Everybody forced here up in 23 24 series one hockey six box number four random teams or random now Then we'll get started. Good luck everybody. That is a four and a four over there Eight times. Oh, he was never made it. Hmm. Interesting names first one two three four five six seven and eight DW down to Kristen P. He probably feels pretty safe that he's not hasn't they won't make it teams eight times one Two three four five six seven and eight Tampa Bay down to Dallas Everyone they played in the Stanley Cup final in the bubble Dallas got whooped They can open every sport down All right DW with Tampa Bay Kerry Kay Panthers Henry C senators DW sharks Taiji flyers Stephen Kay Leafs Christopher a Canadian's John W. Penguins Nangas Kings Taiji Blues Daniel G. Kraken Rick T. Canucks Kevin L. Bruins Mark L. Capitals Nangas Flames Lana K. Prez Daniel G. Avalanche Nate S. Rangers Frank Y. Ducks Min Q devils Jerry H. Jackets Stephen K. Oilers DW Hawks Christopher a wild Daniel G. Coyotes Mike C. Knights Jim G. Islanders Brody C. Sabres Mike C. Red Wings Stephen K. Canes Jim G. Jets Kristen P. Stars Let's get him posted. Let's get started Jake The real Jake Guthridge is here.  He never uses it anymore All right stat box of Kutra dry side of Superstar and a silver of Sam Bennett for the Flyers Silver was outburst. Yeah outburst over outburst over Stars on his morning leaves got a Brian Russ clear For the penguins and a cop it in young guns Bruins I'd recap the clear to Jaker Gensel there's no jaker Gensel Jake doesn't know who Jake Gensel is so you can't is not allowed to do that one That's not cool. Mitch Marner teachers pet Caulfield Superstar and a young guns canvas of gutman for the Hawks Oh Yeah, that would be not great if we made a jaker Gensel got a Nazeem Kadri special edition Pelletier Dustin Wolf young guns flames Solid one airport of flames All right, here we go in business All right, come on Phillies. Let's go Let's go Phillies Line a 285 Capri saw portraits wild York strand canvas for the Kraken Star search Kent Johnson jackets McDavid stat box Oilers and Stasny young guns for the Predators You'd off double. Let's go. That is a posture knock on the star zone to 50 for the Bruins Star zone pasta, I guess that would be Some of the exclusive is it? Poshmark 18 and 50 there you go Boston great one there stars on Crosby and a herosie young guns for the Canucks But roll a dive for the checklists here one two three left four five six right for all the checklists for the whole break For these will go right. He's a go right Come on. Kathy honest Yalla teachers pet Carter Hart Superstar in a canvas of Arvidson I think I'm gonna go to the soldier's game Thursday. I didn't go last week. I was too tired, but I'm going this week I'm going this week I'm gonna get a hot fight got Dazzars Mark Andre flurry for the wild McKinnon Superstar Any traveling fans there? Ready to get ready Special edition is Chuck for the Senators Derondo and a gust young guns for the Hawks Dude, he's he's got like he's not a perp Richard Bye Donnie Make sure to buy all the Star Wars spots tonight got Braden point 285 Mark Stone Knights portraits You don't need a loan you will be alone. Oh Got him Star search Sanderson Senators report card could chuck and a rusek young guns for the savers All right There's one back and advance on a throw Fired up fired up advance on the throw there it is there it is. I Don't know why he tried to throw home If you would have just thrown the second That's that that's that's the experience right there you got to throw that you got to hit that the second immediately Yeah, dude, he's like it's the fastest catcher in the league I Breaking allure. I believe Thursday Star search stutzler Senators report card McCann our poor car teachers pet Kessel young guns blues Let's get some breaks filled up everybody. Let's get some breaks filled up closest thing to filling is probably killed the divisions at five Merlin's at 11 now And we've got mosaic no huddle is moving pretty pretty nicely also 13 to go on mosaic No huddle. I'll give you a Offering you to fill up breaks if you buy every spot tonight, John We'll give you every spot on the trash list one through ten every spot remaining in breaks tonight We'll give you spot on the trash list all of the spots and All those spots in the break that you purchased will give you as well.  It is a phenomenal deal. I've never offered that before Nusion Hopkins Oilers 95 McDavid Superstar Canvas of Gensel jaker Gensel is what we'll call him And Angelista special edition Derondo young guns for the Islanders Do we would have an amazing night if John bought every spot left? Pedersen Cadre honor roll on the superstar young guns Silver outbursts of Angelista for the predators That's a good one. That's a good one Eichel honor roll Gerard young guns Did I skip the bidard? I did pass it didn't I as soon as I looked away, dude As soon as I looked away Yeah, there it is dude monster as soon as I looked away Yeah, dude. I thought John was gonna buy all the spots.  I forget which one It'll go right Be cool would be cool God Slavkovsky on the star surge from Montreal Got Luke Hughes young guns. What a box here amazing box devils Got a uh Dushane special edition report cards to Sturkin our report card teachers patch Sturkin and again young guns flyers Dazzlers is Fox for the Rangers Kyle Conner Chuck I I agree. I I hear you on that mic got a deluxe of 250 Logan Thompson for the nights Logan Thompson nights star zone Stamco's and a hunter mccount mccount young guns for the jackets There it is bro.  Hello jaker genzel Yeah, the first ones were going crazy like they're rare, but they're not like That rare got dazzlers blue is uh marsh marmal For the stars ranton and zegross What it's like whenever you like two cases two three cases or so something like that So it seems like they've been falling Red special edition is carlson sharks There's a cross v derondo young guns for the islanders Jake doesn't even know who jake jake genzel is Erickson stat box Uh, we got a larkin superstar kent johnson canvas for the jackets Oh, is that what There we got one Dude, I was distracted by by john and chat messing around. I missed it. It's going like right past it God could chuck stat box big rookie mistake there guys stutzel superstar And dobbson silver outburst for the islanders Yes, that's that's a sweet one. That's a sweet one So that's how you uh more than 10 extra break spot right there Uh mckinnon special edition got matthew could chuck 285 panthers and a guinning flyers young guns Yeah, it's only the second case who opens so Lofton you got especially cove superstar canvas of skinner Every other case maybe three cases. I don't know uh connect me for the flyers Peter's pet Crosby and clevin young gun senators Crosby probably was a teacher's pet Capri sob 285 got a marner just a marner one is so ridiculous Zuccarello canvas He looks like a child too. I know He's a he's a maple leaf. He's a child Larkin star zone luke Hughes debut dates and a luke Hughes young guns second luke Hughes of the break That curveball is getting Yeah, he's he's I think what's his name was von darlin was talking about the spin rate Star surge adam fox like he means like one of the top hunter mccount young guns Yeah, it seemed like they were in first inning they were hitting his his fastball pretty well, so he was like, all right. Well I Keep them guessing You know they hit the fastball got our saw baneers on the portraits going to the kraken Sanderson there on the canvas They're also swinging it all of it right now They got them. They got them. They guys got the hitters guessing We did we did Star zone petterson got your aorio and a castle young guns are the blue so they got third castle of the break Yeah, they know went right past it big fail He's bringing he's saving their season right now They got it. They need to start sitting it. They really need to start sitting on it. They will got dazzler schmaltz Second time through the lineup. I bet they they did start tea and all But I'm sure that's kind of the plan as I get him through First time through and see what happens forceburg on a roll as it is essentially of the game seven for them Debutates on the gold here is going to be owen beck from Montreal Carlson sharks and a tristan robbins young guns for the sharks the first robbins. I've seen in just about two cases SSP young guns the alan that is why he's going off Lane cella any red socks and Bruins cards you have Got z-gross teachers pet Especially called portraits for the canes there in a canvas of hagel Lane big-time islanders collector Verhagi star search for the panthers black and white canvas eichel For the knights there and young guns canvas. I think this went right You know, I don't know.  Wow Wow lane bet you feel Pretty foolish It's the best franchise there ever was you got vaslavsky portraits The lighting at choking in the playoffs got a orio canvas young guns for the capitals If three islanders cards zero Bruins cards, what? Lane probably has the dano char islanders cards Seth Jones special edition boon Jenner Uh, don't know. Yeah. Did no, yeah, or did or didn't oh, yeah for the flyers I don't have a posture to be fair I gemmed a mac avoid young guns and sold it Matthew nye's star search for the leaves Well, I bought it like 10 bucks. I was like and then a general like okay. Well, I'll just buy another raw one and keep it Uh kaiser debut dates with a style for young guns for the hawks I wrote the Ilias fire. Yeah, the autos if I got an auto, I'd keep it. I have some Bruins autos that I will not get rid of Got a nice big z auto Kill macarre. He doesn't have he doesn't have autos a lot of stuff though Gotta get the dano signing in some high-end hockey nielander and a canvas of jake alenther montreal Now he's got more time on the van maybe you will So play hockey get a kind of check for So i'm saying he's still around he's like an ambassador or something for Bruins He does something for the Bruins Oh, you know, he's around but he's not playing he's got time. He's got time It was cool to see them play with the islanders Got mathews Kenan Nestorenko on the young guns for the ducks Nola does not have it tonight Got man, there's like a pre-sub superstar Uh tanev on the canvas with the flow All right, zuccarello star zone tage thompson stat box and an aiden mcdonough young guns with the canucks first mcdonough young guns that i've seen as well Very odd that we're seeing new ones and we're almost through two cases. Got a piece of the card sheet there. What? Yeah It was definitely young guns that has that purple on it What's what? Larkin and the report on the teacher's pet special to cop again portraits and a canvas coffield mcdavid rpa That guy's pretty good Too bad he's an oiler It's true He ain't been the same since gretzky left Guys we've got 12 to go on the uh mosaic no huddle We got to get something filling here though Only 12 to go on it Again, we'll break in any order whatever fills up next is what we're ripping next Whatever fills up next so you guys have control over what we break in what order Cooley got hues jack hues on a roll and then a strome Outburst silver for the capitals Yeah, getting obi stuff is a good idea, too Got gadro special edition for the the jackets Ridley greeg on the clear young guns senator's very nice card And a ellison young guns for the ducks right behind it There's last year with the spot to get in the brakes Four or five young guns they're pretty solid this year too or a series one at least Quinn he was on the portraits for the canucks canvas ever his leagans Yes, sanderson. Yeah, there are a few a lot of young guns All right star surge of edinson got ulmark on the teacher's pet And a castle young guns blues a lot of castle in the case No, I wasn't as much of a skater, but I did play a lot of floor hockey There's a panarin deluxe the 250 for the rangers Copatar pelletier flames young guns Astorov debut day at sydney krozby portraits uh lefrenier canvas star surge baneers for the kraken burgren gruden young guns penguins stampcoast 285 adam fox honor roll and a burgren canvas For the wings That was a much quicker inning