Okay, welcome everyone. We're very grateful to have you join us this evening for this important conversation. Hello, Chris. Chris, you're muted, get your mic on. My name is Dan. I am the director of development and programming for the bed for Playhouse. We are continuing to operate in this virtual setting. While we are working our way towards reopening, which we have done pending any further developments with COVID, hopefully we'll be able to stay open and continue working our way towards our goal of resuming some sort of normalcy. I want to just give everybody some few tips for the evening. If you are on your laptop or PC, the Q&A button, there was a Q&A button at the bottom of your screen and you can feel free to post a question. And to Chris at any time during the evening, we will have a Q&A session at the end of his presentation. We'll get to as many of them as we can. If you're on a phone or an iPad, I believe it's at the top of your screen. Please don't use the chat feature. There is a chat feature, but it kind of causes a little bit of confusion with regard to the timing of when questions are imposed. So please direct all your questions through the Q&A. We are a 501c3 non-profit. We've been working pretty much since March to bring these types of programs to the public virtually. If you find this program be worthwhile, as I think you will, and you'd like to see us do more of it over the next several months and beyond. Before you turn off your devices this evening, consider going to the Bed for Playhouse website, which is bedforplayhouse.org, and making a donation. Any amount helps. We have a couple of programs, both virtual and in person in our cafe coming up over the next few weeks. You might find something there of interest to you. I really appreciate your support, especially in this time when the future is still relatively uncertain. And so with that I want to just introduce to you Dr. Chris Bogart, who is the co-founder and executive director for the Sasko River Center Sensory Kid and Southfield Center for Development. He held various clinical positions, staff psychologists at Beth Israel Medical Center, director of psychology at the Rockland Children's Psychiatric Center in Orangeburg, New York. And he administered an American Psychological Association approved externship training program for clinical psychology and social work graduate students. He supervised staff psychologists on children's and adolescent inpatient units, devised a hospital wide behavior modification program for children, provided numerous classes lectures training programs on various topics such as parent education executive functions, assessment and coaching psychological testing stress management as conducted research studies in many areas, including attention deficit hyperactivity disorder, social skills training and depression and children. I'm sorry for reading that Chris I didn't want to make sure I didn't miss anything because it was, it's all it's all very important and very impressive. So the floor is now yours. Thank you Dan, and thank you to the Bedford Playhouse for inviting me to be with you guys tonight. And thank you Dan again for organizing me Dan was incredibly helpful and figuring out the technology and getting all this setup so I really appreciate all that support. As Dan mentioned we'll definitely have a lot of time for some questions and answers at the end if you do have questions, as we're going through, send them on and I'm happy to if Dan wants to jump in with a question we can do that. I want to talk for about 30 minutes 2530 minutes. I always end up having a lot more material that I want to share then is really allowable within the time and so what I did is I created a nice slide deck that I've provided to the Playhouse for them to be able to share with you guys at at a later point so all of the people who present tonight will be able to be sent out to folks who are interested in it there are some resources that will tap into at the end, and hopefully some helpful material that will be useful for folks as they navigate through this period of time. I wanted to share my screen with you guys. And, as I was preparing my thoughts for tonight I was trying to come up with what I thought would be a representative title for what I was going to be presenting on. This is one of the main heading of adapting to the next new normal and the reason I chose that saying or that phraseology is because it captures a couple of pieces that really underlie everything that we're going to be talking about tonight. The first one is the word adapting what we're going to be talking about our ways that you as parents that we as the adults in our children's lives can help our children to become more adaptable because the reality is, whether it's this pandemic, or some other pandemic that comes at us next year or the year after the reality is that for us to be able to effectively navigate our way through childhood into adulthood. We need to be adaptable. The reason I chose the late later words next new normal is because over the last several months since March when we went into our first shelter in place period. I've heard the term, the new normal used about 400 times and every time I think that we're at the new normal it seems like the next day we've got a next new normal because of some other bit of information, or something else that's come our way and so I thought that the term the next new normal really captures this because the reality is what we're adapting for today we need to be able to alter and be able to adapt to something new tomorrow. And the more that we can foster adaptability in our children, the more we're going to be able to promote their social and emotional well being so that's what I plan to talk about for the next 25 30 minutes. And specifically, I'm going to talk a little bit about what is adaptability. And really phrase that in the context of what we currently know and what we don't know specifically about the COVID-19 pandemic, but also what we know and don't know about lots of different things going on. To really be able to wrap that into a short discussion of the brain because if we understand a few basic underlying features of the brain and we approach this a little bit from a scientific perspective. It's going to give you a great idea, a great set of ideas about how to foster emotional adaptability through your own self care. Some tips for developing emotional adaptability and fostering social development in your kids. And then as I said we'll wrap up with some resources and can conclusions and then move on to some questions and answers and hopefully that's covering what you guys are looking for tonight. And we're going to start off with. What is adaptability. Adaptability is the human capacity to face adjust to, and ultimately learn from life's experiences and challenges. And it's made up of three primary components that if there's nothing else you remember about what we speak about tonight. If you can target your interactions with your children in a way that develops and reinforces their flexibility. Strengthens their resilience and improves their ability to manage their impulses or develop self control. If you can intersect with your kids in ways that support these three features. What research has shown over and over again is these are the three critical variables that predict long term adaptability and long term social and emotional health in children and predict who becomes a happy, healthy 2030 40 year old. So everything that we're going to be talking about tonight in terms of some of the tips that I present to you are really going to be targeted towards how do we foster flexibility, resilience and self control in our children. Because one of the greatest scientists of all time really brings this home with this saying, it's not the strongest of the species that survives nor the most intelligent. It's the most adaptable to change and so if we can focus on adaptability and specifically flexibility resilience and self control. You're 98% of the way there in terms of helping your children develop social and emotional well being. So, let's talk a little bit about a few things that we know and we don't know and the reason I'm presenting these next three slides is not in any way to up your own level of stress or worry. The three slides though, are meant to give us the context for why adaptability is so critical and why we need to turn to the science of brain development to be able to solve some of these pieces because when you consider all the different things that we don't know, and the very few things that we do know. And then the next slide we're going to talk about the various different things that you as parents are juggling. And we're going to talk about some of the social concerns, you'll realize how much strain we're placing on our systems currently so here's some of the things we do know. The spring into the summer we flattened the curve once, but now we know that new cases in the United States are back up again. Hospitals are rapidly approaching capacity, but within that context we know that the death rate is dropping in the United States which is great news. Not necessarily, but we do know that the death rate is dropping. We think it's because our level of knowledge about the virus has certainly improved and we have a lot more different treatments and we catch things earlier. And so the death rates dropping but we don't know exactly all the reasons why. We do know that COVID-19 is primarily airborne. We know that surface transmission is possible but it's much less likely. It's likely that if you wear a mask it does protect others and more research is showing that it actually protects yourself as well. We