What's the word y'all? Today we're gonna be ranking NBA teams on how watchable I think they're gonna be this upcoming season. We did this towards the end of the 2020-2021 season and a lot of people was hot about how I spent my time watching NBA teams. Remember, this is my subjective opinion so if I rank your team low, it is what it is. I just won't watch it as much as you. I think that's fine. It's only one person that can live my life and that is me. And if I wanna live it watching the Bulls be bad, I'll do that. You feel me? Leave it like, subscribe and let me know in the comment section what you agree or disagree with. Just don't be toxic. All right, so here are the tiers we got him in. Just let me walk you through these really, really fast. Tier one and tier two are very, very similar but this is different. Tier one is won't miss a game meaning that if it is up to me out of the 82 games this organization, these organizations play, I am trying my hardest to watch every single game. It's unrealistic because even the Bulls who I try to watch every single game of, I do miss games because real life takes control every once in a while. But I try my hardest to watch every single Bulls game. I put that right there because you know I'm a fan of this team. Whether you like it or not, I will be tuning in to majority of the Bulls games. The next one is Must See TV. I'm gonna make an effort to watch as many games as possible but it's unrealistic for me to go out there and watch 82 games. Pretty fun. A lot of these teams might have special features or special players in a team that make me go out of my way to watch them. Enjoyable is exactly what it sounds like. This team is gonna be good and enjoyable but it's like enjoyable is like the seats here in this universe, all right? Early season is one that we added. All these other ones were on the video from 2021. Early season means that this is a team that I might tune in a bunch through the first 20 games of the year but I don't see myself carrying 70 games into the season. These are mostly the tank teams, let's be honest. I'm very intrigued on a lot of the tank teams to see these young players evolve. But realistically, we're gonna get to the point where we halfway through the season, instead of me watching the real-life game live, I'm watching highlights or possessions of my favorite players on those teams. And then the last one has got to be a special occasion. That's F tier, that's my nice word of saying, bro. If it's up to me, I ain't, if it's up to me. But even this feels disrespectful because this team might be early season because I'm still a fan of Donovan Mitchell but I feel like I could watch Donovan Mitchell possessions or get the notification when the jazz in a closed game when Donovan Mitchell might take over without watching the first 40 something minutes. I just don't know what to expect from them because I'm expecting nothing. I'm gonna put them in the gotta be a special occasion which is they're in a closed game with a couple minutes left or Donovan Mitchell got 30 points at halftime and I'm tuning in to watch the rest. But then there's not a ton to really care about on that team. I like the eight, you know what I'm saying? Eight might get some young people that might blossom a little bit, I don't really know. But going into the season, this is the way it is. I'm gonna also do this at the end of this season so we can see what team's improved or got higher in the next year or what team's disappointed me, all right? I am a firm believer that this 76er team will be must see TV MVP candidate Joel Embiid. I think he might be the favorite going into next season considering he's spent a second a couple times in his career. James Harden looks in shape and I'm still high on James Harden's ability to be great after last season not being that. Tabriz Maxi aimed up my official most approved player. Tabriz Maxi was the most approved player in conversations last year, but I think he's gonna take another jump. They just brought in PJ Tucker. They got the Anthony Melton. I think this is much watched TV when you think about Joel and James Harden being one of the best pick and roll duos in the NBA. I think they were actually number one. The Washington Wizards get the early season tag because I don't really know what to expect but I like a lot of the things they did this off season. The Monte Mores pick up to make him their starting point guard is a dub because he's one of the more safe point guards in basketball. Porzingis after he got traded there looked pretty solid in the spurs that he had. Bradley Beal is back obviously. And they got a couple of people on that roster like Denny Mdia where he had you more than I'm intrigued about. But I don't know if I'll be watching them a halfway through the season, but if they're better than anticipated, then they can jump up. I think Atlanta Hawks are gonna go to the pretty fun tier. I won't go as far as to their must-see TV even though Trey Young, Trey Young by himself might make them must-see TV but Trey Young was there last year and they weren't even really here because I was disappointed in what they was doing. So I'm gonna put them in a pretty fun tier because Trey Young is very close to must-see TV and Jean-Té Murray is beefing with people before the season even started. So I'm excited to see what the heck that's about. Cleveland Cavaliers were my number one league pass team last season. I'm gonna guess that early season they're gonna be must-see TV but I am a little afraid that they gonna let me down this year and not be as fun as they were last year because now there's expectations and as you know, like same thing with my Chicago Bulls if you come out the gate and guns blazing and you look pretty good, that next season it's extremely hard to match that energy and I hope that the Cavs and or the Bulls don't let me down. I'm gonna go pretty fun for the Detroit Pistons. Jaden Ivey, I watched his first game of his summer league career and then watched the game before he tweaked his ankle and he was electric. K-Cuttingham is electric. Isaiah Stewart was shooting threes in summer league. I'm gonna say they're pretty fun. They are borderline maybe here but I'm gonna go pretty fun right now because I don't know if I'm completely convinced they're gonna be super competitive. I wouldn't be surprised if they were but if they're gonna be like next level competitive I don't really know. Pacers are gonna go early season for me. They got my boy Tarris. They got J.L.A. Smith who we made a video about a couple of days ago and they got Benedict Mathron who I'm high on but I think they're gonna be an early season team because I think themselves their goal is to be in the Victor Robin Yama sweepstakes so I don't expect them to be 40 games to the season really trying their hardest but recent himself is really fun but the rest is kinda iffy. Milwaukee Bucks is must-see TV, NBA champion I won't say favorites but contenders of course. Great team. Giannis is on it and Giannis and himself is close to here but I don't think I'm gonna get to this point. I will go must-see TV for the Bucks. If I wasn't a Bulls fan obviously the Bulls wouldn't be here but legitimately this is part of fandom for me. The Raptors. Ooh, where do I wanna put the raps bro? Where do I wanna put the raps? They're between pretty fun and must-see TV for me. They got a lot of things on that roster that I really, really enjoy. I'm talking myself into must-see TV. I'm gonna put them in pretty fun with the ability to raise up once we all done. Mavericks on must-see TV. Mostly because their off season for me was a bit in Christian Wood is probably gonna have some really crazy, great numbers and I'm excited about that. Luca Dodgers is must-see TV as an individual talent but I'm a little bit afraid about the Jalen Brunson loss and not really replacing them at any point, Gar. I thought Gorand Raj was a lot to go there and instead he's in Chicago this upcoming season but I'm gonna say just because Luca is Luca and they still got pieces around him that could shoot and play good defense I'm gonna put them in must-see TV tier. I am putting Denver in must-see TV, man. I'm putting Denver in must-see TV. Listen, I'm a fan of basketball, y'all. My job in life is watching a ton of basketball. So yes, we're gonna have a lot of teams in must-see TV because that's just what I do. When the game started six o'clock on a random Wednesday, I come here, I put the main game on the big TV and I put the other games on the small monitor. So it's gonna be a lot of must-see TV. They're close to here. I'm not gonna put them here. I'm not gonna put them here but they're close to here because I miss watching Jamal Murray and I miss watching Kevin Porter Jr. Michael Porter Jr. But I do believe that we're gonna get like 60 games of the season and they're still gonna be must-see TV but I won't be breaking my neck to watch them. So I'm gonna put them in must-see TV right now. That's easy. That's easy. They were must-see TV last season. Nothing has really changed. This is still legit. Memphis Grizzlies is that.  