Got zegros special edition panarin stat box and a greeg young guns for the senators senators doing well really really well Give you dates guppman dry acidal portraits go into the edmonton and forster canvas young guns Flyers Make sure to like the stream everybody do appreciate it quite a bit got robertson special edition stars Carrier you've got a hunter mccount young guns for the jackets Quinn Hughes fiala eichel All right last one everybody Well, let's see a really low number here. I want to see a one-of-one out of this I thought they have one-of-ones They always had them but Like a Gold outburst would be cool I don't know. I don't think I've ever pulled one. So I wouldn't think so. I've never pulled a one-of-one out of Flagship hockey though Not easy to do stars own pasta capri soft stat box and getting young guns for billy Kinects knee marchand portraits March and canvas to foley. I'm just gonna do anything this year They actually look decent Larkin taves mcdonough young guns canucks these and so forth. We just gotta make sure they score defensively there Yeah Good good goalkeeping as well. Yes tending Uh, paneran star zone lindholm stat box and a matthew nye's young guns for uh, toronto. There we go Nice card toronto That's first goal. I think Two three nights ago Over the weekend. We'll just say that dry sidle Pallott andre pallott for the devils gets a portrait It's gonna be sean's haircut pretty soon They're buzzed the side of his head star surge velardi Yo see you've got another one going, uh, right to the the leaf spot young guns checklist dazzlers of cosmenko for the knucks rockfaber neelander That is a luke hues deluxe young guns number to 250 Holy cow this break has been absolutely wild devils min-ku-kay Holy crap, dude 171 of 250 That'll do That will do Uh kitchuck special edition coppin in young guns for the bruins Well, it's not a one-to-one, but uh, that might be bigger than a lot of one a lot of ones you can pull out of this Of the young guns chase Khadri and a canvas of hoffman debut dates of devin levi you got carlson silver outburst of Coppin in for the blues Which would still be awesome Forester here's a clear sealer for the flyers Young guns devin levi. There you go savers teacher's pet is a Larkin there's a petterson and a canvas young guns of matthew nye is pretty nice there for the leaves Okay, yeah, what a what a six boxer Pretty rare. You could rip six boxes of a series one and pull a couple of three-figure cards Our young guns here of levi Coppin in checklist. They all went right goes matthew nye is on that one matthew nye is mcdonough beginning For the recap what's that the canvas young guns for the recap Got a mccount Greig gruden palatier kessel ellison mcdonough Nestoranko Stalber uh denoye Went to the right as well matthew nye is on the checklist there robbins kessel mccount hughes Um clemen ginning dirondo mccount ginning hughes again clevin rusek gust harosi stashney dustin wolf Got coppin in and a canvas of matthew nye is on the young guns Outburst silvers we had a coppin in strome dobson Young guns evangelista for the preds Sam benets we had clear of sealer clear young guns of ridley greig for the scents There's a clear of brian rust. We had a pasta star zone to 50 for boston Yeah, the last six bucks were crazy. We had deluxe to 250 young guns devils jq's As well as the connor bedard draft short print of the uh, hawks draft knight sp All right, that is gonna do it. Thanks again everybody moving on now to whatever's full


I'm former Congressman Steve Israel from New York. I'm now the director of the Cornell University, Brooks Institute of Politics and Global Affairs. And I'm here at USIP to convene our annual partnership with USIP, our Congressional Peace Games. This is where we bring in members of Congress and staff on a bipartisan basis. They work through a simulated conflict and try and arrive at a solution that doesn't necessarily mean going to war. Well, I learned in Congress that we're living in a world of vuca, volatile, uncertain, complex and ambiguous. And when you have that uncertain and complex geopolitical environment, it's more important than ever that the United States lead and lead based on bipartisanship that Democrats and Republicans stand together and stand for the promotion of democracy and peace and security and stability. That's why these peace games that Cornell does with USIP are so important, creating new congressional relationships that are bipartisan, that pursue those very worthy and noble goals. One of the fundamental lessons that I learned as a member of Congress was that I was only as good as my staff and only as hardworking as my staff. And I really relied on my foreign policy and military staff to advise me on critical issues. A member of Congress has to cover a multitude of issues. Congressional staff really focuses on a much narrower portfolio. And so bringing staff into these games is vital because it makes them better advisors to their bosses. We are living in a world of contention. We're living in a world of greater competition. We're living in a world where our adversaries are becoming stronger. They're projecting more aggressiveness. And so that's exactly the time when you want to step back, show leadership, and understand the full range of tools that the United States has in managing those conflicts. It is a natural tendency, I think, for human beings to see something they don't like and want to fix it. Some want to fix it with a military response. Others understand that there's soft power, there's deterrence, there's diplomacy. That soft power is the best investment we have because it's much more expensive when you have to resort to hard power than when you have to face your interests.


Without saying that I've been feeling highly vindicated ever since all this corona stuff not just because the world is ending or whatever But some decisions that I've made in my life that some of you may be aware of I have now become Extremely happy with I made a bunch of very Radical choices. Maybe that's a weird. Maybe that's a a little bit too masturbatory to say but a lot of choices that made big differences and I'm glad that they have paid off now and I mean, it's not just it's not just about corona virus or something like that But let me explain now first off I'll go ahead and tell you the punchline up front because you know I know most in YouTube videos You're supposed to have people watching for the longest time But I'll just go ahead and tell you what I'm gonna tell you and that is a couple years ago. I Decided to live by a heuristic a rule of thumb and that is whenever I have any kind of life decision or I mean it could be a minor thing like on my channel You know use it picking what software to use or something like that or it could be a major thing about, you know Where I'm gonna live You know who I'm gonna date how I'm going to you know Comport myself in general and the heuristic that I I guess the rule of thumb that I now live by is that if Something if I have a decision and one of the choices will make me more Independent and the other will make me more dependent. I will always choose the one that makes me more independent Okay, now a couple years ago when I had the when this sort of came to my head Maybe it was inspiration or something like that or maybe I just read it somewhere and you know don't remember why I read it But when I started practicing this I was in a much different place I wasn't out here and I'm glad you know I couldn't just go over here and get a bunch of low quads for my low-quad tree or something like that I was in my PhD program a bunch of bad terrible things are happening.  I was less free in what I could do That wasn't just in terms of I have to live in this particular place Like in this city. I don't really have control over You know where I get my food and I'm always rushed for time and stuff like like that But it's also, you know, especially nowadays in universities The environment I guess the most charitable way you could describe it is highly stifling Okay, you just don't want to be around there like it's just not a good place and you know I could definitely feel that increasing.  You got to make six figures out right off the bat and stuff like this And we're on the other hand my other choices were basically I'll just go into the woods or something like that But I will tell you that was definitely the best decision I've ever made It wasn't a decision that happened immediately But when I had that opportunity when I adopted that heuristic that rule of thumb You know, if I had a decision do I want to stay around here for another year or do I want to move?  What am I gonna do? I basically just made the decision Okay, I'm just gonna do whatever makes me more independent And you know, one of the things we talked about on this channel is, you know, how technology, you know how people become Extremely reliant on the technology they use and that's why you know The best technology to use is always just no technology, right for most of the things I was actually gonna do a video on that but you know, so Every decision I started making when the within the course of the year Put me further and like made me more and more free now. It came at a cost Let's just say that, you know, I'd be making more money if I were somewhere else Maybe I would have gotten a big job.  I mean it again It's like the best decision of my life and the reality is especially nowadays with the internet and stuff like that You're really not less connected from people and that could be a good thing or a bad thing Sometimes it's nice to be the less connected to people But you know, so anyway, that's the heuristic I made and the fact of the matter is it's always gonna be good in the long term I'm not saying that you should always be like, oh, I'm not gonna take a job because it's gonna make me less free Because there is a sense in which the money you might get that might make you more free, right? But I think the boomer generation definitely lived by this mindset of they're just always gonna be company men You know, they're always gonna Get more and more money and then they'll just rely You know, they'll just hope that they don't lose their freedom in the meantime, which you know And they just took it to such an extent that I mean they lost basically everything They're the most mentally domesticated people in the whole world You know nowadays you still have people like you know You have redditors who are upcoming based and basically make their decisions and constantly worry about what other people think But for everyone else for all the rest of us, right? You know and we have a lot of choices about what makes us free or what makes us less free And the reality is it's not just a buzzword. I'm not using freedom or independence as a buzzword I'm saying when the world is falling apart like you know now I mean, I don't know if it's actually falling apart, but when You know the society is a whole which is highly inter reliant when there's some kind of mess in that system Well out here it doesn't make a lick of difference to me. Okay, it literally doesn't I mean like I'm not I'm not exactly a prepper but when this whole when stuff started shutting down I realize oh like between my pantry and all this stuff I have like months and months of food if I needed to actually stay here for a while It actually be a really easy and that's just the natural environment living in a place where you're more independent, right? You think about things like I mean everything you do is a long-term investment That was one of the best things when I moved out here. I could start getting things, you know I could you know start getting woodworking tools. I have a place to put them I can start like thinking about oh, maybe I'm not even going to use this immediately But I can always invest in my house and all this other stuff So now that you have your own place to live instead of you know living in an apartment or something like that It's just fantastic It's great and the people around here are totally different like they're so much less Domesticated than people in cities, you know people in cities are always thinking about They're always thinking about what each other think and stuff like that.  