know that being outdoors greatly reduces your transmission risk. And if you do choose to socialize staying in small groups, socially distancing greatly reduces transmission so these are the things we have learned over the last seven or eight months. We have a small sampling of all the different things we don't know. We don't know what's causing the current transmission spike. We've got lots of theories, but we don't really know exactly. We don't know if that spike is because of seasonal variations and if this is a virus that tends to go according to seasonal variations. We don't know exactly how much easing of restrictions is too much. We don't know that if you have the antibody or you really truly immune and if so for how long. When will we have a vaccine and will we truly end this pandemic. When will we have other viable treatments that are available on a large scale basis. We don't know while the risk why the risk to children seems to be lower or what role children play in transmission. And therefore as we engage in the current school year, some hybrid some remote, some in person. We don't know really what the implications for that are. So you can see all of these different things that we don't know that begin to place our brain in a place of feeling uncomfortable because of what we don't know. And after this, all of the different things that you as parents in 2020 are being asked to juggle your own family history and how it informs how you relate to your own children, how to be the best advocate for your child, how to collaborate with teachers and other supports being a good partner, the continuum of today's education and how to support your children in person hybrid and distance learning. And getting enough sleep yourself and your helping your kids juggling needy relatives, juggling your own hobbies and exercise and life activities, your own work commitments, caring for your children's schedule and routines and their medical care and their social care and making sure they've got food to eat. In the midst of that you've got the hum in the background of the daily news feed. And you've got COVID-19 and this is just a small sampling of I'm sure what each of you is juggling on a day to day basis so we've got all the things that you're juggling we've got all the things that you know and don't know. And you've got the hum in the background that you hear from different people of will my child experience long term setbacks and social skills development because of this pandemic. How to best keep your child connected to the outside world. You don't want your children to miss out on important childhood experiences and what's going to happen if they miss graduation and sporting activities and other hobbies. Your child might be experiencing depression related to social isolation. And all of our kids are spending way too much time on screens and how much is too much, how much is the right amount. So you've got all of these social concerns underlying this. And so I presented these three screens of different information, not as I said to place more stress or to put into your awareness all of these different things that you're juggling. And first of all to say, even though what we're going through is unusual, the research overwhelmingly shows that most kids are going to come out of this fine because of our biological wiring that shows us how to adapt. And if we weren't we would have gone extinct thousands of years ago look the dinosaurs we wouldn't be able to survive, because our environment is always changing. Dr. Jack Shunkoff and excellent early childhood expert pediatrician. And this phrase really underlies everything you need to remember, because as much stress as we're feeling and the concern that we have the reality is our kids are hardwired to adapt, as long as we can keep in mind, a few basic good thoughts and ideas to help them move down that path of adaptability. And so what I wanted to turn to now is I wanted to turn to a little discussion of the human brain because in terms of how we can best foster adaptability it all goes back to what we've learned over the last 50 years about the human brain.  It begins to put stress on us. The human brain we also learned from science hates to be reminded of our lack of control. And when you put on the unknown and the lack of control into the human brain, the emotional centers of the brain get triggered and start releasing cortisol and adrenaline which are stress hormones that help us to be able to up our game and to be able to be wired to adapt. But those emotional centers when they become triggered, they also tend to lead to rigidity in our thinking and less access to logic. And so everything that we do in our personal lives and everything we do in supporting our children needs to go back to how do we help our kids feel a sense of predictability, a sense of control in our lives. And if we put into place a series of different steps that help our children to feel more predictability about their environment, reduce their sense of what they can't control and focus much more on what they can control. And if we do that ourselves as the adults, we're going to help our brains be able to adapt, reduce the emotional centers getting triggered and allow ourselves to be a lot more centered and ready to be able to handle things that are coming at us. So we need to control what we can control. And that starts with us as the adults. You cannot possibly help your children in terms of becoming adaptable if you yourself have run out of steam. And so what's critical is first for your kids to be able to adapt, you need to foster adaptability in yourself through self care. And secondly, I'm not meaning to sound trite and cliche. What I'm really trying to tell you guys is that what's most important to children is not what you say to them, or how you say it. What's most important is what you do yourselves. There's a research principle that's called the 102070 principle. I don't know if you've heard of that. But the 102070 principle basically says that your kids here, basically 10% of what you're saying to them. You focus on about 20% of what they see, or what they see in your affect and your energy level, and about 70% of what they end up doing is modeling what you've done. And so if you focus on modeling adaptability by acknowledging the challenges you're having in your own life, don't try to pretend everything is hunky dory, acknowledge the bumps that you're going through. But first put on your own oxygen mask before you try to help your kids with their own oxygen mask back when we could get on planes. You may remember them using that phrase and first put on your oxygen mask your own oxygen mask before you help others. That's very true emotionally as well.  So focus day to day on what you can control and try to remind yourself that you're not going to be able to control everything else around you, and whatever you can control try to take a deep breath and move forward. And you can best focus on what you can control by staying present. These are the big words that we hear in every sort of holistic intervention and if you tune into any sort of presentation like mine, you'll hear them talk about mindfulness as if mindfulness is some new concept that we've just come across in the last several years. The reality is that mindfulness has been with us for the last 10,000 years it goes way back to ancient Chinese cultures and some of the ancient practices and Buddhism and even kind of the precursors to Buddhism, where by helping human parents focus on the present and what your personal experiences right at this moment are that focus on the present is what allows you to feel more in control. And so at the end when I go through some resources I'm going to steer you to some really great apps for yourself and for your children that help promote a focus on the present and some mindfulness. Make sure you take time every day to relax and that means time for yourself, not everything that you're draining yourself by giving it to your partner, or to your children or to your job. Take some me time and show your kids that you're doing that. Tell your kids, this is me time. Go off and do your own thing right now because I'm focusing on me right now. And I promise you doing that in front of them will model for them to do that for themselves. You're getting regular sleep, exercise and diet because again, if you model that they're going to do that and pick your time when you're going to be turning off your own devices and make sure that you pick your turn off time for your kids as well. The thing I see parents do all the time is they say to me they're frustrated that their kids are constantly on their phones on their laptops on their iPads all that sort of stuff.  