But I'm gonna put must-see TV for the Memphis Grizzlies as well. I'm so intrigued about the Minnesota Timberwolves. I'm putting them in the, I won't miss a game to here. Yep. Now this is definitely gonna change throughout the season but I honestly do believe I will be watching at minimum the first 20 games bar none. And the reason why is that I wanna see what they look like in the beginning and how they improve. And I mean, I guess the opposite can happen too. How they adjust the plan with each other. I mean, they made one of the biggest trades in NBA history this season and they have two legitimate centers, two of the top three, two of the top four centers in basketball are on the same team. Maybe five, depending on how you look at some people. And I'm curious how this gonna work. Anthony Edwards is that guy.   I know what the Mav is gonna give you but this team, there's a lot of possibilities. So because of that, I won't miss a game. At least I'll get through the first half or so. Gotta be a special case for the Spurs. I won't talk too much about it. I think Keldon's gonna be a stud. I even think Josh Primo's gonna be pretty silent. Jacob Hurdle was one of my favorite centers in basketball but let's keep it a buck. They sold heavily at the beginning of this off season. They know what they're doing and I know what they're doing and what they're doing is not trying to win. Clippers must see TV. Phoenix Suns. Last year I think I put the Phoenix Suns in tier A. I was so disappointed on what they did last season and how it ended. Like, I'm skipping them for a minute, bro because I don't know where I wanna put them. But the Portland Trail Blades are gonna be in a pretty fun tier. I think Dane, a lot of people are skeptical about Dane because of what last season.  He's gonna be great again. Anthony Simon's really good in the minutes that he was getting without Dane. Josh Hart is super underrated. Jeremy Grant pickup is really solid. I'm gonna go with pretty fun but I won't say they're must-see TV at least right now. The Kings are a tough team. You know what? I'm putting the Suns in pretty fun. Show me, bro. For the last two seasons I was enjoying every single game imaginable. And yeah, we talking about regular season here but the way, again, the way it ended was so, so drastically bad that I don't even wanna put them in must-see TV because I think a lot of people, even if this tier goes out and wins 55, 60 games, everybody be like, you know, show us, show us. And that's kind of how I feel too. So I'm gonna put them in pretty fun. They still got some like, Chris Paul is literally my favorite player of all time and then Mikhail is the homie. So I will be watching a ton of their games obviously but I'll put it in the pretty fun tier because there are times when it's not pretty fun. The Kings, I think I wanna put them in enjoyable tier. I'm excited about a lot of the stuff they did this off season. I don't know how realistic it is that they win a bunch of games considering I think the defense is probably gonna be pretty bad but early stage is gonna be fun. I think they're gonna be an enjoyable team to watch. I'm kinda high on the Knicks, man. But the way the Knicks play basketball, it's so grinded out because Tom Thibodeau is their coach. I'm gonna put them in enjoyable even though I think they're gonna, they're gonna be a playoff team this year. I'm gonna put them enjoyable and leave it at that RJ Step, Jalen Brunson. They finally have a point guard over there. Isaiah Hardenstine is my favorite backup center in all the basketball. So they got a lot of stuff there but I'm gonna put them in enjoyable right now. Legit don't think I'll miss a game with the Pelicans. I don't. They had me last season and now we're adding Zion back in. Come on, bro. Come on, bro. Stop, stop. That's all I need to know. This team is about to be electric. They're gonna be fun as heck. Zion, Brandon, Ingram, CJ. Come on, man. And Herb Jaws clipping up on a, oh, it holds it over Roddo. Forced to turn over us and we still got Big Jonas Valinus. Come on, man. That's, I won't miss a game. At least I'm gonna try not to miss a game with the Pelicans. This is interesting. This team could go in either of these three tiers because they will be enjoyable because Lamello Ball is a highlight reel in themself. Hopefully James Book and I get some PT but it's Steve Clifford. So we'll see. He's got a mixed track record when it comes to these younger players. It could be an early season team because losing Miles Bridges is such a bad thing for the organization. Or it could be a special occasion team because I don't think they're gonna be very good. I'm gonna go early season, see where they start, I'll see how they go and then we'll move it accordingly. Jalen Green is a stud and Tyree Eason is my favorite rookie in this entire draft class. So I'm gonna go enjoyable. I don't think they're gonna be trying to really compete. I think they still are looking to have good lottery odds. I'm gonna put the Miami Heat in pretty fun. Kind of feels disrespectful. That's not ranking them based on their individual talent or the talent as a team because they're a good team. Don't get me wrong. But it's something that's missing about them that makes me wanna watch them every single game. It's not that they're bad, obviously. They're very far from bad. But it's missing something. Maybe it's missing an extra player that I really, really like. Obviously, I really like Jimmy Butler. Obviously, I really like Bama DeBio. But nobody else in that roster is like, oh, I need to tune in because I really have a fan of that guy. Tyler Leroy was good. I'm not saying that they're not good, but these other teams I can name multiple. Like the teams that are in musty TV and want me to game, I can name three to five players that are like, I really, really love. And the Miami Heat basically have two. They're really high two, but still two. They had three last year because PJ was there. And now PJ on another musty TV team. But it's like, the Heat are gonna be a very good team as they usually are.  That's how I look at it. Do the Brooklyn Nets even get added anywhere? Cause what do we expect from the Brooklyn Nets? I don't know. If we're looking at what their roster is right now, I'm gonna say they musty TV, but I mean, I'm gonna go actually, they musty TV maybe for the drama and not so much the basketball, right? Okay, C is gonna be enjoyable, at least in the first half of the season before they shut Shay down. Shay is gonna be an all-star as long as they let him play. I don't see a world where he don't put up the right amount of numbers. And when they did play healthy last season, they weren't a good team, but they weren't a terrible team. I think their defense was 17th in the league last year with all the bad things. I got there from the athletic NBA show. Shout out to them. So I think they're gonna be enjoyable. Like these younger teams are gonna be enjoyable. Warriors, you know I'm going with that one. I will not miss a game with Steph Curry, Clay Thompson, Jermah Green. All of them gonna be healthy coming off a championship run. Wiggins, of course, and Cavanaugh Looney. That is a team that I will not miss a game of if I can help it. I'm putting the Celtics in must-see TV. A team that went on the finals run and when they actually, hmm, I wanna put them a little bit higher. I'm gonna keep them here. Because last year they were must-see TV in the bad stages and when they were ramping it up and obviously in the finals run, I'm gonna put them in must-see TV. The Lakers are must-see TV. Whether it's a dumpster fire, a car crash, a crime scene, they're must-see TV, but no matter if it's for the good or for the bad, no, you cannot deny that fact. And LeBron James in itself is must-see TV person, for me at least, because he ain't losing much in his older age. And I do believe that Anthony Davis is gonna have a nice little bounce back season. And I'm putting your Lendo Magic in enjoyable with the potential to go to pretty fun. I'm gonna put him enjoyable. I like this nice young core of teams. They're gonna be enjoyable. I'm putting the Knicks up. This feels like the right tier for the teams that are gonna be fun, but maybe not a lot of expectations. I'm kind of rocking with this. And the more I look at it, this is like an NBA player tier ranking or NBA team tier ranking. Cause these teams are probably not competing for much other than lottery balls. And these are the pretty fun teams. And maybe they're fun because they're trying to win basketball games. You know what I'm saying? Let me know what you think.  Or what teams that I have too high in your personal opinion? I'll be in that comment section as I always am. I'll see y'all soon. Peace.