You know wait. No, what's the expression put?  I mean, you know, it's like people evaluate each other more based on what's real Because the fact of the matter is you know, this is a you know, this is an uncle Ted thing of course The great thing about being independent is that you can always see what your work is doing You know, you can go out and till a garden or something like that You can go out and like create something once you have that ability You don't have to you don't have to think about the opinions of others because you see what you're doing, right? Whereas if you live in a city and you're constantly plugged into the system Even though there are a lot of things in the system that are much more efficient, right? Oh, it can get us food, you know more economically efficiently and stuff like that One there's the thing of everything being reliant on each other So again, if something has to close down everything falls apart And two, you know, it's really I mean, it's hard it's hard to explain like you're You don't really feel like you contribute to the system and you really don't like you're not really necessary in the way that you are here So yeah, that's what I say. So if I have recommendations for people It would just be lived by that heuristic now. I'm not telling you immediately to just move out into the woods or something like that Your life conditions might be different You know, I don't know I'm not gonna speak for other people But I definitely recommend it basically every life decision if it makes you more independent It's probably gonna be good. Now, of course, that doesn't mean, you know, I mean that in a limited sense Let's say, um, the example of getting married, right? So getting married if you're getting married to a high maintenance person, right? That's probably gonna make you more dependent on them You're gonna have to like constantly think about them stuff like that But if you get into a good marriage, right? Sorry, they're not nat season one annoying thing So that's why I'm like rubbing my face and stuff But if you get married to a decent person, right? That should be someone who makes you more independent, right? Because you can rely on them to do things than otherwise and that's the same thing with all your friendships Like if you have friends who you think are a big liability, right? If it's a big pain to keep up with them watch their feelings or something like that I mean, it's not just the feelings thing But that's one of the things I mean a recommendation I have for people in general It's just how especially younger people just have less friends, okay? This is a honest recommendation because a lot of people and it has to do with your personal independence Like I think when you're young especially you sort of want to be the alpha male You know, you don't have all these friends and stuff like that But the reality is most of these those people won't last a couple years.  I just have a lot of regret if I if I could go back like I would care so much less about that kind of stuff Not just I'm not talking about social life in general I'm just saying there's so much noise in your life that people worry about people worry about all this Stuff on social media and stuff like that. I mean, I definitely believe if it's on the internet. It's not real You know, that's why my YouTube channel. It's not really real It's just like a figment of my imagination that I do for some reason and then somehow I get ad revenue Occasionally or some I don't know where that cuts it just comes out of the sky. That's how I think about it But anyway, so that's generally how I think and again, you could apply this in different domains as I said When I when one of the reasons that I use free software in Linux and stuff like that is that when it comes down to it It's it's a great investment to learn how to use Linux and stuff like that because it makes you so much more independent Instead of having to rely on how user interfaces change all the time stuff like that It's great to be able to do your own thing. You know what? I mean, it's just great to be able to be a little more self-reliant and even though it takes some time investment All of this stuff does if you're investing in if you're you know investing your time in the system again I hate using that word but there's no alternative that I can immediately think of but if you're investing your time in the system Or something like that that good. That's that's system internal. It's not gonna matter outside of that But once you're investing your time in yourself, you're never gonna lose that, you know That's one of the mindsets actually when I was a kid people ask me like You know, why why did you first start learning like languages or something like that? You know, I learned Latin when I was I don't 15 16 something like that and the reason I did is because you know My mindset back then is I could make a lot of money and that would be good I'm not I will never knock someone who makes money money making is always a good thing But you know, you can lose money, but there are some things you're really never gonna lose Like if you really learn something that's useful And that has been like learning Latin was a fantastic investment. It doesn't sound like a fantastic investment, but it was That's one of those things.    I'm not all the way there. There are always things that I I don't know how to do I'm still figuring out. I'm still reliant on other people. I'm not saying you need to like live totally alone in the woods I'm just saying you need to move to having that ability. It's always a great thing to be more independent So all right, that's it. See you guys next time


Good afternoon, everybody. Thank you for joining us again today for another edition of Condo Insider. With me today, we have Jane Sugimura, who is the president of Hawaii Council of Community Associations. She's been forever the president. I mean, we've been around since 1975, but a lot of people are still becoming aware of us. And I think we're really making a difference on some of these things that we have to comply with. But so earlier in the week, we had, by invitation with Councilmember Carol Fukunaga, we had a Zoom meeting that included the fire department, the heads of the fire department. And our topic of conversation was on these ordinances in relationship to fire safety, the life safety evaluation. And so it was actually really good. There were like about close to 100 participants, condo board members that had RSVP to be in attendance. And a lot of things came out of it. So we kind of want to go through some of those issues or some of the conversations that we had in regards to the life safety evaluation and compliance. I know one of the big things that the fire department presented was kind of the top categories that are creating condos to fail the life safety. One of the big ones were the vertical openings, the fire alarm system. And then also, which is surprising to me, is they're failing because of the lack of smoke alarms or smoke detectors as some of them. That's the battery operated ones that have to be within, the city code is they're supposed to be over every single bedroom doorway. So even if you have a hallway and two doorways on the opposite ends, you still have to have them above each individual doorway. They can't be just in the middle of the hallway. They have to be over every single doorway. But that simple little five or $10 alarm is creating some of these condos to fail, which to me, that's an easy fix. Yeah, and to me, it is an easy fix, really, because, but the problem is I don't think anybody knows about it, you know? And I think until I got onto the task force, I wasn't even aware, but there is, I mean, there was an ordinance that was passed by the city, except that because they're inside of a unit, nobody ever inspects it. I don't think any condos ever inspect their units, but in connection with this life safety evaluation, that was one of the 17 items.  And we kept telling the people of the 17 items, there are things you can't do.  It is what it is, right? If you've got a nine-story building or a 40-story building, I mean, it is what it is.   And things like standpipes, standpipes are, you know, big pipes that are put into the building when they construct it. So you're supposed to have a standpipe by every exit stairwell, okay? And if they didn't put them in, when they built the building, you can't put them in, well, I guess you can put them in, but it's gonna be very, very, very expensive. So that's one of the things you can't change.  And in fact, they're so cheap. I know my building, we were talking about buying them en masse over at Home Depot or Costco and just giving them to the unit owners and having, you know, maybe, you know, our staff, the maintenance staff install them. But, you know, to me, I said, no, no, no, you can't have the maintenance staff doing that because then when we tell people, you can't use our staff to do your handy work and handyman, you know, the fixing. And so if you say, oh, but we're gonna use the maintenance staff to install your, I mean, your smoke detectors, I think that sends the wrong message. So, you know, people, I mean, they're not hard to install, right? And they're cheap. They're not, they're easy, they're easy. Yeah, and they're cheap. And so that was one of the 17 items that I figured, okay, everybody could pass this, but it seems like that's, but, you know, on the plus side, you know, when that's one of your things that you're failing, that's an easy fix.  And then you have your life safety, you know, the licensed professional come back and do the inspection. And that comes off your LSE. But so what it's saying is that a lot of associations aren't taking the time to educate their owners that they got, and I know in our building, we sent out a memo saying, you know, if we don't pass this life safety evaluation, it's gonna cost everybody an arm and a leg to comply.  You know, let's see how many doors we gotta replace. Make sure that you have metal door closures at the top. And these are the things that make your door close automatically, right? And if you have a doorstop, make sure that the doorstop is off when the licensed professional walks through the building. These are things that people, I mean, the associations have control over.   But, you know, so I'm not so much worried about the smoke detectors. I'm surprised that that is such a big item. The big thing is, what do you call it? The vertical openings. And what came out when the condo people met, right? We had our own Zoom meeting before we met with the fire department is since the ordinance says that buildings that are 10 feet or 75 feet high are exempt from all of the ordinance, why can't we start our so-called problem areas? Like, if you're gonna install sprinklers, start at the 11th floor, right? Or with vertical opening. And the whole purpose of the 75 feet and the 10 stories is because that's how tall the ladder's off, right? That means that the fire department can fight the fire from their trucks without coming into the building, okay? Which makes- I don't think that make a ladder that goes up to 26 floors, right? Yeah, so 75 feet is like the maximum that that ladder goes and that makes it safer for them. They're outside the building and they can fight the fire. And so if that's the case, then why not, when we install sprinklers say, if you're gonna install sprinklers, you can start at the 11th floor, right? Which means the cost of installation is cut in half. Right, right. And if we're talking about vertical openings, that means your cost to fix or to do the adjustment means that you don't have to start for two, right? You can start at floor 11, which is a huge savings. Yeah. Although I don't think the fire department quite addressed that, although we raised it. But to me, I thought some, I don't know who brought it up, but I thought that was a really good idea to start. Since it's already in the ordinance that buildings under 10 stories or 75 feet would be exempt and all of the requirements for vertical openings, because all old buildings have vertical openings. Right. You're not gonna get away from that. And for people who are listening, who don't know what vertical openings are, when you build a building and you have to have wires and plumbing that go from the first ground floor all the way up to the top floor, which is, and if you're 40 stories, it goes all the way up to the 40th floor, they cord the building, they made holes so that these pipes could go up from the ground floor to the top. And then if it was electrical wires or whatever, you ran them through the conduit to get to the 10th floor or the 15th floor or whatever. So there's all these, and that's inside the walls of your building. And then because the holes that they drill to put the conduits into it are usually larger than the conduit, you have to put some kind of a sealant between the pipe, the conduit, and the floor. And so there's this sealant or putty or foam or whatever you wanna call it, but there's something between the pipe and the floor so that the air cannot get through.  