And they talk about how they're reading their iPad in bed at night and they've got their phone next to their bed and they're checking texts and emails all the way into the night and first thing when they wake up in the morning the first thing they do is turn their phone back on. Again, you can tell your kids, you need to turn off your devices you need to take some downtime you need to just turn off that blue light and turn off all of that passive input of energy into your brain through all these devices you can keep saying that your kids, and if you're not doing it yourself. I guarantee you they're not going to do it themselves either. And so model that and set up some good parameters on that have family meetings to talk about when the turn off time is enforce it but enforce it for yourselves as well. Socialize and socialize safely. Again, if you're modeling, getting together with your neighbors in the backyard, and everybody takes off their mask and everybody starts getting closer together and you have a couple of drinks and then, by the end of the night, you've got 20 people hanging out within three feet of each other. Your kids are going to pick that up and they're going to do that as well. If you model safe socializing keeping social distance wearing your mask. Whenever you go out, really respecting others by showing them that you care for them by putting masks on and by keeping that distance. And if you model safe socializing by having a lot of zoom get into others and things like that, you're going to really help your kids do the same thing but you're going to help yourself by staying connected and turn to others for your help if you're feeling anxious, depressed, stressed out, empty, turned others for help and show your kids that you're doing that if you show your kids these steps, I promise you they're going to internalize it, and they're going to realize that you mean it and they're going to start doing these things themselves. So let's turn to some really specific practical ways that you can support emotional adaptability in your kids. Step one, the importance of play. Play is the language of children. And a really cool saying that I heard that I read was from there's a national Institute of play run by a guy named Dr Stuart Brown, and he wrote that the opposite of play is not work. The opposite of play is depression. If you think about that, if you think about when you take play out of your own life, how you start to feel more empty and start to feel a little bit less energy. You'll start to realize why that is so critical for kids because kids primary language of expressing things and learning things about themselves is through play. It's absolutely critical that we put into our kids lives chunks of time each day that are unscheduled time without purpose.  All of those are great things as well. I'm talking about time without purpose, because that's what instills creativity. It's energy. It develops problem solving skills and improves social thinking so make sure every single day has a chunk of time or several chunks of time that are time without purpose that promote play in your kids. Place into your day routines and predictability because getting up on a specific time every day, having meals of predictable times. Having time where the devices are turned off. Having time where bed is encouraged and sleep is encouraged having predictability and routines gives that sense of control that helps the brain calm and reduce some of those stress hormones. Validate the losses that your kids are going through. Validate the fact that this is a really crummy way to have Halloween where you can't go out and do all the different things you would typically do and stop at your friends and spend time talking and all these different things. It's crummy to not be able to go to grandma and grand pops for Thanksgiving. It's crummy to not be able to get together with everybody for Christmas validate these losses don't try to pretend they're not there. Leave with empathy, talk about how this is frustrating and upsetting for you. If you talk about it and show empathy to what they're going through. It's going to help them feel validated it's going to help them feel more in control of their own feelings. There are clear rules and expectations. What I always ask families to do that I work with is to set up a weekly family meeting. That can be 15 minutes, five minutes, 10 minutes that set up a weekly family meeting where you talk about what's working what's not working. What are some of the expectations for the coming week, pull out a family calendar. There are different things that each person is going to be doing talk about what's not working and what you guys can do differently. Talk about the losses and the frustrations but also talk about the successes and the things that you're really happy about and celebrate the really fun things and make sure that there is that predictability and make sure that these different pieces are emphasized because again it goes back to supporting control. It's important to remember that on a daily basis, you're finding something to laugh about as many times during the day as possible. What research shows over and over again is that the number one way to reduce stress hormones is to laugh and to laugh a lot.  Laughter is the best medicine is something that goes all the way back to the King James Bible that's when this was phrased, we all know that laughter helps us feel better laughter helps boost the immune system. It relaxes the body. It protects your heart. It burns calories these are all some of the research findings of what laughter does, and it strengthens your relationships with others when you laugh with other people. It brings you closer together. So make sure you're putting humor in and drawing your children into laughing as well. Number six.  You're going to need to repeat things that you asked them five times more than you might have had to in the past. Try not to get frustrated by that. When kids are feeling stressed, they're going to forget things more easily. They're going to ask you to repeat yourself. You just accept the fact that you're going to have to repeat things more go slower with homework they're going to take longer to learn things. I say this to many different presentations to school teachers and I'm presenting, except that during the pandemic, you're going to have to repeat things a lot more because stress if you remember reduces flexibility in the brain. It forces the person to have greater difficulty reaching the logic centers of their brain and when you can't reach the logic centers. It forces you to ask multiple times. What, or why am I doing that. Be patient with that. It's going to be there for during the stressful period. There are ways to have meltdowns expect dysregulation, but when they do get dysregulated. There's this saying that we use a lot in the field of psychology connect before correct so before you correct and give your kids a punishment or consequence, spend a moment using empathy to connect with them. I see you're really frustrated. I understand how upsetting this is for you. Slow down when your kids are screaming and crying and getting upset. If you can slow your own voice down and talk in a lower tone. What you're going to be doing is you're going to be doing something called co regulation, going back to the brain. The brain has built into it, what are called mirror neurons and mirror neurons or nerve cells that when the person around you is calm, cool and collected. It triggers in your own brain, the need to calm yourself and so when your kids are really upset and screaming and having a temper tantrum. Slow down what you're saying, talking a lower tone, connect with their frustration and their sadness before you move into correcting them and telling them what they need to do differently. That's going to help them to calm themselves as well. Make sure that they're getting enough sleep. Sleep is critical during this period of time. There's countless research articles suggesting that even one hour reduced sleep. That is the cognitive functioning of a child by about 18 months. So if you've got a 10 year old who for a couple days in a row is getting one to two hours less of sleep. They're going to function much more like an eight year old. They're going to not be able to remember things as easily and they're not going to be able to think as quickly and clearly and so sleep is critical. It's important for you to model it. It's important for kids to get it. Make sure that's built into their day as much and as calmly as possible. The practice in good sleep hygiene is critical. And what that means is try not to let kids eat for an hour before they go to bed, turn off all their screens, at least an hour before they go to sleep. Try to have their room relatively cool and relatively dark and use their bed only for sleeping. Don't let them use their bed for studying and for watching TV and stuff like that. It should be used for sleep. It should be tied in the brain that when you're in bed, you go to sleep. Do if you're going to be reading in bed that's okay for the last few minutes. But in general, if you're reading for an hour before you sleep, sit up in a chair, and then get into bed for the last few minutes, snuggle there with your kids, help them to go off to sleep but make sure you're reinforcing that connection between the bed is for sleep. You need lots of opportunities for movement every single day. And promote an awareness of feelings. There's a great saying name it to tame it, and I'm putting on your radar this guy mark bracket from Yale, who developed this program called ruler. If you Google ruler. It's actually in your local schools if you have kids in the Bedford schools they're using this ruler system so it's probably come on to you.  