Thank you. Thank you very much. Yes, this was a lot of fun, everyone. Thank you so much for coming. Thank you. Bye. All right, bye. Have a good evening. Bye.


Market mechanism. In economics, the market mechanism is a mechanism by which the use of money exchanged by buyers and sellers with an open and understood system of value and time trade loss in the market tends to optimize distribution of goods and services in at least some ways. The mechanism can exist in free markets or in captive or controlling markets that seek to use supply and demand, or some other form of charging for scarcity, to choose among production possibilities. In a free market economy, all the resources are advocated by the private sector individuals, households, and groups of individuals in a plant economy. All the resources are owned by the public sector local and central government and, in a mixed economy, some resources are owned by both sectors, private and public. In reality the first to are mostly theoretical and the third is common. Resources are advocated according to the forces of supply and demand. Government interference in the market mechanism leads to economic inefficiency when it is applied to private goods. Prices convey a lot of information. They not only tell producers what to produce but also inform the producers to produce what people want. The more inaccurate the information gets, the lesser will be the economic coordination which will in turn lower satisfaction of wants. Thus interference in the information conveyed by prices is destructive to economic development if misapplied or overused. However, the market mechanism often cannot optimize for public goods, going to problems such as the tragedy of the commons. For example, modern highways have been good for economic development, but it has taken government planning and allocation to bring them into existence. Other market mechanisms include government fiscal policy and monetary policy, described by the Friedman rule proposed by Milton Friedman. These policies will influence demand by price adjustments through taxes and charges and through adjustments to the value of money by the related supply of money.


Hi, Cathy. This is Ashley Logsworth Toyota. I wanted to send you a real quick video greeting. That way you can see who you'll be working with Thank you so much for your recent interest and trading in your 2010 Holliander and we would love the opportunity to appraise it for you when you have a chance to stop out of dealership Please give me a call. My number is five zero two two one four seven one six six Or you can also email me back and I'll be happy to schedule an appointment. Thanks. Bye


Okay. So, I know that the title of the talk was originally Outcomes in Cardiomyopathy, but it's really difficult to talk about just outcomes without also mentioning medical therapy. So while a lot of this talk is going to be review of, you know, good bread and butter, heart failure, what you do with medications, some review of the evidence, there has been a little bit of new research done recently with a couple new medications and we'll talk about appropriate use for those. And then some special situations in which cardiomyopathy involves particularly women and where if you recognize and treat in specific ways a little earlier, you really have an impact on outcome and improving outcome. So you heard a little bit earlier, I'm sure Dr. Nyer talked a little bit about the differences between the types of heart failure and really you have to look at the classification when you're talking about medical therapy, which is there's heart failure with reduced ejection fraction versus preserved ejection fraction. And quickly we talk about HEF-REF or HEF-PEF. Specifically HEF-REF is when the ejection fraction is less than 40% and in HEF-PEF it's generally accepted that the ejection fraction is above 50%. And the interesting thing is that despite all of the trials and evidence and all the research we've done, most or pretty much all of our proven therapies are for HEF-REF and there's really a lack of proven therapies for HEF-PEF, which makes it very difficult to treat. Specifically in my talk I'm going to focus more on HEF-REF and they've been a recent set of guidelines for the treatment of heart failure. Most recently there was an update in 2016 but the main guidelines were found in circulation in 2013. So I'd refer you to that as the main reference for this talk. So in general there's about one in five people in the U.S. will develop heart failure. There is earlier onset in men. HEF-PEF is actually equal among women and men though it's more common overall than HEF-REF and that might be because we're diagnosing it more you know since it's a little bit more recognized now probably in the last decade. Overall HEF-REF is more common in men. Over the last 20 years overall there's been a reduced incidence of heart failure however there's an increased percentage of patients with heart failure being classified as HEF-PEF and those HEF-PEF patients have higher rates of hospitalization and overall there's been an increase in the mortality rate from heart failure specifically for HEF-REF and something that's important to know especially as you're thinking about where your patients are in the spectrum of what kind of therapy they need the number of hospitalizations in the last one year is very predictive of their outcome and we know that if you have two or more admissions in one year the mortality increases to about 50% mortality. There are some special populations when we're talking about heart failure in particular African Americans and women about 3% of the African American population eventually develop hypertension and most frequently that I mean sorry heart failure and most frequently that has to do with hypertension and it should be noted that across all nationalities hypertension is the number one risk factor for development of heart failure with preserved and with reduced ejection fraction. In African Americans heart failure happens at an earlier age of onset and it's usually more advanced at the time of diagnosis they do overall have higher rates of hospitalization and a much higher mortality rate and then the other special population is women and that's mainly because although they respond to therapy the same as men there are some particular situations in which women develop cardiomyopathies