So, shifting gears, we're going to talk about another kind of interesting aspect of Strabismus that is I think rewarding to think about keeping in mind that when we deal with patients with Strabismus, understanding why you have a head tilt, face turn, chin up, chin down position is important and trying to obtain equal vision, normal binocularity, normal head position is important. So understanding patterns for business is also a big deal and you all know that place. I gave this talk at a meeting in Jaiper, India about six weeks ago. I have no financial interest. My wife wishes I had more but there we are. We're going to talk about first the pattern, a pattern, the common patterns that we see. Also touch on y patterns, x patterns and lambda patterns which some of you may not be aware of, also worth knowing about. Now the incidence, if you look at horizontal Strabismus across the board, about 15 to 20% will have an A or a V pattern. They're certainly the most common players. What do we know about etiology? Turns out that oblique muscle dysfunction is the most common cause. Inferior bleak overaction is associated with V patterns, superior bleak overaction with A patterns. Definitely worth remembering. It helps you tie things together. It turns out if you have orbital dystopia seen with mid-facial hypoplasia like Crouson's disease, V patterns are much more common. Why? They have an abnormal pulley system. It turns out that there's an orbital pulley system that involves locating the muscles, gives them a lever arm. Joe Deemer in Los Angeles has written about this extensively, has done extensive things with MRI imaging including Cine MRI imaging, looking at these pulleys in action. They are real and probably in the future will involve collaboration between Strabismus surgeons and orbital surgeons to get the best possible results in muscle surgery. Horizontal muscle restriction, like what you see in Dwayne syndrome, can involve slippage of the muscle, lateral rectus muscle usually over the surface of the globe. That's what causes up shoots and down shoots in Dwayne syndrome. It turns out in X patterns Strabismus, which we're going to talk about, that also is, has been shown to be an etiology. Now for terminology, there's been a chain suggested because what looks like inferior bleak over action, superior bleak over action, may in fact not be due to those things. Instead of inferior bleak over action, the suggested terminology is over elevation in adduction, superior bleak over action replaced with over depression and adduction. If you've been doing this for a lot of years, and that would probably include me, it's difficult to shift gears, but it is something you'll see in print. Now definitions, A and V patterns, the most common scenario, if you measure the horizontal Strabismus 25 degrees up by putting the chin down, 25 degrees down by lifting the chin up, and you have a 15 diopter disparity, V pattern, you have to have that much disparity to diagnose a V pattern, and an A pattern, 10 diopters of disparity, so a little bit less, that is just what's used by convention, there's no magic to that. Now V patterns are the most common type of pattern seen, most commonly associated with infantile isotropia. You remember infantile isotropia, there are three things that go along with that. One of them is a V pattern with inferior bleak over action. The other is latent, the stagmus, and the other is dissociated vertical deviation. So again, the term over elevation and adduction is used. You also can see V patterns, as Griffin mentioned, with bilateral superior bleak policies. When you see a unilateral superior bleak policy, if you see a large V pattern, you should look very carefully for subtle overaction of the contralateral inferior bleak, under action of the superior bleak, and if not, warn the family before you do unilateral surgery that they're likely going to be back in the future for additional surgery. Now this patient has V pattern, isotropia. What we see here is large angle isotropian down gaze. The patient is ortho in up gaze, smaller angle isotropian primary position, and in both left gaze and right gaze, you start to see this over elevation of the adducting left eye, the right eye here, and it's much more dramatic in the oblique positions up and right and up and left. This patient also has V pattern, isotropia, large angle isotropia, and down gaze. There's much more than a 15 diopter disparity. There's probably about 35 or 40 prism diopters of disparity between up gaze and down gaze. So is this a V pattern? Yes. You see the over elevation and adduction or inferior bleak over action, and so that is V pattern, isotropia. You also can see V patterns with exotropia. In this patient who has large angle isotropia and up gaze is essentially ortho and down gaze, and again you see this over elevation start to show up in straight, right and left gaze, and it's much more pronounced in the oblique gazes. Now the pattern you see in this patient, this patient has cruzons disease, and in this patient what looks like inferior bleak over action, you can say it is inferior bleak over action, you can operate on that patient, recess both inferior bleak muscles, and the patient would look just the same postoperatively. The issue here is not that you've got inferior bleak over action. The issue is malposition of the orbital pulleys, and so what you need to do instead in this patient is to reposition the lateral rectus muscles. And so what we do in this patient with cruzons disease, and we'll touch on this again, is instead of recessing the inferior bleaks, even though it looks like inferior bleak over action, the appropriate thing to do is vertical transposition of the lateral rectus muscles to account for the V pattern, that would involve recessing them if or resecting them either way, and shifting those muscles superiorly. Now treatment of V patterns, if you have over elevation and adduction, weaken the inferior bleaks with a caveat that you do not do that with again craniofacial syndromes with wild abandoned, think about what's going on. If there is no over elevation and adduction, vertical transposition of the horizontal recti, we're going to talk about which way to do that, and then the other issue is this is going to deal either of these with the disparity between up and down gaze. You still need to deal with the primary position deviation, so you do horizontal surgery on either medial or lateral rectus muscles for the primary position deviation. If there is DVD present, you may want to anteriorly transpose the inferior bleak in addition to weakening it. Now, this works, and this is one of those things as a resident when you take O-caps, you just need to memorize, and it is also useful to think through why it works, but in essence for an A pattern or a V pattern, if you shift the medial rectus muscles towards the apex, the lateral rectus muscles towards the open end, notice it works, whether it's A or V, whether you're doing a recession or a resection, this will work. It turns out that when we shift the medial rectus muscles down in a V pattern, when you inferiorly transpose those muscles, you get more effect from a certain amount of recession in down gaze. You correct that larger amount of esotropion down gaze. That's why that works. The same thing happens in the V pattern. If we're going to resect the lateral rectus muscles, when you shift them up, you will get more effect in up gaze with that resected lateral rectus muscle. This tends to collapse the disparity between up and down gaze. You're still left with doing something for the primary position deviation, but this is one of those things that we'll look at again here because that's important to remember. Let me back up there. Now, A patterns. A patterns are more commonly seen with exotropia than esotropia. They're also more common than D patterns in down syndrome and spina bifida. Spina bifida, particularly spina bifida with shunted hydrocephalus, it is very common to see an A pattern. This patient has A pattern esotropia, large angle esotropian up gaze, smaller esotropian primary, the patient is essentially ortho and down gaze. The patient with A pattern exotropia. What we see here is a patient who has large angle exotropian down gaze, smaller exotropian primary, and is essentially ortho and up gaze, in contrast to the over elevation we saw with the V patterns. With this patient, you start to see this right eye head down towards the floor and left gaze, the same thing with this eye, and it's much more pronounced. This eye has gone right down, almost out of sight, the left eye and then the right eye and gaze down and right, gaze down and left. So this is an A pattern. Now, treatment of A pattern. What do we do to treat A patterns? If you've got over depression and adduction, superior bleak overaction, we weaken the superior bleak. You can do that in any