So, the last section of what I'm going to talk about is let's turn to to supporting social development, because a big part of this is if our kids are emotionally stressed, and if they're cut off from a lot of activities. Are they going to be to be able to develop normally and properly during this period of time. And again I'm going back to that saying of, please don't worry kids are wired to be resilient. They have built into your day to day life. So many different opportunities for social development, just in your family, that there is huge amounts of research to suggest that kids are going to come through this just fine, as long as you take opportunities in your day to day life to promote social connection. So whether it's through their siblings through their pets through playing games with you through having conversations and time with you at dinner. All of these different social connections at home are where kids are learning social interaction and social communication and learning to empathize learning to connect other people's feelings. Learning to share the stage, learning that they may be in their own mind, the center of the universe but they have to consider other people from time to time. And so you have so many opportunities in your family to strengthen their connection to the larger world, and to reinforce empathy, responsibility, perspective taking, resolving conflicts, how to live with other people, and how to have a social impact and a few of those different areas can be done just through reading stories when you're reading a story with your kids. Make sure you take a moment to ask about the characters, why do you think the character did that. What do you think the characters feeling there why do you think they might have chosen that action versus a different action, what would you have done in this situation. How do you think when they did that how do you think that affected the other people. What do you think they're going to do next and so make it an active story reading when you're reading with kids. If you've got really young kids four or five, six year olds, this is a really cool book be kind by Pat Sivlo Miller. It's just a really nice book for younger kids that really emphasizes empathy and social connection through sharing opportunities to do for other people. The conversations that you have with kids are daily opportunities to model turn taking, discuss emotions, resolve conflict. One of the things I say to the kids I work with is to try to think of a conversation as being very similar to playing ping pong. And so in ping pong it's not very fun. If when you're serving you serve once, and the other person never have always back to you for ping pong to be fun it has to go back and forth and back and forth and back and forth. And that's what a conversation should be. If you put that metaphor in their mind of a ping pong match, and to model turn taking of you talk, you ask me a question I talk and share something with me. You talk and we go back and forth and you ask about my experience, and I asked about your experience, and you ask about my experience and I tell you why I'm thinking this way. And to go back and forth is one of the best things you can do to help build social skills for kids. Make conversations fun do a while you're out on a walk or playing a car game, set up different empathy building projects, decorating hearts flowers to put in your windows for other people to enjoy on their walks. And to be one that would really get me very happy if my neighbors came over and offered to rake my leaves and I would be very happy and able to support their own empathy, and would probably go back and do something nice for them as well so doing empathy building projects in the neighborhood, delivering food to senior citizens are making extra food when you're making something and delivering it to your neighbors. And this is for postal workers or trash collectors or other first responders or people in the neighborhood have done kind things. And playing games or great vehicles for social thinking skills and some of the ones that we use in our therapy practice that are really great ways to have great conversations with why you're doing them are these six that I'll put on your radar but there are Apple's Apple charades. Sorry, guess who chess is a great executive functions game and cranium is a great thinking game as well. And then just a few things that I think all of us have probably experienced over the last several months, or some of these video chat platforms to be able to tap into other people, and to have lots of conversations, and their great virtual community platforms as well. Messenger kids jackbox games house party teleparty roblox and their billions of others but these are just some that I want to put on your radar and case you haven't heard of them as yet. So I'm going to wrap up with a few resources and as I said I'll be sending these out via the Bedford Playhouse, but these are some great books that I really recommend very strongly from some of my favorite favorite authors, raising children permission to feel by mark bracket, one of my favorite people bring a brown rising strong building resilience by Kenneth Ginsburg. I've mentioned to you about some apps for helping with mindfulness and meditation these are three great apps that are great for kids headspace stop and breathe smiling mind. These are great websites for you to tap into as well to get some great activities workshop and worksheets to help build resilience and building other resources, these are things I've shared with some of your teachers, but they're great for you guys as parents as well. And so conclusions. The constant in life has changed. This goes back throughout human history. The reality is we have to be adaptable change will trigger stress stress is inevitable. It's not a bad thing. It helps us to develop resilience. And you can do that best by staying in the present and focus on what you can control. So if you have a model calm for your kids, I guarantee you they're going to internalize that, and they're going to be able to develop that adaptability that we're all looking for. Okay, brief shout out for Cisco River Center, this is where I come from. We've got a great program and Stanford, Darian and Wilton, do a lot of different testing therapy and sensory work so if you have any needs, please reach out to us.  All right, Dan back. All right, thanks a lot Chris I was great great stuff. So just want to remind everybody to please post your questions in the q amp a forum at the bottom of the page. And I also should mention which we failed to do at the top that we are going to be posting a recording of this talk on our YouTube channel and we will send that around to everybody. So if there's anyone that you think might benefit from viewing this, and from some of the information that Chris provided, you'll have a link that you can share, and they can watch and rewind and go back and review a few things. So here's a couple of questions. Let's start off with this one Chris how do you know this is an anonymous anonymous question. How do you know when your child needs professional help with their social and emotional issues. So, the general wisdom around that is that you're looking for a few markers, and these are not markers that is these things exist over a couple of days that you should become alarm these are things that if you have a child who is demonstrating this over a couple of weeks, then obviously it's time to reach out to somebody who has some expertise to help guide you. So some of these markers are a child who begins to show much less enthusiasm about different things that they typically would have a great deal of enthusiasm about and so as they start to be much more apathetic towards the opportunities that they would typically like, or they start backing away from friends on a consistent basis. One of the best ways that children project their need for help is through what in our field we call biological symptoms and some of these are physical symptoms of poor appetite, or the opposite, if they're just eating non stop and they can't get a sense of getting full it's like they're stress eating. They're not going to have a culty sleeping multiple days in a row, or they're constantly complaining of aches and pains. And those are some of this, some of the signs. Some of the ones that are obviously much more prominent and should always be referred to somebody who can help evaluate further is if your child starts talking about I don't want to live, or I wish I was dead or the world would be better if I wasn't around I want to start talking in those types of more self injurious or self denying ways either if they're expressing a lack of desire and a slack a lack of willingness to move forward and obviously if they express any potential plan in that direction those are big risk factors that you should help for it but the more subtle ones are the change in their daily habits changing their daily interests, backing away from activities and friends that they typically like, and some of those physical symptoms over a period of time. Another question that's come in. There's a couple that are sort of related so I'll ask them both and you can, you can decide how you want to answer. So, first question is, do you have any tips for parents of young children with autism or other special needs. How can we support their social and emotional development with the in person school and therapy they need has moved to virtual. And then there was a similar question, almost virtually the same about children who have anxiety issues. So, so children with special needs and I and I'm using that term in a very large umbrella but will speak specifically to children on the spectrum, or children with specific anxiety issues or depression issues. So children with special needs, we do know for a fact are having greater challenges during this period of time because their access to their supports, and the structure that they really rely on has been reduced. So, for many children on the spectrum, getting to school each day and having that expert support and having that structure and predictability about their life has suddenly been taken away from them, and all of this is placed on already overburdened parents. But as you rightfully tapped into their reduced amount of social connection affects how much they're going to be able to benefit from learning social cues and skills from other people. All that being said, I really would go back to some of the different pieces that I was talking about in the presentation is being really key for children