like peripartum cardiomyopathy which I think you heard about earlier and also chemotherapy induced cardiomyopathy specifically because of the prevalence of breast cancer in women but also because there's some research into the way women respond differently to chemotherapy and makes them a little bit more susceptible to chemotherapy induced cardiomyopathy. It's important to note that when we're talking about medical therapy and outcome the guidelines are based on the classification and when you start different types of medicines is based on the clinical status of the patient and so you'll often see these two different types of classification systems the AHA and the NYHA class and so just to review that for you all there's AHA stages A, B, C and D. Stage A is someone who's at risk for heart failure classically that's someone who has things like hypertension and other cardiac risk factors and just to remind you that hypertension is the number one risk factor for development of heart failure and then I put on there this thing called obesity paradox which is something interesting which it has been shown that patients who develop heart failure who happen to be obese actually have better outcomes than people who are thinner and we don't really know why.  Stage C is clinical heart failure and stage D is refractory and stage disease these stage D patients are the ones who are on inotropes having L-vads and talking about transplant or listed for transplant and then there's NYHA class which has generally been shown to be the most predictive of overall mortality and the higher the NYHA class the worse the outcome. So class one is they have no limitation of activity or symptoms with exertion they can do whatever they want to do they just happen to have a low ejection fraction. Class two is they have a slight limitation usually these patients are comfortable at rest but they do have some symptoms like exertional dyspnea with some activity. Class three they have marked limitation they're comfortable at rest but with minimal activity they get very symptomatic and then class four is rest symptoms. So when we're talking about medical therapy for heart failure in the literature we kind of use this catchphrase guideline directed medical therapy and these are the medications when we talk about guideline directed medical therapy for heart failure to improve morbidity and mortality these are the medications that we're talking about so I'm just going to kind of run through them real quickly ones that you've been familiar with for a while. The first is a beta blocker which has a 1a indication it improves mortality more benefit sorry morbidity and also has been shown to improve LV remodeling and improve the LVEF. In beta blockers you want to start them prior to hospital discharge this was shown very clearly in the impact heart failure trial the only caveat to this is if the patient required inotropes during that admission you want to be a little a little bit more cautious with starting beta blockers before their discharge and specifically the medications that have been shown to be evidence-based beta blockers in the setting of heart failure are curvetolol besoprolol and metoprolol succinate okay so you might see a patient that comes to see you and they have heart failure with a reduced ejection fraction and you see they're on metoprolol tartrate or a tenolol you really want to switch them to an evidence-based beta blocker because those are the ones that have been shown to actually have these positive impacts on outcomes. The second type of medication are ACE inhibitors that also has a class 1 indication for patients with HEFREF it improves their mortality their morbidity and their symptoms and there's a 1a indication for an ARB as first line if the patient is ACE intolerant but you can only use it as first line therapy that's really a 2a indication so the guidelines still want you to try an ACE first unless you have a good reason like ACE intolerance which would be like an ACE cough so then you can start with an ARB as first line therapy and then the other 1a indication is aldosterone receptor antagonists so spironolactone or a plurinone and those are 1a indications in patients who have symptomatic heart failure with an ejection fraction less than 35% or if they have coronary disease and they have heart failure from coronary disease so ischemic cardiopathy and their EFs less than 40 and diabetes you want to go ahead and make sure that they're on an aldosterone receptor antagonist and then these patients and specifically you want to make sure that their creatinine is less than 2.5 in men or less than 2 in women before starting it and their potassium is less than 5 there's been there's an interesting curve when the studies came out showing that aldosterone receptor antagonists were beneficial in heart failure there was a significant increase in the amount of people going to the hospital with hyperkalemia because they were starting they were getting started on it with either their creatinine a little too high or at baseline you know adding it to the ACE or the ARB your K can go up so when you make this change you want to make sure that at least in the next two weeks one to two weeks after starting the medicine you recheck their labs make sure their potassium is not becoming too high and you want to be really careful with having them on potassium supplementation if they're on all these medicines at once so we know and there's been there's been a lot of trials supporting these medications this data is from meta analysis but basically if you combine all of the 1a indication medications you see the relative risk reduction in mortality which each medication so with a beta blocker you decrease their mortality by 35% an ACE 23% an aldosterone antagonist 30% then we didn't really talk about cardiac resynchronization therapy but 36% and so if you do all of these therapies together you get a 77% risk reduction and basically the number needed to treat to prevent one death is four so that's overwhelming evidence to use these medical therapies and all of your heart failure patients with reduced ejection fraction a little bit on some of the newer medications just to reiterate because there is a little bit of confusion I've just seen amongst cardiologists in the community is when to use some of these newer agents these specifically were addressed in the recent 