Right. And after 30, 40 years, those seals deteriorate. So there's no more seals. So now you got air, you got holes. That's what vertical openings are. And when you have a fire, it creates an updraft. So if you have 40 floors and all these vertical openings because you have pipes that go from every floor, you have conduits with wiring in it that go from the ground floor all the way to the top, right? You have all of these pipes where the seals have all deteriorated. And in order to fix it, that means you have to break through a wall and seal it. And I guess the product that you use to seal the vertical openings is not expensive. It's the breaking through the wall and doing the sealing and closing up the wall and you do it for every floor and you have to do it, I guess, in stacks, right? However, they have the pipes and that's what's really expensive. So if you wanna prevent the updraft, maybe we can have the vertical openings sealed every two or three floors, every five floors. You know what I mean? Not every floor. And then we can start for us floor 11 and go to the top which will cut the cost of repairs because I'm hearing estimates on, I heard an estimate from a building that saw 23 stories and they have to do vertical openings from the second floor all the way up to floor 23. And it's a bill of almost $750,000. And what a mess because with your unit owners, that means somebody's gonna be, I don't know where it is but certain units are gonna be right up against where that opening is.  And that wall is gonna have to be open for an X amount of period of time because they're gonna have to make sure the sealant dries and then if they might have to go back and reseal it again if it didn't completely fill. So that's gonna be time consuming but it's kind of amazing because I was exposed one time. I can't remember what the circumstance was where it was the vertical opening and I was like, wow, you can hear the wind just travel into that area. I was kind of surprised, you know. So- And that's what the fire department says. And they said that at the Marco Polo, I mean, that fire traveled six floors. It went from floor 20, it started at 426. It didn't go down, it went up, right? It went up to I think the 32nd floor. And the way it got up, people say, well, how can that happen? It doesn't come, and people think, oh, that's, and you saw the picture of the fire where the flames are shooting out of the windows, right? That's not how the fire travels. If travels inside the building through the vertical openings. And one of the, and I was on the task force and what we were told, the vertical openings at the Marco Polo, some of them were as big as a person. That mean, because you're talking about a huge building with big pipes, right? And so they said that the vertical openings were huge. And so what happened was the fire, you know, broke, you know, it burned through a wall, got into a vertical openings and then it shot up, right? And that's, and so it doesn't travel from the outside and jump from floor to floor. It travels from the inside of the building and then it goes up and then it burns out through the wall. And so, you know, that's the scary part.  It's not, it's gonna come out, come at you through the wall, right? The vertical openings. And plus they have that wind advice. I mean, the wind advantage too, because in that, where Makropolo is, I mean, that wind that comes down, I mean, it's, if you've ever lived in a high rise in Makiki, I mean, if you don't have those door closers, the wind literally, I mean, I've had instances where my fingers got caught in the door when the wind just slammed it shut, you know? So that wind also just fueled that thing incredibly, you know? So that's another reason why to have, especially with the door closers, you really want that as well, right? That was another item that some people want to try. And one of the things that, you know, that's why the matrix, there's 17 items and a lot of it focuses on doors because with the Makropolo, with the unit where the fire started, the people ran out, they left the door open and then they went down the hallway and the corridor was left open because there were no metal door closers that made the door shut, okay? And what that does is it allows the fire to travel. And that's what makes it, you know, dangerous. And that's why, you know, on the matrix, you know, one of the thing is fire raider doors, they look at the metal closures on the top of the doors to make sure it closes automatically and that there are no door stops, right? That will make the door stay open and they look at doors with louvers. Louvers are no good, right? And so, you know, these are things, you know, all of them. I mean, basically, you know, they're looking at, and the Makropolo had all these problems. They had doors with louvers, they had doors that didn't have automatic door closures and, you know, they left them open. They had vertical openings. They didn't have standpipes by every stairwell, I'm told. I'm told that they had the standpipes at the up. And you know how long that building is? That building was like a huge wave, right? Right. The standpipes were at the two ends. So they had no standpipe in the middle of the building. You know, so which makes it kind of hard when you're talking about, because that standpipe is where the water is, right? And so, you know, and in our meeting, in the condo meeting, I know some people expressed some dismay that we, the other condominiums, we have to pay for what happened at the Makropolo, right? That's what they kept saying, but we're not the Makropolo. Our building is different. It's smaller, it's narrower, you know, and you know, we don't have fires. We've never had a fire. And so how come we got to pay for what happened at the Makropolo?  Something happens and unfortunately at the Makropolo, and you know, this ordinance that was implemented, 19-4 was not the first time in the city that the city considered mandatory retrofitting of fire sprinklers happened twice before. It happened in 2000, happened in 2005. I was on both task force and we were able to stop it, okay? At the Makropolo, you had four people who died. The fires in 2000 and 2005, nobody died.  And so now we have an ordinance that all of us, you know, are trying to comply with. And two things that we found out that those two meetings are private meeting with the condos and the one with the fire department. A lot of us are gonna need more time because we're finding out, we're finding out because of the, you know, because when the ordinance was passed, nobody knew what would happen with implementation. Nobody knew. And now that we are into implementation, now we kind of know. And, you know, it's kind of disheartening because the fire department said they had what 196 LSEs, right, turned into them. And out of the 196 that got turned into them, only nine buildings got passed these fours. That's awful. It is. And I think one of the big concerns for some of the people that were in that meeting were that, yeah, they may have completed their LSEs and it shows a failure, but there's no follow-up between the fire department or that professional completed it to help them put them on a roadmap to be able to, or even go through the easy fixes so that they can pass, you know, and put them on a plan. And then the other comment that I remember was, you know, with Theodore, he, I mean, it was really good. That's why I kind of like want to review that chat because he had all the timelines and he said the timelines don't make sense for compliance like your permits. And, you know, once you get a permit you got to start within 180 days. But, you know, like he said, he may not even have his financing in complete by that, you know, so now his permit's gonna, he has to go revise his permit or reapply for a permit. So that's another issue. But then the fire department says, well, we'll always work with you. And that's set to be a little bit uncomfortable with people because you can always say that in the beginning and we'll work with you. But when the time. So now we got it on tape. Yeah, yeah, true, you know, but when it comes time to it, you know, because right now we're dealing with new players in the fire department, right? Right. So when it comes to really time to it, how are they really gonna work with these individual AOs? They can always say, well, you know, you're not in compliance, you know? But, you know, that's why I thought this meeting was interesting because, you know, there was, and I was, I was, you know, when I saw the fire department, you saw how many there were. There were more than about six of them, right? More than six, I think there was 10. Really? There was a room full of fire department people because it was only supposed to be two, right? On the panel. But then when we sent them the list of how many of us were gonna show up, all of a sudden you got a room full of fire department captains. And I'm thinking, okay, we got their attention. This is a good thing. Yeah.  To me, I thought that that was a little bit of a disappointment because, you know, to me the ordinance is a work in progress because none of us knew, not even the fire department, how it would play out. And what we're finding out and what we're finding out, at least I'm hearing, you know, I'm hearing anecdotally that some life safety licensed professionals, they were told, they knew at the front end when we started this whole thing that they would not make their money on doing the life safety evaluations. They would get there, they would make their money implementing the changes. Right. And I guess, you know, the fact that out of 169 you only got nine buildings passing that shows you that, yeah, we kind of knew that the buildings are old and they're gonna need some work. But the problem is what we're finding out is that some life, some licensed professionals are taking advantage of associations and saying, you know, well, you know, in order to get a passing score, you gotta do X, Y, and Z except X, Y, and Z cost you a million dollars. Well, the one that really stands out the most is the one that recommended that they do a diesel generator and to put it on the roof so that if there was a fire, the fire department could access the elevators via the generator. And I was like, I thought we were told never to use the elevator in case of a fire. Right. And the fire and the elevator company was really upset that that was one of the recommendations. Yeah. And so situations like that, shouldn't we be able to go to the fire department and say, hey, this is what the design professional said. I mean, isn't this against? And to me, the fire department should be able to go back to that design professional, say, what are you doing? You know, and kind of put them on the right path. Well, anyway, that's what they said that that's what, what I said, you know, when we brought that up, they said that they would meet, that they meet with them regularly. And so that they would have a talk with them that this is not in their best interest. There's a lot of business out there. And the thing of it is, is that all of us talk and they saw, they saw over a hundred of us, right? On the zoom. And so, you know, we have a network. And I think that's one thing that, you know, the people on the meeting learn is you got to talk to one another and compare notes, right? And, and, and so that's very powerful because now the fire department is going to be, because they agreed with us that the licensed professional should not be taking care and taking advantage of associations just to make money on the implementation of repairs in order to get a passing score, because that's wrong, right?  