of a number of fashions. Typically surgeons will do what they're comfortable with, what they know works best in their hands. You also may want to think about what will have more or less of an effect on the different functions that the oblique muscles have. With the superior bleak and the resonance, what are three things that the superior bleak muscle does for us? Dr. Jardine talked about this a bit, but first of all, it is cyclorotorimuscle, correct? So you're talking about an encyclorotorifunction. Secondary effect will be the vertical function, depression. The tertiary effect is going to be abduction. And depending on what you want to do and what you're trying to accomplish and what you're trying to not accomplish, you may want to think about which of these procedures to do. But typically a posterior seven-eighths tonotomy will try to take care of the vertical function of the superior bleak with minimal effect on the cyclorotorifibers. And then you've got recession, spacers, full tonotomies. If there is no over depression in adduction, vertical transposition of the horizontal muscles are more appropriate. And what about the horizontal surgery for primary position? If you do this at the same time, there are two ways to approach. A couple of ways to approach this. One is to say, you know, the end of the torpedo is straight ahead, and I'm going to do the full amount of horizontal surgery in primary position. But most surgeons will decrease the amount of horizontal surgery because you will see less exodeviation if you weaken both superior bleaks. Remember, it is an abductor. It does have an effect mainly in down gaze, but also in primary position. And other surgeons will simply weaken the superior bleaks and come back and deal with the horizontal muscles in a second surgery. That's something that you'll figure out with experience in terms of what works best in your hands if you're going to do this sort of thing. Now, why patterns for business? This is a really cool entity because it really, again, this is where things look like you have inferior bleak overaction, but it isn't inferior bleak overaction at all. It turns out that there's aberrant innervation of the lateral rectus muscle just in up gaze. So this patient will look perfectly straight in primary, perfectly straight when they look down. So developmentally, everything they need to do where it's most important is working just fine. But when they look up, their eyes go way out to the side, and we can see what that looks like here in this patient who is perfectly straight in primary, perfectly straight in down gaze, and has large angloxatropia. This is what gets the parent's attention. It turns out most parents are taller than their children, at least when the children are very young. So when they looked up at mom and dad, the eyes go way out, or grandma notices it, and then you've got a problem. So part of our job at times is to educate parents about what really matters for the child, and as the child gets taller, this won't be as obvious to them. Their eyes will still be straight in primary position, still be straight in down gaze, right gaze, left gaze, and so part of our job is at times not to operate on patients. If you get your arm twisted and they want to have the eyes fixed, the thing that you do in this circumstance is to do a superior transposition of the lateral rectus muscle, keeping in mind that this is not true in fear of bleak overaction. If you weaken that child's in fear of bleak muscles, you will not be happy with the result. If you superiorly displace the lateral rectus muscles, and you may not have to recess them at all if there's no primary position deviation, you will collapse that wide pattern. Axe pattern strabismus is another entity that you may or may not ever see in practice, but it is really cool. What happens here is you see both over elevation and over depression when you get a little bit above or below the primary position going in the lateral gaze. The reason you see this is that you've got slippage of the tight lateral rectus over the surface of the globe. So this is similar to up-shoot and down-shoot that we see, particularly in type one dwinds when they try to add up their eye with a tight lateral rectus. And the treatment is similar. And if we look at this drawing, what we see here is a patient who's ortho and primary, large angle exo and up gaze, large angle exo and down gaze, and hear what looks like inferior bleak overaction and superior bleak overaction when in fact that isn't the culprit, important to recognize again, because weakening both superior and inferior bleaks probably will not fix this. You can either recess the lateral rectus muscles, particularly if they're very tight, but keeping in mind if they're ortho and primary, if you recess the lateral, you're likely to create an esotropy, aren't you? So the appropriate thing may in fact be to do a Y-splitting procedure where we split the lateral rectus muscle lengthwise, spread the ends out, what's called a sagalization procedure to diminish the up-shoot and down-shoot without changing the primary position deviation, an elegant solution, and again, one where you need to think about it ahead of time to do the right thing for the patient. Now, lambda patterns, this is actually just a variant of a pattern exotropia. It is really superior bleak overaction and they typically will have ortho and primary position, up gaze, large angle exotropia and down gaze and the appropriate course of action is to weaken the superior bleaks. Now, summary to kind of put this together. A and V patterns. You want to weaken the offending oblique muscle if there's over-elevation and adduction or over-depression, oblique dysfunction. One big caveat here. Let's say I showed up in the neuro-optimology clinic having been seen over the weekend in the emergency room. Someone at home suddenly noticed that my eyes were doing funny things when I looked down. And they noticed in neuro-optimology that I had large angle, A pattern exotropia and superior bleak overaction at my age. The question would then be what do we do to fix this because I want it fixed because somebody at home thinks I look funny.  And I come back a week after surgery telling you, doctor, everything looks tilted. I can't even walk. I can't drive. I can't function. What went wrong? What we didn't do was think about the effect of weakening the superior bleak when somebody A has fusion potential and they're an adult. So this issue of weakening the superior bleaks is a great idea in small children where we're most often confronted with this but sometimes in an adult who's got fusion potential, when you weaken the superior bleaks, remember the superior bleak is an encyclorotorimuscle, you weaken it, you're gonna get an x-cyclorotation and in an adult they may not be able to compensate for that. And as a result, they're gonna have torsional deplopia. They're not gonna like things. So even though for that A pattern exotropia, the right thing would be to weaken the superior bleaks, you may wanna say, you know, I just don't think that's the right thing for you. And instead, we just downshift both lateral rectus muscles. Very important point and I have seen a number of patients who've had that happen. What happens when they come to see me after somebody has weakened their superior bleaks is then you have to offset either vertical rectus or horizontal rectus muscles, which you also can do to try to compensate for the torsion where they need to help the most, to try to help them get things in a range where they confuse the deviation. So if there's no oblique dysfunction, do vertical transposition of the horizontal recti and you can do either unilateral or bilateral surgery. You can shift for a V pattern, a medial rectus down and a lateral rectus up if you're doing unilateral surgery as opposed to bilateral surgery. And let's look again at this diagram. This is worth looking at one more time. This again is an A pattern. This is a V pattern. And with this, we've got the lateral rectus being shifted towards the open end of the pattern, medial rectus towards the closed end. That you do need to just remember if you're gonna be trying to sort this out. And for the residents, I can guarantee you on OCAPS there will be some sort of question that relates to having remembered this. And we'll talk more about this. I think I'm gonna also be speaking to the residents on Friday morning, so we'll talk about this then. And as far as references, again, if you look here, the basic science course section, pediatric ophthalmology is for business has a section on patterns for business. The preferred practice plan, it's noticeably absent. It should be in the next update included, but it wasn't in the last update in 2012. The images came both from the academy website and from clinical key. And here we go. Questions? Otherwise, have a nice day.