2016 guideline updates for heart failure but basically there's two new medications on the market right now for heart failure reduced ejection fraction the first is an ARNI you guys know it as intresto it now has a 1b indication for symptomatic heart failure patients who are already tolerating an ACE or an ARB and you can replace those ACE or ARBs by this ARNI to further reduce their morbidity and mortality okay the key to this is that the patient symptomatic so it's really not for patients who have NYHA class 1 heart failure okay and they also note that you want to make sure that you have at least a 36-hour washout phase so when you decide okay I've got this you know NYHA 2-3 patient they're on the guidelines are that they have it they can tolerate at least 10 milligrams of an alapyril twice a day you decide to make the switch you stop the ACE or ARB you give them 36 hours then you start the intresto the other new medication is evaporidine or corlonore and it has a 2a indication in patients with symptomatic heart failure who are currently on maximally tolerated doses of beta blockers and in sinus rhythm which is key but still have a heart rate above 70 percent sorry 70 beats per minute and this medication has been shown to reduce heart failure admissions other parts of medical therapy that we should all consider for our heiferous patients hydrolysine nitrate combination this has been shown to have a mortality benefit in African-Americans with very symptomatic heart failure so stage 3 and 4 and it's used in combination with a beta blocker and an ACE inhibitor you can use it a little earlier in patients who are intolerant to Acer ARBs because they say they get hypotensive with other medical therapy or they have advanced renal disease and it it precludes them from being on an Acer and ARB and then finally did joxin one of the oldest heart failure medications that we have it has been shown to reduce the risk of heart failure hospitalizations but it only has that morbidity benefit it doesn't have a mortality benefit it still has a 2a indication and a lot of this data was actually done before even the beta blocker trials but it's not going to be repeated so I think it's always going to have this 2a indication it has been shown though that withdrawal of digoxin can precipitate a heart failure decompensation so you want to be careful if you have a patient who's been on ditch for a long time and they come in and you decide to stop it or someone stops it in the hospital it can be detrimental down the road and then finally diuretics they have a 1c indication pretty much all of us who have heart failure patients know they usually are on a little bit of diuretic the mainstay of therapy is loop diuretics and in general if someone comes in when the acute exacerbation the guidelines say that you want to double the dose and consider giving it IV there has been something in a lot of dose trial which basically showed that there's no difference between intermittent high dose versus continuous infusion so you don't have to put everyone on a lacyx drip or a bumex drip just just hit them hard with it intermittently and that you know will get you the same effect and then there's always metolazone uses a booster I find it very effective in patients who have some higher creatinine and are really holding on to fluid you just have to be really careful with hyper hypokalemia because even if they have renal disease these are the patients if you're having them on a lot of metolazone that they're going to end up meeting potassium replacement even if their creatinine is elevated and then another one that I think is important to mention is anti-coagulation because in the past there was a tendency that if people have a very low ejection fraction like less than 20% there was always this kind of question like should we put them on blood thinners what if they have an apical aneurysm is part of that maybe you know basically it's been shown in several trials that it's it's contraindicated unless you have another reason to put them on anti-coagulation so unless the patients have AFib they have a prior thrombotic event or they have a known LV apical thrombus you don't empirically put people with low ejection fractions on warfarin you it's too high of a risk of bleeding so I think it's helpful to talk about the way we can classify cardiomyopathies in general when we're talking about heffereff we apply these medications across all spectrums of heffereff but there are some particular etiologies of cardiomyopathy that we can handle in a little bit of a different way and also have different outcomes than just the general run of the mill so in general we're talking about cardiomyopathy there's genetic mixed and acquired genetic is things like Hocom, ARVC, LV non-compaction, some of the ion channel disorders there's this mixed bag of dilated and restrictive cardiomyopathies and among the dilated cardiomyopathies about about half of them are ischemic and in that 37 percent other a lot of that ends up being a familial cardiomyopathy if we go through all the genetic testing and then acquired things like myocarditis, tachysubo, peripartum, and tachycardia induced so some special populations I just wanted to touch on because they have interesting and often better outcomes than just general run of the mill heffereff the first being alcohol mediated cardiomyopathy it's important to remember that just being a drinker you know their patient comes in they have a dilated cardiomyopathy and they say they drink you know three beers a day that's really not enough you can't say oh it's because of your alcohol intake this requires a high amount of alcohol consumption so an average greater than five drinks a day for many many years before you can really say that it's due to the alcohol and really with abstinence and alcohol use and good heart failure medication you often see a significant improvement and normalization of the LV function the other type of cardiomyopathy that you can see a very good outcome with just control is tachycardia mediated usually this heart rates consistently above 110 beats per minute and it's very rarely with sinus tachycardia so this occasional inappropriate sinus tachycardia patients you see you really don't have to worry about them developing developing a cardiomyopathy the way you do your patients with chronic aphid with RVR it is reversible with