It seems like I, you know, a lot of these buildings that I'm hearing about, that's what their licensed professional tells them. So fine, okay, I said, fine, okay. So what's it going to cost us? And, you know, so we went out and we got a bid for the hardware and our licensed professional gave us a bid for engineering. And it was almost $100,000. I said, that's ridiculous. So I went out and we got alternative bids. So if we do, if we do install the fire, you know, alarm system, we're not going to use our licensed professional. We're going to use some other company because he priced himself right out, you know, because I'm not paying that kind of money.  You know what it costs. You know what other licensed professionals in Honolulu are going to charge if, if they're, if they, you get this request about, oh, we're going to install, upgrade our fire alarm system. So we need engineering. What are you going to charge us for this, for 200 unit building, for 100 unit building, a 300 unit building, right? And, and so now he knows. And, you know, to me, that's what us other associations have to do. If you get a huge amount, I mean, you're not wedded to that licensed professional.  So you don't have to put in sprinklers, you know? And we all know that the Marco Polo, and they have 568 units, they paid a little over $5 million to sprinkle their building. Okay, so you can take that as, you know, benchmark, you know, to, to, to, to give you an idea of what it's going to cost to put sprinklers in your building. And, and in the Marco, in Marco Polo case, I mean, unfortunately, I mean, they had this horrific fire, but a lot of the, the, what do you call it, the cost of installing the sprinklers was paid for by the insurance companies.  And it's at the expense of all of us, you know? Of course we don't have a fire. We don't have a fire. So it comes, you know, it comes from our owners. We have this special, special assessment. I had a quick thought too, you know, in getting into this compliance with the smoke detectors is probably reaching out to all the, the rental management companies to get their owners to comply. I think they need to be educated. Right. And then I think I might try to see if I can make a phone call to it. You know those guys that do the, the dryer ducts? Yeah. Try to see if they can do an added service to install the smoke detectors. Because they have access into those units. Yeah. So that's an easy fix. And then every year when they do clean it, they can check the batteries at the same time. Right. You know, but that would be the only other person that would have a yearly access into some of those condos. Right. You know? So that might, I might reach out to, I think Pure Air is one, but that might be a thought that the AILs can easily ask their own people who does their dryer ducts to see if they can do that install. As an added service. We're kind of running out of time right now, but one last shot I want to get to our audience is we found out that there are a lot of people who are upset with the ordinance. And I've been telling people who call me directly, hey, where were you back in 2018 when we were fighting with the mayor, right? And we had all these hearings. And so if we had the cloud, and think of it, think of all the people who live in condos. If we had the cloud, in other words, if we had people calling their council members and saying vote no for the mayor of Caldwell's, ordinance 19-4, we wouldn't have be having this conversation today, right? And so, and condos are notorious for not allowing politicians or elect candidates into their buildings. I think, hey, if you want to avoid these kinds of things, you got to become best friends with your elected officials, which means next year is an election year and we're going to have people who are going to, and Carol Fukunaga, who represents Makiki and part of Kakaako and downtown where most of the condos are, she's term limited, she can't run. We got to make sure that whoever gets her seat is condo friendly. Her term ends next year, right? 20-22, yep. 22, yep. So November, so there's going to be a new, there's going to be an election. She's going to be, a person's going to be elected for her seat and for council district eight, which is my district, which is Pearl Ridge, Pearl City. And so there's lots of condos out there. So I'm going to ask that same question of candidates and what I'm going to do is encourage condominiums to open their doors, have coffee hours, invite your candidates in and become their best friends because let me tell you, if they know that you're interested and when it comes time for them to vote on a special, all you have to do is email them, call them and say, hey, vote no for this bill. Oh, yes for that bill. Then we wouldn't be having these Zoom meetings and meetings with the fire department. And because you saw what they said, they said like, I know we're not going to change the matrix. That meeting was so powerful. I am so glad Zoom is around, you know? It was powerful. So I think we're near our end. So I want to thank you everybody for joining us today. And we're going to have more, probably more conversations on this Riverside in the future as we progress further. So thank you, Jane, for taking time out of your day to join me today. And we will see everybody, we'll be back here again next week Thursday for another topic. So thank you everybody and have a good rest of your day. Thank you, Jane.


If you're travelling throughout the state, it's your responsibility to be fire ready. Check fire danger ratings before you go, and monitor conditions on the way and during your stay, including total fire bans via local radio and the Vic Emergency app and website. When travelling, your safety is your responsibility. The reasons why are black and white. Authorised by the Victorian Government, Melbourne.


This is stock number 9817. We are here at Summit Automotive in Fond du Lac, Wisconsin. You're new and used light-duty truck headquarters. Today we are checking out this super clean 2015 Ford F-150 Supercab short box. This truck has the 2.7 liter turbocharged V6 EcoBoost motor which pumps out an amazing 325 horsepower From this HD video you will be able to tell that this truck is extremely clean all the way around Blue flame metallic is the color. We shoot all of our videos in 1080p So if you have HD capabilities on your computer tablet or smartphone device turn them on right now because it's like you're right here looking at the truck with me this truck comes with the chromed alloy rims these are 18 inch rims and it has Falcon wild peak 275 65 R 18 tires on them and they have probably about 90 to 95% of the tread left These might even be pretty these might even be new tires. They aren't your brand new tires on this truck. So brand new tires Hood is an excellent condition. I didn't see any major dents or dings on that you get the chrome trimmed grill factory fog lights Front bumpers in nice shape passenger side fender is A nice condition as well and the passenger side rim no major scuffs or scrapes on that and As you go down this side of the truck you can see just how clean that body is how reflective and mirror like that paint is We take these HD videos So if you are far away or even if you're close by and just cannot make the trip down You can still see the truck hear the truck and have confidence in the vehicle that you're looking at Before you even get here Blue flame probably one of my favorite colors on the f-150s really good-looking Color very clean down this side of the truck Frame and underbody is in excellent shape and these back tires are brand new as well Back rim no scuffs or scrapes on that and the frame and underbody is Real nice on this ride Lower rockers all look really good You get the chrome tipped exhaust as we come around to the back no dense or dings on the rear bumper Has a full towing package which includes receiver hitch four pin and seven pin wiring Back up camera bed is in pretty nice condition Little bit of light-duty usage, but nothing terrible tailgate shuts nice and solidly As you come to this side of the truck just as clean as that passenger side For full disclosure. This back rim is in nice condition as well. This one does have the Capless easy fuel And once again very clean down this side of the truck does have the door code entry Which we have the code for heated mirrors with built-in directional signals and blind spot mirrors Inside the XLT package gives you the gray cloth interior. There are no rips. There are no tears on the seats They are in really nice condition This one comes with the rubber floor Easy to clean and maintain has the power pedals auto headlamps Power windows power locks and power mirrors the SuperCAD Lows you to open up the doors like so and They also have a power window on the back window The back seats are just as clean as the front seats. No rips.  You can see that this one has 39,160 miles You get the leather-wrapped steering wheel. That's in really nice condition Bluetooth and audio controls on right cruise controls on the left Comes with the AM FM and Sirius XM radio capabilities It does have a CD player as well and turned out four-wheel drive six-speed automatic transmission with the optional tap shift has the sync system to connect to your Bluetooth phone and finally your stability track or stability control and your start-stop feature is Right there. You can turn that off and then your backup camera shows up right there Passenger seat just as clean as the drivers. No rips or tears on that side Very very nice and clean Headliners in nice condition as well. No rips or tears and it does have the map lights right there We'll take a quick look under the hood. I Personally like to thank you for checking out the video today. Hopefully from this HD video You will have been able to tell just how clean this truck is all the way around inside and out Under the hood. We had the 2.7 liter v6 eco boost motor 325 horsepower It's very smooth and you base very clean This truck has been fully safe deed and inspected by our service shop has a fresh oil and filter change All the fluids have been checked and topped off Has four brand-new tires and this truck is 100% ready to go To see more pictures of this truck or one of our other 450 new and used cars trucks SUVs minivans wranglers half tons we coder tons one tons you name what we got it go to our website www.summitauto.com full pictures and descriptions of every single vehicle on our lot videos of every single used vehicle that We have all it's some auto comm if you want to check out just our used inventory You can go to trucks on 41.com. That's trucks on 41.com And if you want to make this f-150 years give us a call right now<PHONE_NUMBER> Ask for one of our sales associates to make this f-150 years today. Once again that number is<PHONE_NUMBER> Thanks again for checking out the video if you'd like to check out more you can go to youtube.com Slash summit auto remember to like subscribe and share on this vehicle video and all the videos that you see there In fact in a second you will see a link to subscribe to our youtube channel on your left a link to more half-ton truck videos Like this one on your right if you have not been to our website on the bottom a link to this vehicle on our website Click those check us out and we really look forward to help you with this super clean to you on 2015 forward f-150 super cab short box XLT. Thanks again