My name is Matt Ray, I'm a Senior Technical Evangelist with OpsCode. We are the company behind Chef, which I'm going to talk a little bit about. If you have more questions about Chef afterwards, please, you know, follow up with us at the booth. But, you know, the main focus of today's talk is going to be about Chef for OpenStack. So let's go ahead and jump into it. As you may or may not be aware, deploying OpenStack is not as simple as it should be once you go past one box. We all love DevStack, but really you need to be on more than one machine if you're going to be running anything at scale. So I'm here to tell you that Chef makes it easier, of course, you know, that's my pitch on it.  You've got your app and it's up on a box and, you know, things are going well. You're starting to iterate over it. You've gone online, you know, identified a little bit of a bottleneck at the database. So, you know, we're going to move that on to another machine. And then we're going to need, you know, two of those, of course. And as, you know, as things get better and better, well, we turn out we need two application servers.  And, you know, things are going to continue to grow and grow and, you know, put in some caching and things get better. But all these things are tied together with configuration, you know. All these machines are talking to each other and they need to know about, you know, what everyone else is doing. I mean, the application servers are trying to talk to a database. So they need the caching layer, you know. And of course, maybe you don't want to do it that way. Every infrastructure is kind of a unique snowflake.  So everyone's infrastructure is a unique snowflake, you know. Servers, they're pretty much interchangeable. But infrastructure, it's pretty unique.  Maybe, you know, MySQL's not working out for you and Postgres is where you want to be. This is going to introduce some NoSQL to your stack. Well, you know, things are going to continue to change. And as you continue to gather success, you're going to want to move into multiple data centers. So you're going to have to recreate what you have, that you've carefully curated in data center one into two and three.  You know, machines come and go. That's great, right? I'm going to go ahead and have a seat. But that's all great and all, but you really want to hear about Chef, of course. So as your infrastructure changes, you're going to need to capture those changes. So Chef is built on the idea of infrastructure as code. This is a pretty central concept for kind of the big DevOps movement. Maybe you've heard about it. But it's based on the idea that everything you do to your servers is captured in source code. And because it's source code, you treat it like source code.  You make versions of it. You tag it. You branch it. You patch it, you know, just like any other code base. And the idea behind this is the reason you want to do this is you can reconstruct your business from source control and backups and, you know, access to new bare metal resources, you know, and data center two, data center three, or a different cloud, you know. So as you need to move your infrastructure around, you can do that because you know how everything works together. So in Chef, Chef follows a client server model. We call our client, the clients are on nodes. So the Chef client runs on a node. It generates configuration for that node. It asks the Chef server, hey, what am I supposed to do?    And the server goes, configures itself, sets up all the right software, and then it's going to push its information back to the server. It says, hey, I'm all configured here. You know, Nova API ready for business. And, you know, everything's looking good. And this is all backed in version control, of course. And so that node is an abstraction of a server. And the things that you do on that node is you work with resources. Resources are abstractions of things that system administrators do. You know, whether it's installing packages or writing config files or creating users and directories and managing your networking, those are things that sysadmins do. Chef has resources to represent those. Now, these resources are just an abstraction away from what the actual underlying implementation is. Chef is giving you a declarative interface to your resources.  You're not saying apt-get install-y apache2. You're just saying, put it on this box. So when you move package apache2 to Red Hat, it just works, because there's a yam provider. And so underneath the resource are providers that do the dirty work. There's a yam, an apt, depackage, whatever, that are going to implement what you want. But what this allows you to do is define the policy you want to implement. You want these servers to talk to each other. You don't care about the details. So you're declaring how they work together. So you gather these resources together in recipes. Recipe is just an ordered list of the resources and how you want them to be applied, the exact same order every time, which is nice, because you can reason on it. And you take those recipes and you package them in cookbooks. A cookbook is everything you need to provide a particular service. So an apache2 cookbook, a Hadoop cookbook, Nova cookbook, a Horizon cookbook.  You turn those into attributes. And what this allows is you to reuse these cookbooks for any sort of application. And there's literally hundreds of them on communityopscode.com, like 600 as of this morning, where people are sharing how they implement, how to deploy just about everything. And so Chef is written in Ruby. And rather than have a domain-specific language for configuring things, we use Ruby. It's a nice programming language. It allows us to do things like assign variables and iterate over loops and calculate things dynamically. Because it's written in Ruby, maybe your recipes might need to configure something by talking to a web service or using some third-party library that's already written in Ruby, where you have all that flexibility and power available to your configuration management system. You're not limited to what you can do. And because all this information that we've gathered on the nodes has been pushed up to the server, the server exposes it for search. And so we can use that search to tie our machines together. I don't have to have a spreadsheet in advance that says, my SQL database on IP address this, this, this talks to this guy. I just say, my SQL database is up. And so when I need to have another machine talk to it, it asks the Chef server, I want to search for the nodes. I want their web servers. This is an example using HAProxy. It's a software load balancer. I'm saying, find me the pool members who are running the web server role. I want to write out my HAProxy config with those guys. It writes out the HAProxy config. So maybe today I have five web servers. Next time this guy runs, maybe we have 15 web servers. It rewrites the config file, restarts the service. And I'm now balancing all those applications together. And so when you have an infrastructure that looks like this, and you add another box, those updates can become automatic. And just this one extra node has 12 resource changes. That's not something you want to do by hand, because chances are good, you're going to mess up. I mean, you're pretty good. But when you do this 100 times, you might mess up. And so Chef allows you to build just about anything, whether it's workstations or clusters or infrastructure as a service. Chef is going to help you build that. And it helps you automatically reconfigure everything. We have clients for Linux, Windows, Unix, BSDs. It works great with load balancers, with metrics collections, with monitoring, because those things are dynamic. A new machine comes online, it's automatically monitored. And you know exactly what ports to listen on. You know exactly how to talk to it. And so moving things in and out of clouds becomes trivial, because you've abstracted away the underlying infrastructure. So that's great, right? But the Chef community is what makes this all happen. Chef is Apache licensed, which is very permissive. It's what OpenStack itself is licensed under. It means that we've had over 900 individuals outside of ops code contribute code to Chef. These are people at companies like HP and Dell and Rack Space and VMware, Calzada, SUSE, people in the room, people out in the halls, they're contributing, they're writing cookbooks and they're sharing. So how does this all tie back to OpenStack? So we've got a project called Chef for OpenStack. It's a project. It's not a product, key distinction there. Why? So at the last OpenStack summit, there were a lot of people, I gave a similar talk and I said, HP's doing cool stuff and Mercado Libre's doing cool stuff and Rack Space and Dell, and they're all doing stuff separately. And what the feedback was was they would really like to collaborate, but it's hard for them to tell their boss, hey, over here at HP, we want to work with Dell. Or Rack Space wants to work with three most. And so we formed a community project. It's called Chef for OpenStack with the goal of reducing fragmentation and encouraging collaboration because deploying OpenStack is not secret sauce. The secret sauce is your business, whether it's fanatical support like Rack Space or cutting edge infrastructure. That should be your secret sauce.  