on the spectrum and for all children. What I mean by that is, please don't underestimate the incredible value that you have as a parent, or that other adults in your direct environment, whether you know you have a neighbor that you include kind of in your social bubble or a, an aunt or an uncle or a grandparent or all of these different important adults as well as their siblings as well as any other children they come into contact with are great opportunities for them to learn social thinking predominantly through games and activities that promote the idea of try to step into the other person's shoes. So, when you're intersecting with your child who's on the spectrum, by being able to, being able to play a game but then to be able to say, you know, kind of almost talk out loud and have a running dialogue where you want the child to do is to kind of consider that inner language that is the language that you want them to be developing and so when you're playing a game to be able to be saying things like, hmm, well I could move over here but if I move over here, then that's going to cause this other person problem that might not necessarily help me get to here and by narrating some of your different steps by thinking ahead helps the child to be able to have that sense of the inner dialogue of other people. When you're reading a book together to be able to stop and say wow that made me feel blah blah blah by being able to tap into some of the emotions that you're having and the emotions that they might be having by being able to ask them.  What do you think they might be feeling by being able to put out there what we call social bids of like, hmm, I wonder what I'm going to do tomorrow when I get to work. They're putting things out there that are beginnings of questions that then prompt the child to be able to say, what do you mean mom? What do you think you're going to do? Those types of things are what a child in the spectrum, if they were at school, they would be getting a lot of those opportunities. Those are the different opportunities that you want to promote. The flip side to that is that we obviously need to try to tap into as much professional support as possible. So I do know because I work a bit with your district and I do know by working with the other districts in the area that they're working overtime to still try to provide as much of the special education support for kids on the spectrum and kids who are anxious and kids who are learning disabilities as possible. Obviously, every teacher that you're going to come into contact with has a lot more that they're juggling but all that being said, they still have the resources to be able to provide a lot of these different supports for our kids. I think the piece about anxious kids, the very brief answer to that is that I truly, truly believe if you are putting into place a lot of the different pieces that we talked about tonight in terms of opportunities for movement, opportunities for, you know, for downtime, opportunities for play, opportunities to talk about stress, but then to also move away from it and have laughter and all these different pieces. All of those are great coping skills for kids who are feeling anxiety and who have anxiety disorders and one of the best treatments that we're delivering to kids with anxiety disorders is teaching them mindfulness. So if you can tap into some of those mindfulness apps and try to help your kids tap into them as well, that's going to be a great lifelong strategy for them. We're getting some great questions here Chris. So the next one is, do you have any tips for how you can help a child or a teenager who seems depressed but is resistant to professional help. The biggest challenge obviously for anybody who is needing help is if they don't want to be open to it, they're going to be obviously challenged to be open to the different ideas. And so what I typically try to encourage parents who have a kid who is saying I don't want to talk to a therapist I don't want to speak to anyone or you know I don't want to speak to anybody about this nobody would understand or whatever. What I try to coach the parents on is to say, look, let's have a little bit of a deal here. I understand what you're saying, but I know for myself in my own life when I've been really stressed out one of the most important things for me was when I was able to talk to someone about it and I didn't think it was going to help it first either but they ended up having some good ideas, and just the act of talking help and so let's make a deal. If you will agree to speak to somebody for three times. At the end of that three times, we'll get together we'll talk about it and if it's truly not something you want to continue on we'll try to figure out some other way to try to help you through this period of time but if you'll agree to those three times. I'll agree to talk about, you know, us, not going in that direction if it's not helpful to you and on top of that we'll put in there, something that you can work for meaning at the end of those three sessions, you get to, you know, you get to have an extra two hours late on a Friday night or you get to pick the family dinner for the next few days or you get to pick extra desserts or you get more time on your video games or whatever you know but sweeten the pot a little bit but get them to agree to a few sessions because most well trained clinicians are going to be able to build a relationship over a couple of sessions to help bridge that gap and are able to get to the point of building that connection and to give the child a real sense that maybe this is worth it. The other thing I would recommend is if you truly have a child who won't even go for one session to talk to somebody on their own, what I would say is look, and this has become a family issue. And what we're going to do is we'll go as a family, you don't have to go by yourself but look, you do need to do this it's just the same thing as when you go for your yearly physical or when you go for your dental checkup. When we visit, we're going to get together as a family with a person, and that means your one child, who might be feeling depressed and anxious, as well as your other child who might not have those issues as well as both parents, and we'll get together with a family expert to help guide them through this and so sometimes by taking the pressure off of the child feeling like they're the identified one who's got the problem, and working on this as a family issue and going to a family trained you can really make headway to then still be able to make some progress in dealing with some of this. We've got a few questions that are kind of on a similar theme again. So I think a lot of people are funds relevant and you touched on this I think in the presentation. But we have a couple of questions about handling anger management issues meltdowns resistance to getting dressed for school, resisting help with homework. Usually as a result of kind of like the new normal you have any, any you elaborate on tips for handling those situations. Yeah, I do believe from everything I've heard and I do know from, you know, the number of parents that have been reaching out to us. They're, you know, just because I mean, I think we can all, as adults, talk about the stress that we've been feeling the fact that this feels never ending. The fact that we keep her, you know, we keep being told just dig deeper it's only going to be a few more months oh yeah actually going to be a few more months after that it's going to you know and all of this pressure is leading everybody I think to have these moments of just, you know, wanting to melt down a little bit and so I do think that, first of all, normalizing the reality that kids are going to be having more of these anger moments meltdown moments and being able to lead with empathy I know I said that earlier I'm saying it again but being able to lead with empathy as opposed to you know, as opposed to the exasperation that comes with it leading with empathy and saying I get it. I totally get it I'm feeling the same way. I know so many people are feeling the same way I get it. I'm really sorry that you're feeling this way. I think when our kids start feeling out of control when our kids start screaming and having anger issues. What that does is it tends to raise our own blood pressure and get us upset. And we hate seeing our kids this way and sometimes what that does is it gets us much more stressed out and so we start responding back in an angry way or in a setting limits way. If you step in there first in that softer, slower, calmer tone. If you say, look, you can't be throwing things around and breaking things will deal with the consequences later. Let's just deal right now. We've taken a few breaths. Let's just you take a break. I'll take a break. Let's disengage from each other. I understand that you're really frustrated and understand that you just did stuff that is not part of what we do in this family. But for right now, let's just calm down for a moment. Let's all take a time out at those types of disengage, slow down, take a breath, reduce the pressure model that for them. If your kids totally melting down and really freaking out saying I'm going to take a break myself right now and I'll come back in a couple of minutes and stepping out there yourself modeling that for them helps them to calm down. When they are calmer. Then you can go back to it and say, hey, let's talk about what triggered that off and let's talk about what you might be able to do what I might be able to do what somebody else might be able to do in this situation. Let's work our way through this because I know you hated feeling that way I know I hated feeling that way I know I hated you feeling that way by talking about it at a later point, putting that in is there as a family. Meeting to try to work your way through what triggers off some of those different pieces. That type of calming in the moment, going back to it later, coming up with a family plan and working your way through tends to help out.  