So, yes, I will be presenting on visualizing comfort, palliative care and ophthalmology. Thank you for the introduction. So, I hope this presentation can help us better understand the options or resources we have available here to help provide patients with more individualized care. The share, yeah, let's forget. Oh, no, you're good. Awesome. Thank you. So, we all likely strive to develop, or we all strive to deliver optimal eye care with a particular emphasis on restoring or preserving vision as a fundamental aspect of this mission. However, engaging in various conversations with patients has helped me to reassess the true essence of what best care means. These interactions have presented a challenge in recognizing the significance in preserving grace and dignity in medicine. An aspect that may not always be readily apparent but holds up most importance. And if you haven't watched how I'm gonna highlight a little bit. That conversation starts with how we define the blind and the paid-by. Out of every 10 individuals affected by blindness, one person experiences a condition known as a painful blind eye. This is described by many as vision that is unsalageable and poorly responsive to popular, or poorly untalented. A clinical examples of this include what's listed here. There's a lot more examples of what can prompt us to kind of conserve eye care efforts. In these cases, traditional efforts have been made to help provide comfort but has been poorly infected. So, how do we define pain? I think we ought to challenge a conventional understanding of pain to encompass not only physical aspects but also emotional and financial factors that patients may encounter. These interconnected elements oftentimes magnify one another and then disturb patients' overall experience. Of course, there's the obvious and sometimes not so obvious physical pain that a patient is in. And as evidenced by the cluster of this slide, there's a plethora of studies that show that there's a connection between the emotional and physical burdens that patients might experience. In 1969, Elizabeth Kugler-Ross defined five stages of grief. We've probably all been kind of pushed to memorize these stages. And I think it's actually really important to consider this in our conversations of palliative care discussions. And our role as providers is often crucial to assist patients in making well-formed decisions. And to achieve this, we may need to understand or better understand the time frame for attaining acceptance in these five stages of grief. During my literature review, I saw that it took about on average four weeks for people to define a painful, blind eye, i.e. the pain persists for at least four weeks. Is this duration sufficient for patients to make perhaps critical decisions that might include an evisceration or a nucleation? Grief, of course, is complex and deeply personal. There's no predetermined timeline for how long each stage should last. So it's of utmost importance for us to deeply connect ourselves with our patients and help make them make the best and most rational decisions. This is another cluster slide, but I'm not going to delve into all the possibilities listed here, but it's showing us the various modalities that we can use to help address patients who are in need or in discomfort. It's important to note that these interventions can often lead to significant financial burdens, exacerbating the emotional and physical distresses patients' minority experience. Fortunately for us, many insurance providers recognize the necessity of covering these interventions when a patient receives such a diagnosis. However, we also need to acknowledge the challenges faced by being insured. To support them, we do have charitable institutions here that have been established, examples of which include like the Callister Fund for prosthetics or billing offices offer charitable care after charges have incurred for our patients. These are just a few of very many resources we have available. So what is palliative care? It's a specialized approach to medical care that focuses on improving the quality of life and providing relief from physical and emotional burdens of individuals facing serious illnesses. The primary goal of palliative care is to enhance comfort and support both patients and their families throughout the course of illnesses, regardless of their primes or disease. Who is palliative care? I think healthcare professionals come together in a collaborative effort here to address all aspects of patients' wellbeing. I really also want to emphasize the importance of loved ones in this process as well. They play a huge or critical role in providing holistic care. And in the realm of ophthalmology, there are various tools that we can use to provide palliative care. Here are a list of some of the many. Of course, there's pain management, symptoms of patrol, which I'll talk a little bit about later, low-division devices, psychological support, which can come in the form of counseling or spiritual support. There are also various support groups for specific eye conditions of visual impairments, allowing them to share their experiences with one another, obtain emotional support and access valuable information. An example of which would be in our neurologic clinics, we have migraine support groups, which are listed in a lot of our handouts. The talk of the patients seems to be very, very beneficial for them. There's advanced care planning, education, specifically for patients and their families, could be super important to help them understand a little bit more about their condition, treatment options and available support resources as well. And as previously mentioned, care coordination and it being a collaborative effort is super important. And back to that involved slide, I won't touch in detail on all of this, but essentially there's so many different ways in which we can target the pain and symptomatic management. There's no established guideline that offers clear directives on how to approach patients in these various circumstances. A group in Columbia offered an algorithm which I think serves as a nice starting point. A lot of these symptomatic treatments were already aware of. And I would like to dive a little bit further into the kind of community resources we have here at the Marin Eye Center. And actually in the state of Utah as well. So patients with severe vision loss may benefit from using low vision aids and devices to enhance the remaining vision and improve daily function. Several programs exist to help facilitate that. This includes the Division of Services for the Blind and Visually Appared or DSBDI. Veterans Affairs has a low vision group as well. The Utah Council of the Blind, of course we're blessed to have both outreach and our low vision group here as well. Many of these services can also connect you with other services and such as a library for the blind, senior services, Medicaid if there's financial assistance in need or meals on wheels. For the DSBDI, it provides a wide range of complementary services to individuals in need. These services can include cane training, home management guidance, assistance with technology, computer usage without screens. Additionally, they provide support in patients pursuing their hobbies. And that includes activities like quilting, crocheting, crafting pens or cookies, and even woodworking, which I thought was really, really fascinating. They can learn to operate saws. And I believe the only specialized tool that they have in these groups are a ruler. Interestingly, in the conversation with Dr. Ord, a lot of these patients, they learn blindfolded even if they have some remaining vision. And she shared that some of them would actually do better with the blindfold on than with it off. For the sake of time, I actually won't click on this link. There is a really fascinating link on the DSBDI. It's about two and a half minutes set. Really dives into the patient experience and the options available from there. The Utah Council of the Blind, like the SBDI is another free service, offers valuable, invaluable visitation services and information on skilled assistance and essential aspects of living that includes cane traveling, braille learning, kitchen safety, organization, mobility and so much more. These dedicated teams are equipped with individuals that help these individuals discover adaptive technologies that can enhance their independence at home. The VA, of course, also has free services for their patients as well. The slow care on the fourth floor, they have various support crews and skills in addition to many more resources. At the Moran, we're blessed to have fantastic low vision department. Dr. Bob Hutchinson is dedicated to enhancing day to day functioning for individuals with vision loss. Among his many roles, he evaluates light and contrast sensitivity, assisting patients in identifying and utilizing tools that cater to their specific needs. Dr. Lisa Ward has our patient support program and offers invaluable services such as orientation to vision loss, private counseling and support groups. Amanda as our social worker, she takes charge of facilitating our free support groups. They hold hybrid sessions both on Zoom and in person. These groups operate on a eight week basis with a two week race in between allowing new members to join. This ensures a maximum accessibility and also kind of ensures that they're not introducing, you know, each other every single visit and kind of really focus on what they need to focus on. Upon receiving our referral Guillermo, loyal is not pictured here, but also works in a low vision group, personally contacts the patients to inquire about their specific challenges, ensuring that we provide the best most individualized assistance. Janice, our occupational therapist, conducts in-home assessments to help patients navigate their daily routines safely and independently. Though not pictured here, Dr. Karina Taylor also plays a crucial role in organizing our monthly orientation to vision loss. She was diagnosed with Stargardt's disease and currently teaches at UIU while holding PhD at their symbol. Serving as an inspiration for so many in these situations. While most of our services are offered free of charge, our counseling service notes his fee base and there are limited by the insurance to be accepted. And this is actually fewer than what we use in our typical offalming appointments upstairs, which is interesting to know. In terms of access, so I won't delve into the specifics of how to get access to these various groups within the Moran. I just wanna assure you that, you know, if you have a question or have a need, there's probably an answer out there. I'm happy to share this PowerPoint with anyone who might need a contact or resources to help reach out. But there's so many invaluable resources just right downstairs for us. And so in conclusion, there exists a critical responsibility in improving the quality of life for patients confronting advanced or terminal eye conditions. Considering the burdens they often face with their numerous medical decisions in line. Our primary objective is to center on ensuring that these patients receive holistic support and compassionate care at every step of their medical journey. To achieve optimal care, physicians must excel at attentive listening, valuing and responding to the unique needs and concerns of each individual. I'll leave you on this quote from a German American theologist, Paul Tillich. The first duty of love is to listen. The sentiment holds true in numerous aspects of our lives, including our roles as physicians. When we made the commitment to serve as healthcare providers, we inherently pledged to demonstrate love and compassion towards our patients. So a few acknowledgments. I want to personally thank Dr. Elisa Ward for sitting down and talking to me and sharing these resources, as well as the rest of the little vision team. Dr. Bob Kirsten who engaged in conversations about various treatment modalities for these patients. Dr. Schachall, who actually first initially described or got me thinking about this, it's something I wasn't fully aware of as a PGI one. So we were just driving down and on and he was driving on and he