heart rate control the only variation being if someone has a cardiomyopathy because of frequent PVC's and they get a 24-hour halter monitor and they have more than 20% of their beats in that 24-hour period being PVC's you really need to refer them for a PVC ablation in order to see an improvement in their LV function so these are two types of cardiomyopathy that with basically either withdrawal of the withdrawal of the offending agent or heart rate you can see a pretty much normalization of their LV function and a really good outcome the other type is peripartum cardiomyopathy I know you heard a lecture on this earlier so I'm just going to touch on it but basically it's diagnosed one month prior to delivery up to five months post and it really has a very good chance of recovery quoted as 50 to 60% of these patients recover with good medical therapy about 25% of them go on to have stable heart failure and about 25% will actually go on to either have progressive heart failure and require transplantation the risk factors is older age multi-parity multiple gestations preeclampsia or hypertension and then the use of beta agonist to delay labor chemotherapy induced cardiomyopathy this type of cardiomyopathy it doesn't have the best type of outcome it's I wanted to mention it specifically because we see it a lot more in women specifically patients who have chemotherapy with anthrocycline's duck's rubison is most commonly used as part of the chemotherapy for breast cancer and also a lot of hematologic malignancies and also then one of the newer agents trust use a map for breast cancer in those types of cancers especially breast most of the patients are women however as I mentioned before there is this evidence that it seems as though women even those who are getting it getting this type of chemotherapy not for just breast cancer they tend to develop higher rates of cardiomyopathy and it seems like women for whatever reason are more sensitive to the myocardial toxic effects of chemotherapy overall this type of cardiomyopathy has a much worse prognosis than the other types of heffreff and it's very important that these patients have an earlier diagnosis and thus earlier chance to get started on this guideline directed medical therapy to increase their chances of having LV recovery it's pretty much been shown in several studies that if the patient gets started on therapy within six months of the development of the cardiomyopathy they do much better and then if they get started on therapy more than 12 months after the development of the cardiomyopathy it's very unlikely and nearly 0% chance that they'll have any improvement in their heart failure so a lot of places now I've developed these departments of cardiomyocology where patients get echoes after every cycle of chemotherapy to see if they've had changes in their LV function to help guide the oncologist and best how to treat them specifically for anthracycline based chemotherapy it's dose-dependent for Tresc Duzumab once you see the ejection fraction drop you can actually withdraw the agent see the EF normalize and then you can restart it safely and overall these patients have an increased incidence of right ventricular dysfunction and along with left ventricular dysfunction and so that can be an important consideration should they need advanced therapy down the road like an LVAD they have much higher rates of needing right-sided support like a BIVAD or a temporary RVAD when they go for mechanical support so that definitely impacts their outcomes and then another special population that pretty much has a pretty poor outcome but you can try to step in a little earlier to change that is sarcoid classically on the pathology you see non-KC and in gramulomas it's usually a dilated cardiomyopathy they often present with conduction blocks because the sarcoid tends to involve the intraventricular septum where the electrical pathways are they classically have aneurysm formation in weird areas of the myocardium as you can see on this echo they have it in the septum in the inferior lateral wall not not always in the apex a lot of the patients will be of Scandinavian descent sometimes Japanese and African-Americans diagnosis with biopsy you can also see it with some changes on MRI and then you can also see the amounts and activity of sarcoid in FDG pets you treat it with steroids but in patients with advanced sarcoid 80% of the death is due to cardiac disease so it's actually recommended that if you have a patient with sarcoid you at least screen them for heart involvement and the easiest way to do that is either an MRI or an FDG pet which they do that here and another one to be kind of aware of is giant cell myocarditis these people present very dramatically they come in in fulminic, cardiac and shock they often have elevated biomarkers but not always they have very unstable arrhythmia is VT storm is also something that they'll present with you diagnose diagnosis with a biopsy or with an MRI and you basically blast them with steroids plus or minus IVIG and you'll see them turn around really fast but that's the important thing because if you don't catch it you'll see them go the other way very quickly because they're so unstable a lot of these patients will require temporary ECMO support to get them through the period until they recover and then something that's important to know is in these patients when they recover they a lot of you know when they do make it through they say what do I do now what can I do well they can do pretty much anything but no competitive sports for three to six months and actually had a patient on like this a few weeks ago as a 19 year old she just like showed up in the hospital and we put on ECMO and hit her with steroids and she walked out of the hospital and that was incredible another particularly interesting type of cardiomyopathy is left ventricular non-compaction these patients it's a genetic disease really not sure of all the genes involved and what makes people progress to heart failure because in the community you can see patients who have LV non-compaction but have normal ejection fraction they do have possibly an increased risk of sudden cardiac death they should not participate in competitive sports that's important when you're counseling your patients who have LV non-compaction no competitive sports if they have an ejection fraction less than 