If it goes into what I was talking about earlier you might be in that place where your child needs a little bit of guidance or where you might need a little bit of guidance. I'm not trying to just scare you to sasko river but we have parent coaches we've got kid coaches for anger issues and anxiety issues and things like that so sometimes if it's going on and on, and you've tried all these things I'm talking about. Sometimes pulling in an expert doesn't have to be a long term intervention it can be someone who guides you guys on a few ideas that you can then try with your kids can sometimes help move you to move you past some of those impasses. Okay. I think we got time for two more and we happen to have two more questions but in the form. The first one is someone has posted that their eight year old son lost a friend very suddenly, and since then has had a lot of bedtime fear and so how can they help him get back to his room and sleep, while being empathetic. So sad.  You're talking about a developmental stage where the child is just beginning to get a sense of, you know, themselves versus the world and that when I was talking about earlier about the child feeling in the center of the universe, and then they start to get a sense of oh my gosh there's this bigger world out there and that means that there's a beginning and an ending to me and that sense of loss and death start to become more prominent. What's being what's triggered off right there is obviously they're their sadness of losing that person is close to them and also their own fears about themselves their fears probably about you guys as parents and something that so what's critical during this period of time is for you as the parent to really up your as much as possible your own consistency and predictability. So, when I go back to before in terms of routines, expectations really trying to emphasize the idea of wake up times bedtime snuggle times reading times meal times all those different pieces, and your availability to them at the times you are predicted to be there for them that's really important because you're going to be looking for that. And then at bedtime, what's, you know what's always lovely for kids is that that's the time where they're most tired. So they're most vulnerable to powerful emotions, just kind of getting into bed snuggling with them and talking about what are some of the fun things that happened that day, and maybe reading a book together lots of great books that have kind of a metaphorical to the usage of loss I can look up a few of the ones that we use and send them on to Dan and he can post them. So that they get to you guys, but there's some really nice books for an eight year old and for you know kids at different ages that help kind of guide through loss through social stories. And this is just going to take a little bit of time it's certainly not inappropriate for them to be having some nightmares and some difficult moments, and the more you're consistent and the more your path into what they're going through and just kind of share their sorrow but also share the the hopefulness of, you know, of of all they have to look forward to and things like that that's the stuff that's going to help them get back on track. So another question for the night I think is one that everybody can pretty much relate to. We've got a few people who've mentioned this what are your thoughts about video games, because you want to make sure that your child doesn't get so caught up in it but that is where they're socializing with their friends so how do you balance that. What's the best way to balance it. And that's we have left I mean this is actually the topic of one and a half hour presentation that we give at the center with a lot of information about what's appropriate what's not appropriate different ages all that sort of stuff and I can even use you all with resources I'll send those resources to you guys as well we just did this presentation. A couple weeks ago I can send you some of the thoughts there but in short, the most important thing you guys can do in terms of video games is set up a social media and video games contract that everybody in the family develops and and what I mean by that is remember I mentioned earlier about having a family meeting every week, one of your family meetings should be about a technology contract that you develop for your family. There's a great template for this that comes out of the pediatricians office in Seattle and I'll connect you to that but it's a great template but basically, all it does is it talks about all the different things that everybody in the family should be involved in physical activities and making meals and cleaning up and hobbies and all these different things and video games and things like that and it kind of approaches you through exactly where video games and social fits into that and it kind of works its way back from, you know, 24 hours to 16 hours because of sleep and then back to eight hours because of school and then back to kind of marches you down to where your sweet spot is in terms of technology time and when that should come in there and how it has to be balanced with other activities in your life, some of which are giving back to the family some of which are doing quiet activities on your own that don't involve electricity, some of which are getting outside being friend of all that sort of stuff and so the short story is it's appropriate for kids to play video games to be online all that sort of stuff. It's important this is a real way that kids are socializing these days and so I actually understand for making sure your kids have a very healthy relationship with it so that they have their connections, but it has to be in balance with all the other things, and you can only do that through having a social media social video games contract with your kids. And you've got to follow it yourself as well. That's the most important thing. Well, Chris, thank you this is great. And as you, as you mentioned, for everybody we will post these resources and forward the recording links and some other information that we hope was helpful to you. Chris, thank you again, I hope we can do this again sometime. On a different topic for all of those of you who are able to join us. We want to thank you. Again, if you want to visit our website which is bedforplayhouse.org, and check out some of the things that other virtual programs that we have. There'll be another installment of this series coming up next month which is still to be determined. But we really appreciate your support and your time this evening. We really hope it was helpful and have a good night. Thank you.


Hi everybody, Joe for Jaspy's casebreaks.com coming at you with 2021 Topps Chrome Baseball Hanger Box number five. With ten of those quick hit baseball mixers spots being given away. If you're watching live, we just have to do one more of these and then we're in breaks filled. Big thanks to this group here for making it happen. There's all the teams right there. Let's roll it in random. We'll do the break first and then the second dice will be for the giveaway. Six into three, nine times for names and teams. One, two, three, four, five, six, seven, eight, and nine. Six into three, nine times for the teams, one, two, three, four, five, six, seven, eight. All right, no trade windows in these filler breaks, but here's the first half of the list. There's the second half of the list right here. Let's just print and rip. Remember, if you're wondering, hey, for breaks that need fillers, how do I know how many we need to do? That's always in the schedule. If you click the schedule and filler information link that Nightbot just dropped or pinned in the chat, it'll take you to a Google spreadsheet. If you scroll down, it'll give you all of that information. I try to keep it as updated as possible, but yeah, that's a place you can consult to see where we're at. All right, big thanks again to everybody for getting into this. Here's the final printout, hot off the presses. Here's the Topps Chrome Baseball Hanger box. Let's see what we got. Let's see what we got in here. Could be a surprise autograph in here, maybe. Hey, look at that, a surprise autograph. Not all of these boxes have autographs. It's Zach Birdie. The autograph for the White Sox, that's going to go to Kevin Crouch. Not bad for a filler. See what else we have here. And we've got a Jock Peterson variation. Nice. Still Dodgers edition here. That'll go to Steve Wright with the Dodgers, a couple of nice rookies there too. Awesome. Not a bad, not a bad Hanger box. Alec Baum going to Josh, Joey Bart, rookie card going to Calvin. All right. Still 10 big hits still in this break. And those are those Mixer spots. So let's grab everybody, top to bottom and everyone in between. New dice, new list, good luck. Top 10 after three, one, two, and three, easy. Once again, top 10 after three. We did three right here. Now from 11 on down, sad times, but I appreciate you trying. In fact, there is one more opportunity to try to get into that Mixer for a fraction of the price. If you want to try again, we've got one more filler to go. Top 10 happy times for you. Congrats to Jeremy, Chad, Michael, Chris, Kevin, Leonard, Dennis, Chad again, Kevin and Steve Wright. We'll see you for the Mixer a little bit later today at jaspeakscrakes.com. Bye-bye.