was kind of mentioning these things to me just put it in my mind to begin with. And also to all the faculty, fellows and co-residents I've had the pleasure of working with who have constantly stressed the importance of listening in both their words and actions. I thank you. And so with that, I'm done. I'll leave you with this out of the blue winter. Many of my co-residents, thank you. Take any comments or questions? I can't see. Oh, Brandon, sorry. Great job. I think about late. So it's an interesting talk. I just wrote a book about an author. I do like to do R&D and he talks about he's served a lot of people in the end of life and the last vision and talk a lot about screening their dignity in contact with their habits. That's something I feel like if I don't ask if I'm not purified, sadistic situations, sadistic character, sadistic situations, the process of getting in contact with the board, what is it an email or a view? I'm not sure you said that. Yeah, no, that's a great question. Number one, she is right here. And so I do want to acknowledge your presence. Number two, let me see if I can flip back to that. Sorry. Council, program anytime. Okay, that's just important. Council, it's an ophthalmology vision rehab patient support program. And one of the choices will be somebody just needs resources, somebody needs emotional support, or somebody needs AAR, which is basically a shared response thing that's going on in their lives that keeps them from maybe applying to the treatment program or something like that. So, and then we can follow the patient and assess what they need. And we also have referrals to DSBDI, the state service, if they need training, that is the best place that they can get the blind skills training. Second best is the Utah Council with a blind it's just a smaller program. And they will go out to that. But the DSBDI has a wonderful center. And hopefully maybe in this year we can also do a tour for residents and fellows. And so just to reiterate the question, it was, how do we get access to low vision resources specifically that we saw? So I just flip back to this slide here. That award, essentially, I mentioned ordering consult. So vision rehab and patient support consult. When we order that consult, several different options will pop up that can lead us to whatever direction we choose to go in. Thank you. Yeah. Any other questions or comments? Yeah, actually. So I mean, I feel like I see this a lot that Oklahoma, the hospice with the eye, I think that probably also shares that presentation. But what was interesting to me is actually the place where Lisa was invaluable to me was the patient who had had a stroke and had a home on a second of day. From that, and he was in clinic, actively suicidal from his vision loss. And you guys were just Antarctic and reaching out to him and supporting him through really the first three months of vision loss. So I guess my comment is one, oftentimes for me is, I think of you and I think that the patients who are like in 2,400 count figures, he actually had like the essential vision that he had as an individual, both of you guys. And so I was initially really surprised to encounter how much stress he was. And so it can happen in any vision loss situation, it doesn't have to be what we totally consider to be. And also these are emergent issues to come up and probably sources are incredibly helpful in those situations. So thank you. Oh, sure. And if Amanda and I are here on the screen, we are happy to come up to clinic to talk to those patients who are not dealing with news that's not going to get better. And I'll just briefly summarize that for those online. That just sits in front of a patient who was significantly emotionally disturbed and suicidal as a result of their vision loss. And our resources here at the Moran were able to be contacted. Dr. Orton and Amanda helped, hopefully, save or alleviate some of the concerns this patient had. So I just wanted to restress that they're both non-emergence and emergent ways to contact these resources. And once again, I'm always happy to share this information if you can't find it. One easy phone call away or perhaps email although I don't necessarily respond to those quickly. No. Any other questions or comments? I'm also going to give Gino a quick happy birthday shout out to this birthday today before I introduce Ashlee. Ashlee, I'll be right in, you know. Alrighty. Next up, we have Ashley Polsky. She is another third year ophthalmology resident and she'll be presenting, oh, actually fun fact. She just completed a half marathon, something I can never accomplish. Congrats to you. And she'll be presenting presentation titled, Ugg Syndrome After Hydrous Microstem Placement. Thanks, Nana. All right, I'll go ahead and get started. I have no conflicts of interest to disclose. And this case involves a 72-year-old man who initially presented to the VA walk-in clinic in March 2022 with a chief complaint of headaches, nausea, and blurry vision in his right eye. He reported that when he awoke that morning, the vision in his right eye was very cloudy and he was seeing halos around lights. He also noted a two-day history of headaches localized to his right brow that were associated with nausea and he had no recent injuries or illnesses and he was not on anticoagulants. His ocular history included bilateral, mild, primary, open-angle glaucoma, and non-excited macular degeneration. And a few months prior to this visit, he had undergone cabaret surgery with placement of a hydrous microstem in the right eye. His post-op course was complicated by an immediate post-op hyphaema as well as CME, both of which had resolved about a month after surgery. His ocular medications included latinopross and bermanidine in his left eye and he was finishing a prolonged ketore lactaper in his right eye for his recent history of post-op CME. His chronic health problems included hypertension, hyperlipidemia, and he has synophilic esophagitis. He also mentioned a history of cold sore since childhood and he had no medication allergies, no relevant family history, and a non-contributory social history. On exam, his visual acuity was 20, 30 minus two in the right eye, which was decreased from 2020 at his prior visit. His left eye, which had not yet undergone cataract surgery was stable at 20, 50 minus one. His pupillary exam was normal and he had full extracurricular motility, full visual fields to confrontation in both eyes. His intraocular pressure was elevated to 28 in his right eye, which was increased from about 12, 13 at his prior visit and was actually the highest IOP ever recorded for this eye. Slate lamp exam of the right eye was notable for traceable heart congenital injection and four plus pigmented and non-pigmented cell within the anterior chamber. There was also a very small layering hyphaema inferiorly in the right eye. And on careful examination, there were no iris trans elimination defects and the posterior chamber IOL appeared to be well positioned without obvious fecodynesis or tilt. And I know sometimes photos show up a little strangely on the screen, but this is the split photo of the patient's right eye on presentation. And hopefully you can see there are numerous pigmented and non-pigmented cells being eliminated by the light beam within the AC. With Gonioscopy, we were again able to visualize a small hyphaema layered along the inferior angle. The inlet or proximal end of the hydrous was visible in the nasal angle as shown in the photo here. And this inlet appeared to be just slightly extruded and in contact with the anterior surface of the iris. And if you look at the diagram of the hydrous microstem that I included at the bottom of this slide, you can see that beyond the inlet, there are these three open windows that run along the length of the hydrous. And these windows should typically all be visible through the trabecular mesh work when looking with Gonioscopy. However, in this particular patient, we were only able to see the very first most proximal window, but not the other two windows which made us wonder if perhaps the stent was positioned too deeply or too posteriorly within the angle. We also performed a dilated fundus exam on this patient which was stable with no signs of macular edema and no new revelations. So given this patient's new findings of anterior chamber inflammation, hyphaema, and elevated IOP, we were most suspicious at the time for UGG syndrome or UVINUS glaucoma hyphaema syndrome. And based on the appearance of his hydrous micrason, we wondered if subtle malposition of the stent could be causing UGG syndrome versus something like chafing of his posterior IOL along the backside of the iris, although we didn't see any evidence for the latter on exam. Other considerations included a traumatic hyphaema which seemed less likely given this patient had no known recent history of trauma. Herpetic anterior UVitis was also a consideration, especially given his history of recurrent cold source since childhood. And although our suspicion for this was low, post-op endothelitis was also considered given his history of intraocular surgery a few months prior. For treatment, we continued his daily catorilac in the right eye, and we also added topical prenus alone and cyclopenelate. We started two glaucoma drops, Timolol and Bermanidine to manage his elevated IOP. And just to cover for any potential herpetic infections, we started him on a seven day course of oral valtrex. So this was the starting point, representing my initial exam of the patient in March, 2022. And about four days later, after being started on the medications I just mentioned, he returned for repeat exam and reported complete resolution of his headaches and blurry vision. His visual acuity measured 2020 at this point in the right eye and his IOP had improved to 12. He still did have some residual anterior chamber cells. So we kept him on cyclopenelate drops and began to taper his topical prenus alone. About one month after initial presentation, his anterior chamber inflammation and high fema had completely cleared and his IOP remained stable on Timolol drops. We had the patient return in early May, 2022 to see Dr. Harry in order to attain some additional imaging. In particular, we wanted to evaluate the positioning of the posterior chamber IOL just to see if there was any potential contact between the IOL and the iris that could explain his episode of inflammation. So Dr. Harry performed ultrasound biomicroscopy at the VA which demonstrated appropriate IOL optic and haptics positioning with no evidence of posterior iris touch. And here's another UBM view again with good positioning of the posterior chamber IOL. And in this view, we could actually see the hydras within the nasal angle which the arrow is pointing to in the photo here. We also obtained anterior segment OCT to get a little higher resolution of the hydras and anterior chamber structures. And in both of these images, you can see a cross section of the iris and then just above the iris within the nasal angle, there's that linear kind of thin hyperreflective structure and that's the hydras microstem. And I wanna emphasize that at the time these particular photos were taken, the patient was still using topical cyclopenolate which is known to posteriorly rotate the iris ciliary body complex. And so at this time, we really didn't see clear evidence that the hydras was pushing or rubbing against the surface of the iris even though that was something that we were expecting with his previous episode. The patient's anterior chamber remained quiet and so about a week after those photos were taken, I called up the patient and had him stop the topical cyclopenolate. And I had plans to follow up with him about one week after stopping the cyclo. Unfortunately, within just three days of stopping the cyclopenolate, he returned to our walk-in clinic complaining of recurrent headaches and blurry vision in the right eye. His IOP was still well-controlled on topical Timmelal. However, sure enough, he had a recurrence of four plus mixed AC cell and a new layering hyphaema within the anterior chamber. So we repeated his