35% they should be placed on warfarin it for full anti-coagulation to prevent formation of thrombi and these little crevices in their LV and it's also important to know the indications for ICD for these patients which includes a family history of sudden cardiac death if they have lots of non-sustained matricular tachycardia on monitoring if their EFs less than 35% and also if they have unexplained syncope and then finally arithmetic right ventricular cardiomyopathy you know a classically this involves men as in a three-to-one ratio but women are diagnosed with this you know occasionally and it's important to remember for them that you also have to advise them and their first-degree relatives that they cannot be active in sports this is a really recognized cause of sudden cardiac death and athletes but it doesn't have to be if we can pay attention to our patients screen them you see this classic Epsilon wave on their EKG so just something to keep in your back of your mind as you're seeing patients so I have just a few questions so we'll kind of test some knowledge so the first question is it'll just be free answer just call out what you think cancer is so there's a 45 year old African American woman with breast cancer and she has had anthracycline based chemotherapy with her last dose given three months ago and she was diagnosed with chemotherapy induced cardiomyopathy with an EF of 25% she does have some fatigue and dyspnea with climbing you know even a few stairs which initial medications would you prescribe so let's go through the options would you put her on metoprol tartrate and lysine a pearl carvetolol and low sartan carvetolol and lysine a pearl or hydrolyzing our schedule combination and lysine a pearl so you know you want to put her on your good guideline directed medical therapy so that includes a beta blocker right first line beta blocker 1a it should all be on beta blockers and we want to use those evidence-based beta blockers so is metoprol of tartrate one of those no so carvetolol and then I haven't given you any evidence that she's ace intolerant and so 1a also an ace so the answer here would be carvetolol and lysine a pearl okay and even though she's symptomatic she's not not yet done on any other medical therapy so you wouldn't jump first to the hydrolyzing isotope combination that's more for class 3 4 heart failure if they're already tolerating their guideline directed medical therapy but still symptomatic okay any questions about that question question to the same patient comes you a year later and you do an echo and her EF is now 55% yay and she asked can she stop her medications because they're kind of a hassle for her to take every day and what do you tell her no yeah sorry so we kind of talked about that she cannot discontinue either medication okay you want to keep her on those watch her watch her LV function and you still want to kind of try to titrate her medications as well question 3 69 year old man with coronary disease and ischemic cardiomyopathy has an EF 30% he's on his guideline directed medical therapy with long-acting metoprol, captupril and a plurinum his resting heart rates 85 and his blood pressure is 110 over 65 he can climb stairs at home without any dyspnea or chest pain and he doesn't have any edema so he's feeling pretty good what changes to his medications do you recommend so my first question is which NYHA class is this patient he can climb stairs he doesn't have any symptoms when he exerts himself he's a one okay so he's an NYHA one he's on a beta blocker an ACE inhibitor and aldosterone receptor antagonist his heart rates 85 his blood pressure is 110 over 65 so do we make no changes he's doing great keep doing what you're doing do we stop his captupril and start in teresto do we increase his metoprolol do we start coronary what you guys think so this one this one's a tricky question it has a few a few extra things in it so the answer is you want to increase his metoprolol succinate okay so the key to this question the root of it is even though people are doing well you want to try to maximize their medications because you're gonna get the best bang for your buck at the highest doses that they can tolerate okay and you know that he needs higher dose because his heart rates 85 and that's not really goal you really want their heart rate to be less than 70 okay and so and I you know I try to tricky a little bit his blood pressure is 110 over 65 that's fine if someone's EF is 20% they don't need a blood pressure of 120 over 80 and really you don't want it to be that high you want them to be down in like the 100s the 90s as long as they're not dizzy put push the meds okay so and you don't want to use in teresto because like I said in teresto is reserved for patients who has symptomatic heart failure so NYHA class two and three okay we're all kind of tempted to use the newer fancier things but the good old-fashioned heart failure medications are really what you go for first and then you wouldn't use coral and ore because they're currently not on maximally tolerated doses of beta blocker okay questions about this question in which patient with heff ref would you add hydrolyzing nitrate combination a white man with a class three heart failure who's already on an ace in a beta blocker a white woman class three heart failure who's not yet on medical therapy an African-American man who has class three heart failure is hypertensive and not yet on therapy an African-American woman class two heart failure who's on an ace in beta blocker already or an African-American man who has class three heart failure who is already on an ace in a beta blocker we're hearing C E okay E good so we know that we use hydrolyzing nitrate combinations in predominantly African Americans that's when the data is patients who are on the guideline directed medical therapy with an ace or an arm and a beta blocker and still symptomatic which is class three or four so you're exactly right last question 55 real women's refer to you after diagnosis of dilated non-eschemic cardiomyopathy and you look at her echo and these are still images for you and this is what we see in her echo anyone notice thing particular dr. Colton sees this a pointer so actually here and then this is short axis here what is this what is she what kind of cardiomyopathy does she have lb non-compaction good so she has mild fatigue while at work