So the last presenter for this morning is our third and final 2B chief resident next year, and that's Reese Feist And he's going to be speaking on oral steroids for bacterial endophthalmitis And we also want to congratulate him because he's getting married in a month So I'll try to go pretty quick so y'all can get lunch So my project it I'm a little bit bummed out So I was going to look at oral steroids and endophthalmitis my IRV is still under review So I don't have any new data that we've been able to pull I'll blame dr. Shakur for that one, but he He and dr. Vitaly are the two providers that really routinely put patients on oral steroids after they've gotten In bacterial endophthalmitis so kind of most of the provider all the proper providers here They'll start with a tap and inject and then they'll do vincomitis and septasitim and then intravitural dexamethasone But then kind of in addition to that some of them will do oral steroids So we're planning to do a retrospective chart review of bacterial endophthalmitis cases that we've seen here So they don't all originate here, but we get a lot of referrals from outside as well Herb and evaluate the frequency of the infections organism type and then the response to treatment between those given oral steroid and those without So hopefully pretty soon we'll get that approved But just kind of as a justification for the study I was just going to review a little bit of the other literature first The endophthalmitis retract me study look was looking at 420 patients with endophthalmitis after primary cataract or secondary IOL plays They essentially randomize into four groups. So they did initial vitrectomy with or without antibiotics So there were two groups and then tap and inject with or without IV antibiotics So for the vitrectomy they're getting 20 gauge aiming to remove about 50% of the gel and eyes with no vitreous separation So try to a fairly minimalistic approach and this was followed by Intravidual amicacin and vancomycin as well as a subconjunction of vancomycin seftaz and dexamethasone They also put patients on topical antibiotics with vancomycin and amicacin which was used up to q1 hour Alternating if there is any evidence of a wound leak or wound infection and then q4 hours otherwise For the IV therapy they had seftaz and amicacin the amicacin was hydrated to serum concentrations, but then kind of one one point years that they did do oral steroids So they're using oral brightness on 30 milligrams twice a day for between five to ten days And their results at at their one-year Point they had 53% of patients who had actually done quite well getting 20 40 vision or better 74% were 2100 or better Their culture data so 47% of cultures were quag quag negative grand positive So staff that be those sort of things and then 16% were other grand positive bugs They found no benefit from IV antibiotics and then they ended up Recommending vitrectomy only for light perception patients that increased the chance of achieving 20 40 vision or better by by three times So about 33% of patients with white perception vision or worse that had vitrectomy ended up 20 40 or better versus 11% so After that and starting even a little bit before that there's been a move to kind of move away from the oral Oral steroids and towards Intraviturals so kind of in that it really in the 1970s was when most of literature Started coming about using intraviturals dexamethasone And Kind of the justification for that was you know lower lower Systemic toxicity and those sorts of things In one rabbit study with the pneumococcal endopthamitis They they were looking at intravitural vancomycin levels and found that the antibiotic level was significantly higher in those eyes Treated with intravitural dexamethasone at the same time So there's been kind of varying studies just mainly in anim in Ravis and those sorts of things looking at the outcomes with the intravitural mode of treatment the largest human study was I think about 250 patients they Unfortunately should know no significant difference in the portion of patients achieving a final best corrected visual acuity of 20 40 or better Actually not too long ago they open there was a Cochran review from From February of this year that was looking actually at it Outcomes of those treated with or without Intravitural steroids so they had found three studies with a total of about 95 patients perspective studies and They then all of the patients in these trials for their European Were treated with intravitural dexamethasone and then a combination of two intravitural steroids There was a trend a trend toward better Outcomes in the the intravitural dex patients, but no statistical no statistical significant difference between the two groups In terms of just the safety of this it does seem to be safe a dose of intravitural dex is it's eliminated from the vitreous cavity after about two days So it doesn't get you through the entire inflammatory stage of the infection But it does offer you some protection. It's found to be safe at doses of 400 micrograms and less Over that dose. It's thought that the Mueller cells are the primary site of toxicity. So similar to the to the Aminoglycosides and the response to those Oral steroids like I said have fallen out of routine use for many providers in the treatment of endophthalitis And as such there's been no studies looking at the outcomes of oral steroids on the treatment of endophthalitis The potential justification would be that by treating for a full course of five to ten days You can kind of get the patient through that entire time of the inflammatory process and not just the two days It takes to wash out But you know this being said it is still it's still fairly controversial There was a poll in 2004 and ASRS So only about 47% of retina providers at that time were routinely using any type of antibiotic in their endophthalitis patients Whether it was oral or intravitural so it's kind of people practice patterns are all over the place Kind of transitioning to that We do have an interesting endophthalitis case that I was going to present and kind of tags on to actually what Julia was talking About earlier with some of the kind of scleral fixated IOLs But this was a guy that kind of came in quite a while ago He had decreased vision in his right eye He was trying to have a chronic macular off retinal detachment as well as a dislocated intraocular winds So in January he had a combined scleral buckle 20 gauge of a trichomy of silicone oil, and then he had his IOL explained to him was initially left a fake egg His subretinal fluid resolved, but he developed chronic macular edema following this He came in about 2250 2200 somewhere in that range and Kind of the best he did post-operative was about 2125 He had no response to pred-14 nevinac at 10 weeks And so he eventually underwent a combined of a trichomy of silicone oil removal membrane peel And then a scleral fixated IOL on April of 2012 So he had this lens implanted with an adiogortex suture So July of 2012 he saw a persistent macular edema with count fingers vision He started on nevinac, but his macular edema persisted. So September Fred Forte was added to his regimen And April it still had minimal improvement in the CME despite a membrane peel despite And two agents so he was given the Nasrdex and had an retinal anatomic success, but still poor vision But then he started getting corneal decompensation These were actually some pictures taken from that time So there had been just these kind of little whispers in the chart of some kind of conge inflammation You can see these sites here. You can't see it as well nasally, but really really well out here Some kind of inflammation over the site of his Gore-Tex suture and that was back in April So his cornea started decompensating and then he had a DSEC procedure At the time of the procedure is noted to have nasal and temporal areas of the exposed Gore-Tex He underwent conjunctival revision with 80 and 90 vicaral Kind of otherwise in the short-term curse of course did require that his graph be refloated on post-op day number six And then in July 2013 the Gore-Tex suture again eroded through and then just over the Over the numerous visits are just these recurrent notes of suture erosion waxing and waning inflammation of the conjunctiva in July he was seen on call and noted to have a micro hyphen with vitreous hemorrhage on his B scan He was seen by one of the older retina fellows at that time as well So There was concern for ugg syndrome at that time because his hemorrhage eventually did clear fairly quickly This was July. So kind of similar similar appearance temporally and then kind of just this this whitish material over the the nasal site so Notes kind of changed a little bit and these were kind of eventually called Gore-Tex granuloma is unfortunately in January 2015 he came into triage clinic and had four plus ac cell and then again wide inflammatory tissue over the sutures had a tap and inject at that time with Vank seftas and then also dexamethasone the cultures, you know even at two years I checked and there's still no growth for bacteria or fungus Kind of given the clinical course thereafter this was Eventually and some of the notes that are attributed to a graft rejection He was treated with kind of varying modes of topical steroids. So maxitrol pred forte those sort of things in December of 2015 so, you know not quite a year later. He came back with again four plus ac cell wide Inflammatory white inflammatory tissue over the sutures and then was also noted this was when Jim Bell first saw him So noted have severe con scleral thinning over the over the line the or with overlying conjunctiva Had a repeat tap and inject again vein can seftas dex and then they also gave him voriconazole To Jim was concerned this could have a fungal component that just been kind of very very mildly festering And this got kind of