And everything we do is Apache licensed. So the what? It is a Chef repository for deploying OpenStack. This contains all of the roles, the attributes, the environments, how these things tie together, how they work together with Chef with documentation. Documentation is very important. Like the shout out to Ann Gentel, doing great work with Doc's OpenStack. It's also cookbooks, a cookbook for Keystone Glance, Nova Horizon Swift, as well as a knife plug-in for OpenStack. I'll talk to you more about that in a minute. The code's all up there. If you go to opscode.com, OpenStack, that's kind of a landing page, it'll have all these URLs for you. We have a mailing list, Google Groups, we have an IRC channel, most of the contributors hang out in IRC. A lot of good conversations happen there. All this code is up on GitHub, so please go contribute for pull request. It's all great. I hear some of the people who stood up and said, hey, we're working on this. A lot of good names up there. And there's a lot of people who aren't on this list that are still contributing. So there are no barriers to entry. It's Apache license. We're trying to make it as easy as possible to deploy whatever you need. Rackspace Private Cloud, their Alamo project, it's the same code base. I mean, it's a parallel fork. They're taking it, and they're making it easy to install OpenStack. This is a great way to get your feet wet. If you haven't already checked it out, please check it out. It was one of the initial sources in the cookbooks, based on work that had been done with some other people. And so that is all OpenSource as well. So if you want to go to Rackspace's version, it's there. If you want to go to DreamHose version, it's also up there on OSOps. So this code is all up there. And they have really great documentation. So whoever did that, thanks. So what is there currently out there? Essex is working. We support fairly smallish installations, maybe less than 100 nodes, because we're still kind of stabilizing it before we really start changing out the underlying pieces. But it's KVM and Ubuntu 1204. Alex C work has been done by Calzada. Red Hat work has already been started. I could talk more about that. We're open to pretty much supporting anything. If I know there's some SUSE folks around, we'd be happy to support SUSE. It's pretty much if you have a feature you want supported and your patches don't break everybody else, we'll take them. Because this is a community.  You vote with your code. Folsom work has already started. A lot of people have told me, oh yeah, it was just great. Or we had to tweak two or three little things in Horizon, all that's coming. And definitely once the Grizzly milestones start up, people will start jumping on Grizzly before too long. Documentation. The documentation has been moved into a separate project because we want to provide high-quality docs that we can move into docsopenstack.org. These are in Sphinx and restructured text. And the nice thing about the documentation is it's backed by examples. So I have documentation for how my lab in my office is set up. And there are several people who have recreated it. They're like, oh, I use this network card and this network card. I mean, not even the same models, but just, you know. If I have two NICs and I want to roll out a small lab deployment, I can do it the exact same way. And I can say, oh, yeah, that's cool. Here's what it looks like. And also, you can tie it back to the Rackspace docs to see as you start to scale up even more. So what's really important here is that Chef is tying everything together. As you start to grow and scale your deployment, you don't want to have to go and touch another box. You just want to say, hey, another compute node. Or, hey, we're adding more to the cluster here. But scaling is going to change how we deploy. And so right now, most of the documentation is around the N plus 1 model of N compute nodes and one controller. We've already been told that work has been done to move the services onto separate boxes. I'll be looking closely at the HA work that's being documented and whatever else people show up with. So whatever is available to us is pretty much where it goes. And the licensing is there to make it available to everyone. So let's change it up a little bit. Knife OpenStack is our tool for talking to OpenStack clusters. So we can use Chef to deploy OpenStack, but we can also use Chef to manage anything on top of OpenStack. So Knife is the command line tool for Chef. It is a Swiss Army Knife of web APIs. It talks to the Chef server API. It talks to cloud APIs. So I can talk to the OpenStack API. And I can do things like list the flavors, the images, create and delete servers, list out the servers, and bootstrap new ones. All the basics list the flavors, what's available to me, list the images that are my current system. But what's cool is I can say Knife OpenStack's server create. And from the command line, I can create new instances without having to go into the dashboard and click and say this and this. I can also pass a run list to this. So I can tell it, hey, I want to go to this OpenStack API, create me a medium server of Ubuntu 1204. And that's going to be a Hadoop worker. And I could run this 10 times. I have 10 Hadoop workers. And they're going to use Search to find the Hadoop master. And I'm now running a 11 node cluster without touching a UI. And this makes it easy to scale. And I can also say Knife OpenStack's server delete to reclaim those boxes as I go. So I can start actually using my cloud like you want to use a real cloud. It's not just, hey, I stood something up in the corner. Now we can treat it just like everything else. And that machine shows up on the dashboard, of course. That's all pretty. And you can log into it. But that OpenStack plugin looks a lot like the HP plugin. It looks a lot like the Rackspace V2 plugin. Because there's a lot of shared code there. Those guys are based on OpenStack. But I can also move my infrastructure from OpenStack to EC2 to VMware to Azure to Google Compute.  So I can do, the dream of the hybrid cloud can be real. I can have an OpenStack cluster for testing and development. And use the same Knife commands, Knife EC2, server create to bring up my instances on AWS, or on Rackspace, or wherever. So what's on the roadmap? The roadmap is we had a session yesterday afternoon where kind of people identified the things that they're working on. My main focus is I'm kind of outnumbered. There's a lot more people in the community than just me, which is a good thing. I'm essentially the documenter and community manager. And I'm documenting how these things work and trying to get people to succeed with the code. We currently support KVM, but LXC support is in a Calzada branch, and we'll be sure to bring that in. Hyper-V makes really good sense with Chef, because Chef treats Windows like a first class citizen.  And Hyper-V makes sense in a mixed cloud, because it's cheaper to run Windows VMs on Hyper-V than any other platform because of licensing. So if you need to do that, that's a great way to do that, because everything else will be on Linux. Database work, right now it's MySQL. There are some people who don't like MySQL, and they said, I'm going to bring in Postgres support. And I said, thanks. Operating systems, Red Hat 6, of course, is coming very soon into the source space. Debian has packages. If people want Debian support, I'm happy to merge. And add that. SUSE, of course, we're happy to have whoever shows up is what we're going to add. They share configuration is not documented with Folsom, so we will be going through that to make sure that we have Pacemaker and Galera working and RabbitMQ working, as well as changing out some of those components for other options, whether it's Cupid or ZeroMQ, whatever OpenStack supports, we want to support. If somebody is going to want that in their cloud. And I'm happy to do that. Quantum work has been started. DreamHose told me that they have done some work to make NYSERA work, as well as OVF. So there's already a pluggable quantum cookbook that should get merged soon. So if you're a quantum vendor, the framework is there for you to plug in your quantum solution into this infrastructure that is getting used by a lot of people for real deployments. If you're a sender vendor, if you're a storage vendor, the DreamHose guys, of course, they're pushing staff, but you could put pretty much any back end in there. And that will be pluggable and supportable however we want. There have been a couple of Chef for OpenStack hack days where DreamHose hosted one, Rackspace hosted one. There's going to be one in New York City next month. Essentially, we show up and fix bugs, talk about the code, work on the roadmap. It's a community thing. I'm trying to get one for Boston and somewhere else beyond maybe Australia, we'll see. So but Chef for OpenStack is also good for the greater Chef ecosystem.  The MySQL cookbook has gotten a lot of work. The RabbitMQ cookbook has gotten a lot of work because people are actually using those things in production environments. And so the cookbooks have to be capable of supporting all the features that you want. We have a project called Test Kitchen, an open source test framework that you, we use it for testing cookbooks, but it could be used to test anything that's built on top of vagrant. And you give it the images that you, the operating systems and the architectures you want to support. So you know, Ubuntu 10.04 on 32-bit, and it will run sets of tests, tear down the machine, run the next set of tests. Well, one of the nice side effects is somebody's already moving it off a vagrant to OpenStack. So we'll have Test Kitchen, we'll have support for OpenStack. So we'll be able to run probably a lot faster than vagrant on your desktop. Librarian is a Chef community tool for managing your cookbooks. We started using it with Chef for OpenStack and it's been very beneficial. And there's lots of tools in the Chef community that solve that problem. SpiceWizel is another tool that deploys your infrastructure for you. Chef for OpenStack uses it, it manages your roles and environments and everything. The work for Chef for OpenStack to get it at working with SpiceWizel has made SpiceWizel better and applicable to other use cases. PixieDust is a minimal pixie-booting solution. Again, Chef for OpenStack has gotten people solving weird edge cases with pre-installing OSes before you can run OpenStack on them. Network card ordering and that sort of stuff. And of course KnifeRackSpace, HP, DreamHouse, they all are based off Knife OpenStack. It's a lot of shared code. And so because those guys are throwing up OpenStack Clouds, it's easy to support them immediately with Chef.  