anterior segment OCT at this visit now that he was off of cyclopenolate. And this time we were a little more convinced that the hydras seemed to be in close contact with the anterior surface of the iris. In these photos, the arrows point to the tip of the hydras inlet. And as we kind of follow that tip with progressive OCT cross sections, the inlet of the hydras seemed to dive further and further posteriorly towards the iris. And of course posterior shadowing behind the device really limits our ability to fully visualize the posterior aspect of the hydras. But based on this downward trajectory that we were seeing of the hydras inlet, we inferred that there likely was contact between the hydras inlet and the iris. So the patient was restarted on topical cyclopenolate and again demonstrated excellent response a few weeks later with resolution of his symptoms and near complete resolution of his anterior chamber cell. So by this point, we were fairly confident that it was indeed the hydras that was causing his UG syndrome flares. And so after discussing options with the patient, we moved ahead with removal of the hydras and goniotomy in July, 2022. Interoperatively the hydras was confirmed to be positioned just slightly too posteriorly which had caused angling of the hydras inlet in the anterior chamber and contact between the inlet and the iris. And thankfully this patient has done very well post-operatively. His vision and IOP have remained stable on topical latanoprost and bermanidine and he has had no further recurrence of anterior chamber inflammation, high FEMA or IOP spikes as of just a couple months ago. So at this time I'd like to transition and just talk a little bit more in depth about UG syndrome and how it relates to the hydras micro-sten. UG syndrome was originally described by someone named FT Ellingson in the 1970s which is why you may sometimes hear this condition referred to as Ellingson syndrome. And UG syndrome is comprised of a triad of uveitis, elevated intraocular pressure and high FEMA. And additional features may be seen in patients with UG syndrome including iris translumination defects, iris neovascularization and CME. And the photo on the right here is an excellent example of iris TIDs in the setting of UG syndrome. And the TIDs in this particular photo correspond to the temporal haptic of a sulcus IOL. Classically UG syndrome is caused by mechanical rubbing or chafing between an intraocular lens implant and the iris. And this often actually necessitates surgical intervention to definitively treat. But in addition to IOLs, there have been multiple recent reports of other types of intraocular implants causing UG syndrome such as capsular tension rings, expressed shunts, eye stents and as in our case, hydrous micro-stents. And I'm sure many of you are familiar with the hydras and have hands-on surgical experience with it but for those who are maybe less familiar, the hydrous micro-stent is a type of micro-invasive glaucoma surgical device that was designed to essentially bypass the trabecular meshwork and stent-open-schlems canal in order to provide a more efficient aglius outflow pathway and thereby reduce intraocular pressure. The hydras received European CE approval in 2011 and subsequently received FDA approval in 2018 specifically for use in combination with cataract surgery for adult patients with mild to moderate po-wag. The hydras is inserted by placing a pre-loaded injector through a clear corneal incision and advancing the cannula tip through the trabecular meshwork until it enters schlem's canal. And then a tracking wheel on the injector is used to advance the micro-stent until only the small in-lamp portion remains within the anterior chamber. And after insertion, as you can see, the hydras spans approximately 90 degrees of schlem's canal. And here you can see the three windows that we were discussing earlier through the trabecular meshwork. And just for review, the hydras has three main components. The first being a rounded distal tip that allows it to pass smoothly into schlem's canal. The second component are those three open windows that I keep mentioning. And these windows are spaced evenly along the body of the hydras. And the goal of this open scaffold design is to dilate schlem's canal without physically obstructing outflow access to egg-based collector channels. And then the final portion is the proximal inlet, which is the portion of the hydras that was contacting the iris in our case. Multiple studies have now compared the efficacy of hydras to other forms of Guacoma treatment. For example, hydras was non-inferior to canaloplasty and achieving a significant reduction in IOP at two years. Hydras was also shown to be quite effective when compared to selective laser trabecuoplasty, with 47% of hydras patients achieving a drop-re-status at one year compared to only 4% of SLT patients. When compared to the ISTN, the hydras achieved a greater reduction in mean intracular pressure at one year and also achieved a significantly greater decrease in number of medications compared to the ISTN group. And when combined, hydras and cataract surgery was compared to cataract surgery alone in a two-year prospective multi-center randomized controlled trial, the hydras cataract surgery group demonstrated more effective IOP reduction and decreased drop burden compared to the cataract surgery only group. And this particular study is known as the horizon study, which was an extremely important trial in demonstrating the efficacy and safety of hydras over two years. About 80% of the original 556 horizon study patients were followed for a full five years. And based on this extended follow-up, Horizon investigators recently published long-term hydras outcomes in 2022. And at five years, the hydras cataract surgery group still showed significantly greater IOP reduction and significantly reduced drop burden compared to the cataract surgery only group. The horizon study did highlight some complications of hydras implantation, including transient post-op hyphema, uveitis or iridus requiring slightly prolonged steroid treatment, micro-STEN obstruction and malposition of the STEN. The only long-term finding that was noted at five years was development of tissue adhesions or peripheral anterior sneakier at the trapecular entry point. And interestingly, about 1.4% of the hydras devices were found to be malpositioned post-operatively. However, none required device removal in this particular study. And although a syndrome wasn't specifically recognized as a significant complication in the horizon trial, a couple of recent cases have been published that highlight a syndrome as a possible, the rare outcome of hydras implantation. And the first case I wanted to highlight is a case from the University of Colorado Department of Ophthalmology. And this patient presented very similarly to our case with persistent pain, mixed anterior chamber cell and elevated IOP about one month following otherwise uncomplicated cataract surgery with hydras placement. And in the corresponding slit limb photo here, they showed that not only was the hydras inlet extruded, but even the first window of the hydras was visible outside of Schlump's canal and was kind of just resting on the surface of the iris. And so in this case, the patient also opted to have the hydras removed after which he had almost immediate resolution and was pain and inflammation, just like we saw in our case. Another case that was published in Glaucoma today discuss a patient who presented with recurrent hyphemas in her right eye about two years after having combined cataract surgery in the hydras placement. And on exam, nothing really seemed to be remarkable about this stand. And in the photo on this slide, you can see that all three hydras windows were visible as would be expected. And the inlet doesn't really appear to be significantly extruded or angled. The ophthalmologist who was managing this patient's care, Dr. Jacob Brubaker theorized that perhaps a hidden vessel within the nasal angle was in contact with the stent and that when the patient was upright, the stent's downward trajectory would allow red blood cells to just escape into the anterior chamber. And he initially planned to also remove the hydras just like the previous cases we've discussed, but based on shared decision-making with the patient, the stent was ultimately repositioned to a new location in the inferior angle after which the patient's hyphemas completely resolved. So this is just another interesting example that demonstrates an alternative approach for managing hydras-related OGS syndrome. In summary, the hydras microsent is an overall safe and effective method of achieving IOP reduction and in many cases also reducing drop burden for patients with primary opening glaucoma. And although cases of OGS syndrome secondary to hydras are rare, it's important to consider this potential complication in patients with recurrent hyphaema and IOP spikes, particularly if there are signs that the hydras is mal-positioned. And as demonstrated in our case, imaging modalities like UBM and anterior segment OCT can be really useful in these OGS syndrome cases, especially for distinguishing between hydras versus IOL implants as the potential cause of inflammation. And finally, although few cases have been specifically published on this topic, hydras removal or repositioning seem to be reasonable options for definitively managing hydras-related OGS syndrome. And I just wanna thank the following people for their involvement in caring for this patient and for teaching me a lot about this case as a new intern at the VA at the time. And special shout out to Dr. Harry and also Dr. Wyatt, one of the VA opometrists who were instrumental in getting me all of these photographs. Here's a list of my references and happy to take any questions or comments. Yeah, Dr. Christensen. I just wanted to say we're actually just approved to do a study on the incidence of mal-positioned hydra-scanicent. So any of your clinics where you're seeing patients who have these will be your information on how we pick them involved with the study that is compensation on auto-managing. But I suspect it's probably higher than what we previously thought. For those online, Dr. Simpson was just saying that they're in the process of putting together a study looking at the rates of mal-position of things like hydra-scanicent. And so keep an eye out if you see any stent mal-position in your clinics. Yeah, how hard was it to get the stent out? I'm pretty sure Cole and Dr. Stag did the surgery, but yeah.  And you just use the injector to like read? Yeah. Retract it? I think Craig had one where it did cause a clot which was unable to repair. But it's not like side-pass, right? That was very, very difficult for them. Which is important. I see, and in view of everything this patient went through, looking back at the decision to put the device in again, what was the need to put it in compelling enough for the patient to go through all of it? Dr. Simpson's shaking her head. Yeah, one of the questions I would ask, you know, is that not involved in doing a home cataract surgery in adults at the VA? Yeah, I mean this particular patient, I'm sure would say no, I saw him many times. And I think by the end of everything, he was very happy to just be on a couple of drops in that eye without dealing with issues of recurrent pain and blurry vision. But yeah, I know we see a lot of other patients that have gotten it in love, not having to take drops, but. Yeah. We're definitely like depending on everything, right? The device first came out and we were like, it's for everybody and now it's starting to swing a little bit more again the other way, which is if you're really, if you have a mild glaucoma and you're stable on your medications, nothing is going to do with the night. And so is it, in fact, I have a patient yesterday where we had a really long conversation about whether or not she wanted to send, she's like, I am 100% fine, just hang on a drop, like stable on a drop, and then follow the patient if that drop needs to be sent. Good presentation. Thank you. Thank you.