cut off But his cultures again returned no growth for bacteria and fungi and they also sent off Vitria sample for a pan PCR at the University of Washington, which also negative totally negative So these were pictures from December 2015 so you start to see again more kind of Pigmentary changes in those sites so Kind of get the suspicion for some thinning under the conch there More kind of a suspicion for thinning under the conch Closer up, but then these are actually some Some retro trains a little bit some Illuminated view so you can see right here how thin that is and also kind of at the other site Just superior to that it's not showing up super well. Thank you, Dr. Betty Can't really see it quite as well up there, but there is also some Transillumination defect up there superiorly And then just here's another view of it as well so you can make it out a little bit better on this shot So in February of 2015 after the inflammation settled down from the tapin and jack He went ended up going back to the OR. He had Gore-Tex suture removal at that time They're able to actually refixate the IOL to the iris with Nine-O-Prolene suture The temporal conjunctiva was closed with amniotic membrane grafts and then the nasal with just sliding conjunctival flap with tenons And he did initially have a wound leak which was successfully treated with a bandage contact The Gore-Tex suture is actually dropped into a culture at tube and then sent for culture and finally finally got something back He ended up growing steratia, and then it was fortunately pretty almost pan sensitive. They're not typically sensitive to the Amoxicillin or ampicillin, but he'd been getting seph Sephthazim which it was sensitive to which was good So 20 and July of 2016 was his last visit. He had stable vision overall He'd been kind of at about 2400 following this this second procedure There's no further thinning notice throughout these visits, but unfortunately in August the patient was deceased So I haven't been able to follow up with him anymore since that time so just Just kind of in terms of this it was kind of interesting to me because the seracea is a rare cause of bacterial endoplamitis and in some of Various studies looking at that kind of the epidemiology of these it's it's you know probably less than 1% and at the most There was a review of 10 cases which was showing all were sensitive of sephthaz But they do horribly horribly poor with this infection It's there was I think one case in there that ended up 2020 But the rest were basically like no light perception Final visual acutus 20 or 2400 better and only 4 of 10 eyes and 4 of 10 also required evisceration Just the infection was just so horrible And so sclerophyxated IOLs have been reported as a risk factor for endoplamitis based on the presence of permanent tracks going through the sclero There's been numerous reports of late failure of polypropylene suture. Dr. Manlis can talk a little bit about this too It's a monofilament monofilament polymer of propene. It's not absorbent But biodegradation has been found in highly metabolic tissues So they recommend kind of placement far away from the lumbus and other sites of kind of actively dividing cells or high blood flow Gortex on the other hand, it's a it's a not absorbable polytetrafluoroethylene monofilament. It's got greater tensile strength So there's numerous kind of prospective benefits to using this over proline It's most commonly used now for heart valve and vascular procedures to cordyte tendinide procedures There was actually not too long ago a recent one-year follow-up of 84 sclerophyxated IOLs with Gore-Tex They had no super erosions and then low rate of other complications kind of that And they've published kind of two series of these one with just the sclerophyxated IOLs and then another in conjunction with the tractomy so kind of that the outcomes were kind of similar to what you'd expect with With corneal corneal edema vitreous hemorrhage those sort of things, but no other serious complications So Brian And these they were very yeah, and those series they were very I'm not sure I you know those patients very so Jim is like I said that the notes were kind of a Little bit light on detail But Yeah, Jim noted some what he calls to true tales And So just kind of in terms of the Gore-Tex, so it's it's been awesome for most people But just if you actually go on the website they they have a specific contraindication against ophthalmic surgery I'm not sure And they don't want to Yeah, and it's been it's been if you get it approved by the FDA and you haven't tested in the eye And you don't say that you can't get it approved. So that that's it's a it's a It's a foregone conclusion that if they don't study that way And then you know kind of that being said like when you Google Gore-Tex sutures So the first thing that comes up is their website and then right after that sclerophyxated IOL And then an American Academy of Ophthalmology It's just a little ironic but So that was kind of what I had you know, hopefully next year I'll have some some actual fresh data that we can use but Keep my fingers crossed with the IRB so Maserated We call them granuloma sutures Point is made very valid The minute you see a granuloma at the site of the suture Sometimes you know You have to have to have to do the suture Miniaturial the suture Everything's up with that So in retrospect putting information on topical You're treating the surface basically so as a matter of principle it doesn't serve you The minute you see granuloma anywhere after the surgery You just remove the suture That thing's up about you know Prevent the flavor of spice the face is concerned Here your sclerophyll will have stopped And we all might have sclerophyll So you get proxies and you can release the pain So so this isolated area where we have some type of prosthesis That just doesn't make sense and I knew you're going to get a bacteria I had a cordial transplant that I just could not suppress inflammation It was like that it just kept rejecting we replaced it several times and this is the third time around And I just looked and I just thought it looked very strange What was happening in the capsular bag And so I pulled the lens in the capsular bag and everything just left the patient a fake egg to see And it's Nick here Nick I think we got a seracea out of that one That was also a seracea So seracea is famous for just sitting there and just smoldering Smoldering sitting and causing this chronic inflammation and difficulty And until you get rid of the sight of it You can't eradicate it Even though it shows it's sensitive this is typical There's no other way So also a good thing that when you consider that Likely you've got that P-acne is another one that can fully elect this Just sit around forever until you finally get rid of it We had a case like that when I was lost After eye muscle surgery With long term smoldering infection I believe it was also seracea So it's a bad It's the pink and red stuff in your shower When you forget to clean it for a while There was a bad outbreak actually in Alabama When I was in med school it got into some TPN That they had mixed up for one of the private hospitals down the road Had a lot of people die from that one actually But it's on the faucets They were using faucet water That cheery note was a type of punch


Myself Dr. Amir Thakur Ji, I am a consultant neurosurgeon and epilepsy surgeon at Manipal Hospital, Bhan Air Pune. And today we are going to discuss something about epilepsy and epilepsy surgery. So as we all know epilepsy is a disorder of the brain in which there is abnormal excessive uncontrollable electrical discharges arising from the brain which lead to abnormal behavior or abnormal movements in patients. So it's a very common disorder and all of us know that it leads to a lot of social stigma. These patients cannot drive or they cannot you know have particular jobs, swimming. So we need to really treat this disorder with advanced techniques. So when we consider treatment of these epilepsy patients, almost 60 to 70% of the patients can still be treated with newer drugs, lot of newer drugs are available nowadays. However around 30 to 40% of the patients still continue to get seizures despite of multiple drugs or despite of very high dosages of the anti-epileptic drugs. So these are the patients whom we consider for epilepsy surgery or the evaluation for epilepsy surgery. These patients are called as medically refractory epilepsy patients. And what are the tests we conduct for this pre-surgical evaluation? We do video EEG, we do epilepsy protocol MRI and we also do PET scan sometimes. And then we analyze the results of these tests together, we sit together with an epileptologist and we see actually which area of the brain is generating these abnormal and excessive electric currents. So that area of the brain is called as epileptogenic zone. And if clinically, electrically or radiologically all the tests are pointing towards one area of origin of these electric currents, we can actually reject that area in that patient without causing damage to the patient or without causing any new deficit in that patient at the same time rendering the patient seizure free. So once we reject this area of the brain which is abnormal and generating electric currents, these patients can become seizure free, the drugs will be reduced and they can lead a normal and absolutely seizure free life. So to summarize in a nutshell epilepsy surgery is a safe and effective option in a subset of epilepsy patients around 30 to 40% of the patients and it can achieve good seizure freedom and definitely lead to a better quality of life in these patients. And so the medically refractory epilepsy patients should be seen by specialist people like epilepsy surgeon and epileptologist and they should be evaluated for a definitive curative option of epilepsy surgery. Thank you.