And I can tell you your customers will appreciate that. And of course Dell's Crowbar project. It's a hardware installer for managing your data center. There's a lot of overlap between the work they're doing and what we're working on. So too long, didn't listen. Here's what's going on. Opscode.com OpenStack, it's a project, not a product. Lots of real contributors, RackSpace, Dell, HP, Dream Host, AT&T, others. Essex is working. Folsom's already started. The features are driven by demand. And we have lots of good documentation and working on examples for each piece. So any questions? There's somebody in the back. No, no. So the question is, would I consider Vagrant to be competition with Chef? Vagrant is a VM framework for quickly bringing up operating systems and on the desktop and tearing them down. We worked with Mitchell Hashimoto, the Vagrant lead a lot. We love Vagrant. We use it all over the place. It's a great way if you're a desktop developer and you have virtual box, it's a great way to get desktop virtualization just quickly cycling through your machines. The things that you run on top of that, it's going to be done with Chef. So Vagrant uses Chef to configure the machines that are on it. So Vagrant brings them up, Chef puts it on top. No, but we definitely love Vagrant. Question? I know you've been around as long as Puppet has, or pretty close to that. But do you know roughly what your market penetration is? People using Chef versus Puppet, using CF Engine, even Juju, which is also Juju as well. So we actually are coming up on our fourth birthday. So Puppet's twice as old. Chef was founded by some people who had used Puppet at large scale. And we're running into some of the issues that I talk about, like search and those sorts of things. And so there were some just differences in philosophy about how infrastructure should be managed. As far as market cap, I can't really speak to that. As far as open stack deployments, I can walk down the hall and point out who's using Chef. And it's a lot of people here. And I think, but if any Puppet people here, they're doing good stuff, too. Like we like to say, as long as you're using configuration management, you've already got a leg up on a lot of people. So go to Dan Bode's talk and ask him. Any other questions? Yeah. I live in Austin. We don't have soccer. So yeah, if there are no further questions, please hit me up on email, Twitter, IRC. Thanks a lot. Stop by the booth.


Three reasons why the narcissist is still watching you you had enough of the narcissist So you went no contact You stopped talking to them You blocked them on social media Because you know they're not going to change So you don't want anything to do with them anymore You don't want to deal with them But the narcissist is still watching you and maybe you know they're watching you Maybe they've made that very clear to you Maybe they've used that to try to intimidate you And it's made you feel very uncomfortable It's made you paranoid It's made you always check your surroundings Because you never know if they're lurking in the shadows At some point you figured out that they were watching you Or maybe they left you a clue Something for you to ruminate over Because narcissists love it when you're constantly thinking about them Wondering why they said or did something Maybe they liked or commented on a social media post through a different account Maybe they called you from a different number Maybe you caught them lurking around your house or workplace They have their way of letting you know that they're still there You can't get rid of them that easily And there are three main reasons why they're doing that Narcissistic supply One of the main reasons why the narcissist is still watching you is for narcissistic supply After everything they've done to you They want to know if you're still hurting They want to know if you're still going through it They always return to the scene of the crime Just to witness the damage they've caused It makes them feel powerful and significant To know that they have altered the natural course and progression of your life It allows them to elevate themselves at your expense One of the main reasons why they're still watching you Is because they want to see if you're still suffering They want to see if you've managed to overcome everything they did to you They're not watching you because they care They're not watching you because they want to help you It's the result of their sadistic nature They can't just leave you alone because they get a kick out of it It gives them an adrenaline rush to see you struggling It's like they're watching a movie They're just sitting back and enjoying the show It fulfills them It makes them feel better about their own lives But if you have managed to turn your life around It's going to make them sick They don't want to see that They're only checking back in because they want to see you struggling They want to see you down and out That's what they're looking for Because that makes them feel better about themselves Which is why you need to stay strong You need to rebuild everything that they try to destroy Don't give them the satisfaction Show them that they haven't defeated you Show them that you're still able to do what you need to do You're still able to live the life that you want to live to sabotage The narcissist is still watching you To see if you're still suffering if you're not suffering They will try to sabotage whatever it is that's making you happy Because they look at it like it's a hindrance to their progress It's an obstacle to what they're trying to accomplish So if there's anything that you're working on They will try to tear it apart Because it shines the light on everything that is wrong with them it makes them feel bad about their lives So they have to destroy it They will try to turn people against you They will harass you They will steal from you Misery loves company They will do anything to make you miserable just like them three Hoovering another reason why the narcissist is still watching you is because they're planning to Hoover you But they need to determine when is the right time for them to come back They want to come back at a time when you are most likely to accept them back at a time where you are at a vulnerable point in your life Maybe you've had an argument with someone or maybe you're struggling financially That's when they're going to come back to play the hero to act like they're there to save the day When really They're just coming back to cause more problems for you If you left them They're only going to come back to punish you So please do not fall for their Hoover attempts They have nothing to bring to you but abuse and manipulation They're watching you Because they're plotting to take something from you Narcissists only have their eyes on things that they are envious or jealous of things that they want to take Or things that they believe are being taken away from them They're not watching you because they want to share anything to you. They're only looking at what they can get The narcissist will still be watching you So please take the appropriate measures to protect yourselves lock your doors Close your blinds especially at night Keep your social media profiles on private and be cautious when talking to strangers You never know if it's one of the narcissist flying monkeys Just stay safe out there Narcissists are dangerous people You never know what they're going to do next. You never know what they're capable of But just know that they may still be watching you somewhere behind the scenes Thank you for watching. I hope this video resonates with you Please like comment Share and subscribe If you would like to donate My PayPal link is in the video description Coach the inquiries You can email me at coaching at Narcseviver.co.uk Thank you for watching and I'll talk to you soon