she's a nice this is my this is an actual patient I have by the way she's an ICU nurse she has some dyspnea when climbing stairs no one in her family has ever had sudden cardiac death and she's never passed out before she came to see you her referring physician had already done a halter monitor on her and she didn't have any arrhythmia is no non-sustain vitricular tachycardia and so you're going to start around good medical therapy with Carvetta law and Lysin April and what else should you recommend now remember oh I didn't tell you this but her EF is 20% she's just getting started on medical therapy yes her we'll say her qrs her qrs duration is 150 intresto warfarin hydrolysis and estradiol or should you put it in ICD or some combination of the two but single best answer so she's new to medical therapy and what NYHA class is she I'd say she's a two so class two new to medical therapy you just started Carvetta law and Lysin April I'm trying to give you that she doesn't have any of the scary scary risk factors to tell you that you have to jump to an ICD okay and remember we we put ICDs in patients unless they have some immediate indication we give the 90 days of medical therapy before we do the ICD so it's not a CD will we give her intresto now probably not because we're just starting her medical therapy same with hydrolysis and estradiol we do that if they're already trying to get tolerating medications so the answer is warfarin she has LV non-compaction her EF is less than 35% she is at risk of developing murals from by in those little crevices and so the key to this is just to remind you the patients with LV non-compaction with EF of less than 35% unless they have an incontraindication should be on full anti-coagulation with warfarin to prevent them from having streaks that's a hard one I can't I can't quote you evidence on that you'd have a lower yeah yeah but I will tell you that this is my patient and her LV function has improved and she is not getting an ICD at least right now so it's possible I have another though I have another patient though who's a man who has LV non- compaction and his LV function isn't going anywhere so I mean yeah yeah well and the hard thing was to her echo wasn't really that obvious that she had LV non-compaction so I sent her for an MRI and that was very clear that she had non-compaction and the EF on her MRI after night and I actually had been a while she got a medical therapy


Hello there, this is Bhavya Kaushal and here are 4 news that rock the news bulletin beyond India. Here's some exciting news for people looking to invest in Uber. The ride-hailing giant is reportedly selling $10 billion worth of stock in its initial public offering. World's largest automaker Volkswagen AG is looking to purchase a big stake in China-based track motors. According to reports, the automaker has mandated Goldman Sachs as an advisor on the plan. Facebook is now copying Google. The social media giant announced some new features to combat fake news and one of them imitates Google's paid rank algorithm. Alexa uses Beware because thousands might be listening to your conversation. According to a report by Bloomberg, it was revealed that Amazon's voice assistant has humans listening to your voice recordings.


It's now time for Member's statements. Member for Ottawa's Centre. Thank you, Speaker. I rise on some somber news today. Unfortunately, we have an intractable problem in Ottawa, which I know is shared across the province, across the country speaker, and that is an affordable housing crisis and a homelessness crisis. I want to salute my colleague, Catherine McKenny, who's the Councillor in Ottawa for Somerset Ward, who is moving a motion later this month for a housing emergency. Speaker, at this point right now in our city, 12,000 households are waiting for community housing. 600 people are living in cramped hotel rooms, which have been rented by the city because our shelters are overflowing. 19,000 households in our city spend over 50% of their income on shelter, leaving them impoverished. And last night, Speaker, according to Public Health Reports, 92 people slept outside in the cold Ottawa winter. I think that should be sobering for all of us, thinking about generosity to holiday season that so many of our neighbours in Ottawa and around the province are living without affordable housing. I want to salute Councillor McKenny's call. I also want to make note, Speaker, of the fact that in as much as we debate how much money we have for housing, another announcement crossed my wires today. And that is that Canada's banks have recently disclosed that they will be paying out bonuses in excess of $15 billion to executives in the banking industry. I want to ask us at Christmastime what kind of a province we're living in when billions are flowing to banking executives and people don't have a safe place to live. We need better priority, Speaker. Thank you. Thank you. Remember for Ottawa West and Appian. Thank you, Mr. Speaker. From a young age, I was incredibly fortunate to be able to rely on the world-class care provided at the Children's Hospital of Eastern Ontario, CHEO. I was born with a cleft palate, Mr. Speaker, that could very well have left me with difficulty speaking were it not for the incredible doctors at CHEO. They have since provided top-notch care to both my brother and I as we were growing up dealing with various health challenges. Since then, I've tried to give back to the hospital that's given my family so much. I volunteered with them for over 20 years, including at their annual Telethon fundraiser, and I was honored in 2007 to receive CHEO's Order of the Good Bear Award. Last week, I had the chance to tour the site of the future One Door for Care project on the CHEO campus, where initial geological work is being done and is already underway. I was incredibly pleased when our government committed funding to this project in our 2019 provincial budget, a cause that I've been fighting for since my election. The One Door for Care project will centralize mental health and developmental services at the CHEO campus, providing a one-stop shop access to families who are in need of support. I'm excited about this project and how it will improve services for children and youth across Ottawa. I look forward to continuing to be a champion for CHEO as an elected representative as I have my entire life. Thank you, Mr. Speaker and Merry Christmas to everyone. Thank you very much. Member of Statements, the member for Kiwetanom. Miigwecha, Mr. Speaker, today I rise to speak about the United Nations Declaration on the Rights of Indigenous Peoples. In March of 2019, I stood in this house and introduced my private members bill to implement the United Nations Declaration on the Rights of Indigenous Peoples in Ontario. Bill 76 would require the Government of Ontario to take all measures necessary to ensure that the laws of Ontario are consistent with United Nations that declaration of the rights of Indigenous Peoples. On November 28, 2019, British Columbia passed Bill 41, which makes it the first province in Canada to pass the law that implements Andrew Drepp. This is a historic shift in Canadian legislation and I commend British Columbia on passing such an important law. British Columbia has stepped up and showed that they have the political will to lead colonialism where it belongs in the past. I stand here, I stand here again and again and talk about many issues, and the equity and the inequality and the access to services in the North, environmental racism, lack of clean drinking water, basic human rights. I normalize when our people pay for the mistakes of the government with their health and with their lives. I am tired of the jurisdictional games that are played with the lives of the people. If Ontario, and it could be, supports the human rights of Indigenous people in this province when, then why aren't they doing the right thing in moving Bill 76 forward? We got you. Thank you, Member Statements, the Member for Peterborough Corridor. Thank you, Mr. Speaker. We've reached the time of year when our focus is on Christmas and the concept of giving without an expectation of receiving anything in return. I'd like to talk about a young girl from Lakefield, a community in my riding who embodies this. When she was just nine years old, Faith Dickinson found herself wanting to do something because she learned that when cancer patients are in the middle of their treatment, they often get very cold. Faith knew that her fleece blanket was something that kept her warm when she cuddled up with it on the couch, and this inspired her to do something to help. Her idea was to make fleece blankets for cancer patients, hoping it would bring warmth, comfort, and a sense of love to those individuals who are fighting this horrible disease. So in 2012, she made her first cuddle blanket and gave it to her aunt who was battling cancer. Her initiative has grown, and she now has a drop-in center in Lakefield where volunteers come in to help make this little gesture that means so much to those who are fighting cancer. To date, she has given more than 4,000 cuddles to patients across the globe. In 2017, Faith was awarded the Princess Diana Legacy Award for her charitable work and was actually invited to attend the Royal Wedding of Prince Harry and Meghan Markle. Thank you, Faith. Your small gesture for those battling this horrible disease has made life a little bit warmer and a lot more loved. Thank you. Member Statements. The Member for Hamilton, East Stony Creek. Thank you, Speaker. I had a visit the other day from Elizabeth Stack. Elizabeth is a constituent, a registered nurse, and one of the 43 and a half thousand members of the Registered Nurses Association of Ontario. They are NAO as asking us, all of us in this legislature, to focus our minds and resources on an escalating public health crisis in our province, opioid overdoses. In 2016, just over two Ontarians on average were dying a day from accidental opioid overdose. In 2017, it was three per day. In 2018, it was four per day. And in the first quarter of 2019, on an average of over five people died per day across our province as a direct result from opioid overdose. And yet, in the face of this crisis, the government response has been wholly inadequate. Rather than meeting the crisis head-on with focus on saving lives, they have placed an arbitrary cap on the number of consumption and treatment services sites to 21. This in a province in which communities from east to west, north and to south in all of our writings are dealing with loss and grief from accidental overdose deaths. Moreover, 18 months into their mandate, only 16 of those 21 sites have been funded. This government's approval process has been bound communities into knots with bureaucratic and political barriers. I urge the government to listen to our frontline health care workers who see the real impact of the crisis every day as part of their jobs. We must listen to our nurses and hear the cries of help from constituents who are struggling with their own addictions, as well as those who are dealing with the loss of loved ones to these addictions. This government must move as though life depends on the response because it does. Member Statements. The member for Mississauga Streetsville. Good afternoon, Mr. Speaker. Twas the night before Christmas, and all in this chamber, will reflect upon 2019. So let's take a look at the numbers. 271,600 the numbers of jobs created. $30 billion in infrastructure funding to build what is needed. A billion dollars saved annually through centralized procurement and fixing the hydro-mess so the lights can stay on for our seniors is a requirement. We announced $27.5 million in support for indigenous economic development. And we've invested $1 billion to ensure that affordable housing is built. We also have teams who collaborate patient-centered healthcare to announcing long-term care projects so those who need not be in the hospital can be elsewhere. We increased the number of high-dose flu shots for those most vulnerable and invested in programs and services for our seniors so they can be more comfortable. We're telling the world that Ontario is the place to be to do business, for jobs, raise a family, we all agree. But we acknowledge there's more to be done. Our law, Travallo Ensemble, and let's continue the work. So let's work together. I conclude my version of this classic. My friends in the opposition, let's try not to be so dramatic. Please, all members, staff, clerks, come back safely in the new year. The opposition, the independence, our government caucus, and our premier. Have a merry Christmas, happy Hanukkah, and a wonderful new year, everybody. The member for Essex. I thank