It made the rounds for several days, was a popular topic of news blogs and discussion forums. But why hasn't there been any follow-up? Well, actually there has been, but only in research circles, and it's not too surprisingly reversed the previous discovery. It appears that the prior evidence was overstated. Cell phones may yet be demonstrated to increase the risk of certain cancers. But the key point is that no research has reliably demonstrated this. This is so typical and expected, at least expected by me, that it can serve as a useful lesson in skepticism of media reporting of science stories. It can also serve as an example of the difference between evidence-based medicine and science-based medicine. When the initial story hit, the coverage was very focused on authority figures and agency statements, which is typical of this kind of reporting. For more discussion of this phenomenon, I refer you to my video version of Ben Goldacre's essay on bad science journalism. The World Health Organization put cell phones on the list of possible carcinogens, alongside such things as dry cleaning and artificial sweeteners. The level of evidence was ranked very low, which to a scientist puts it on a sort of global to-do list of promising research leads. But it was hardly a definitive identification of risk. That takes verification and a different type of analysis. Let's go over the types of studies that scientists use to establish correlations. My goal is that the next time you're presented with these kinds of shocking discoveries, you'll be able to determine what kind of evidence is based on. The first two are a type of epidemiology, retrospective and prospective studies. One, the retrospective cohort study. In vastly simplified terms, grab a thousand people with disease A and compare them to a thousand people with no disease A. Identify factors that may be correlated with a higher risk for disease. The biggest problem with a retrospective study is what is called self-selection bias.  And because they already have the disease, whatever is the risk factor has already happened. It's very easy to misidentify confounding factors. If you look at the 1,000 people in the cancer group and find that 721 of them are heavy cell phone users, while only 614 of the non-cancer group are, how strong is that evidence, considering all the other possible reasons for those differences? Two, the prospective cohort study. Take 1,000 people and follow them for a defined period of time. Document disease outcomes. Did the people get brain cancers? Try to identify which risk factors were most predictive of the outcome. This is the retrospective study but done in advance of the condition being studied. Did the highest quartile of meat-eaters get more gastric cancer? Did the lowest exercisers develop more diabetes? The populations are often heterogenous or complex. And what looks like a simple association can often be a linked series of categories, like finding people who use cell phones to be at higher risk of neural-derived cancer when the actual association may be with something about their income or profession or other environmental factor or genetic factor. It could be a multifactorial linkage where stress and urbanization plus better medical care is responsible for the increase. And cell phone use is really just a proxy. Three, case control trials. In a case control RCT or randomized control trial, the researcher gets to control a lot more about the comparisons being made. You can take humans or non-human animals and mix them up until the populations are evenly randomized. Then expose half the group to the experimental factor. That eliminates the self-selection and the confounding bias because the researchers are intervening artificially. This type of study is not always an option for ethical reasons. We choose not to expose humans to excessive risk if we can help it.  We still have the multifactorial problem where multiple behaviors can be linked and it's very difficult to untangle all the variables of genetics, environment, nutrition, case history, and sheer luck. There could still be a crazy mixture of lots of risks, which is why we need, number four, mechanistic research. This is the kind of work that I've mostly done. The scientist guided by less precise observational or epidemiological data and complimenting the experimentally rigorous case control data look for ways that the experimental factor could cause the correlated effect. This is usually done in some format that allows for almost complete control. Identical clonal cells grown in identical flasks, transgenic mice, or sibling animals. Even within this category there are shades of resolution. Molecular biology is usually pretty good at sensitive and reproducible results. Very small margins of error and results that can be reproduced by different labs or different techniques. We focus on something called method concordance, which is where I take my username, arriving at the same conclusion by multiple independent lines of inquiry. In the case of cell phones, we need to identify a plausible and testable way that the radiation or heat or emotional cues associated with cell phones can interfere with normal cellular development. We'd attempt to replicate that finding in the simplified model of genetically identical animals or cell culture. If the mechanistic outcomes contradict the perspective study, then the smart money is on the more rigorous lab research, less on the epidemiology. Notice how we've gone from very complex and poorly controlled to the very tightly controlled and rigorous design. That doesn't mean the mechanistic research is better than a prospective study. After all, it would take a very long time to test all the possible hypotheses, and the prospective studies provide great clues about what's worth investigating. The problem arises when epidemiological data is presented as confirmed fact, rather than the first step in a long process. I also often see a sort of reverse mechanistic data on some new drug that shows that it can cure cancer or other disease in a flask of cells or some poor mouse with a gut full of injected cancer cells is touted as a major breakthrough in cancer research before it goes out to the control trial and then on to prospective studies. None of these studies is without merit, and they add up to a total picture of the real underlying causality. How do we differentiate between evidence-based medicine and science-based medicine? Evidence-based medicine is any medical practice which is based on a preponderance of evidence for its efficacy and safety. It's a pretty broad umbrella, though, and it includes things we don't understand well or possibly applications of practices that seem to work but shouldn't. Science-based medicine is a subclass of EBM. It includes only those practices that we can understand to a finer degree. We know that they're effective, but we also understand why they're effective. The mechanisms are clear enough to us that we can understand how best to use them in the clinic, when they might not be effective, and what improvements can be made to improve efficacy and safety. Key to distinguishing the two is that we have more than just evidence that something causes an improvement. We can evaluate the epidemiological data in light of a plausible mechanism. For example, Laetrile, a popular alternative cancer treatment, is well characterized in terms of chemical structure and bioactivity. It possesses no properties that would make it a good cancer drug. We can predict that with some confidence. However, it has a long and storied history with quack medicine of the mid-1920s, and so when evaluated in randomized control trials, sometimes it shows evidence of effectiveness, and sometimes it doesn't. It depends on the power of the test and who's running it. Laetrile might be considered evidence-based medicine, albeit very, very weak evidence. It is not, however, science-based medicine, because there is absolutely nothing about how it acts in the body that would make it effective. Cases like Laetrile, chelation therapy for heart disease or autism, or vitamin supplements are sometimes indicated by evidence, but not by a deep evidence of mechanisms. So returning to the example of cell phones, a big challenge is the lack of mechanism. The amount of radiation given off by modern cell phones is too small to reliably damage DNA or cross-link proteins. There's never been a good, well-controlled study on cells that was able to replicate the effect suggested by prospective or retrospective epidemiological studies. This makes scientists a little hesitant to jump behind a single study of a type that is notorious for false associations and lacks rigorous experimental control. There is no process to show that something does not cause cancer. That's simply an untestable hypothesis in practical terms. However, how does a proper skeptic view the outcomes of these contradictory studies? Simple, with an open mind and a rational estimate of risks. We don't have to cast our vote for guilty or not guilty before the trial is finished. Like good jurors, we can wait until all the evidence is in. That's what rational skepticism is all about, withholding judgment until sufficient evidence is presented to accept or reject a given hypothesis. We understand this when we're in the jury box, but forget it the moment we step out of the courtroom. It's more than a coincidence that so many scientists are skeptics and rationalists. The process becomes a way of life, a way of thinking, and a way of viewing the world. Turning those gears off on the weekends is just something some of us can't do. We care about what's true, and we know a reliable process for determining this. Thanks for watching.


Christmas card. The Christmas card is a greeting card sent as part of the traditional celebration of Christmas in order to convey between people a range of sentiments related to the Christmas and holiday season. Christmas cards are usually exchanged during the week's preceding Christmas Day by many people including non-Christians in Western society and in Asia. The traditional greeting reads Wishing you a Merry Christmas and Happy New Year. There are innumerable variations on this greeting, many cards expressing more religious sentiment, or containing a poem, prayer, Christmas song lyrics or Biblical verse. Others stay away from religion with an all-inclusive season's greetings. The Christmas card is generally commercially designed and purchased for the occasion. The content of the design might relate directly to the Christmas narrative with depictions of the Nativity of Jesus, or have Christian symbols such as the start of Bethlehem or a wide dove representing both the Holy Spirit and Peace. Many Christmas cards show Christmas traditions, such as seasonal figures e.g. set of claws, snowmen and reindeer objects associated with Christmas such as candles, holly, baubles and Christmas trees, and Christmas time activities such as shopping, caroling and partying, or other aspects of the season such as the snow and wildlife of the Northern winter. Some secular cards depict nostalgic scenes of the past such as crinoline shoppers in 19th century streetscapes, others are humorous, particularly in depicting the antics of Santa and his elves.