you very much, Speaker. As always, it is a great pleasure to rise in this house to recognize the achievements of the great people in the Windsor-Essex region. Today, I have the honour of recognizing swimmer Julia Lane from Windsor-Ontario, who is a four-time world record holder with a pending fifth world record after competing in a swim meet in Windsor this past weekend. At just 20 years old, Julia holds the Down syndrome world records in swimming for the 50 fly, the 100 free, the 200 free, the 400 free categories, and a pending fifth record for the 50 free category. Julia's first three records were set at swim meet in Windsor-Ontario on November the fourth, and the fourth at a swim meet in London on the 24th of November. Julia's dedication and passion for swimming started at the age of three when she started hanging out around a pool deck. Julia swims six times a week and trains in CrossFit, waking up as early as 4.30 in the morning for practice. She is currently training to compete in the next world Down syndrome games in Portugal in 2022, where I know she will make this entire country proud and inspired by her achievements. Julia is truly an inspiration to our community, province, and country. At 20 years old, this is just the beginning for Julia, who will undoubtedly be setting world records for years to come. I look forward to following her achievements and are demonstrating that with dedication, passion, and commitment, the sky is the limit. Julia, we are also proud of you. Thank you for inspiring us all, and good luck in all your future endeavors. Member statements. Member for Ottawa South. Thank you very much, Mr. Speaker. And I'm really pleased and proud to say a few words about my father-in-law, Lauren Nelson Hooper, who passed away on the 30th of November at the Perlion Rideau Veterans Health Center in Ottawa. And he was born on August 17th, 1922. He served his country both in the forces and the Department of National Defense for more than 60 years. He also left an incredible legacy of a family, an only daughter, Linda, who is my wonderful wife, patient wife. Three grandchildren, Kirsten, John, and James, and three great-grandchildren, Vaughn, Sloane, and Fraser, who all got to visit him the week before on the Saturday, which was really quite special. At age 94, he wrote a letter that got his wife, Eva, and my mother-in-law, a chance to meet the Queen, a really incredible thing which goes to show, even when you're 90, there are things to look forward to. An incredible person had all his marbles, scored higher in cognitive tests than I would, peacefully went into sleep, so something, I think, that was very fitting for him. And I just wanted to say a great deal of thanks to his friends, Olaf and Pat, Joanne and Claire, Joyce and George, and the many others who visited him quite frequently. He was never missing any visitors. But you made a big difference in his life because you took a genuine interest in him because he took a genuine interest in everyone. And I want to thank the staff at the Pearly and Rideau Veterans Health Center, especially the folks on Ottawa II East, the recreation staff, all the staff there. They knew him as Charlie Brown. Yes, he got himself a nickname. He made up his nickname. They took it up, it kind of looked like Charlie Brown. And it was really special to him, and they treated him in a great way.  And I, we, Linda and I, and all our family, can't thank you enough. Thank you, Mr. Speaker. Member Stavins, a member from Mississauga Center. I had the pleasure of attending the Cindy Music Festival in my region of Peel. I would like to thank the Cindy Association of North America or Santa Canada for inviting me. I also want to take the opportunity to congratulate the organizers, the volunteers, performers, and attendees for making it such a successful event. Without all of their hard work and dedication, it would not be possible to put together one of the largest shows of the Cindy culture and music in our community. The Cindy's are an Indo-Aryan ethno-linguistic group who speak the Cindy language and are native to the Cindy province of Pakistan. And they are so very proud of their language and traditions, which they are passing on to their children, which was very evident at the event. Ontario is a vibrant province with a diverse community that welcomes residents from all around the world. And this is reflected in my writing of Mississauga Center across the region of Peel and, of course, across Ontario. In Ontario, we proudly share our culture as well as celebrating the culture of our friends and neighbors of different backgrounds. And this is what makes my job as an MPP so very exciting. Experiencing the vibrant tapestry of cultures that make up Ontario is a true privilege. It is undoubtedly true that music is a universal language which transcends linguistic differences and unites people from diverse backgrounds. So I truly enjoyed listening to the different performers from all around the world and all the way from Pakistan. And I even danced to the different music that was there and there's a video as well. But, Mr. Secretary, I just wanted to say it's been an honour and privilege to serve the past 18 months and I wish everyone a merry Christmas and thank you very much. Next, we have the member for Don Valley Norris. Thank you, Mr. Speaker. Tomorrow is December 13th, the 82nd anniversary of the Lanjian massacre where hundreds of thousands of innocent children, women and men become victims of unimaginable war crimes happened in Lanjian in 1937. There are many survivors with a lifetime of pain and suffering. Two years ago, the Ontario Legislature passed a motion in 1966 which recognized December 13th as Lanjian massacre commemorative day in Ontario.  Rather, public truth hearing leads to a journey of healing. Forgetting the history means betrayal and denying the crime is repeated again. We must all work together as the community to educate others, especially the younger generation, about what happened on December 13th, 1937 to make sure as the years go by, this tragic moment in history will never be forgotten and never repeat itself. We must also acknowledge the horror of these crimes, learn from the lessons of the past, strengthen our commitment to peace and build a better world for all. Thank you, Mr. Speaker. Good job. Thank you very much. Reports by committees. Pursuant to stand.