Everybody forced here rip in two boxes of 2022 tops tier one baseball hobby for Peter M. Thanks, Peter. Good luck First up Jersey card Chris Bryant 272 of 399 Diamond axe rookie auto Tyler Gilbert 18 of 299 and So flat in your Guerrero auto 27 of 125 the jersey number Vlad mad senior Yeah, of course charts. Thank you for hanging out man. It's a really fun night Thanks, the commentary. Oh the commentary that show kids say the darnest things People on the internet say the darnest things Tigers relic Miguel Cabrera 26 of 299 Next up auto Cedric Mullins 273 of 299 Nice rookie auto here Joe Ryan 299 of 299 on the bookends Joe Ryan good rookie pitcher. Thank you again Peter M. We will get these out to you shortly You


Hey everyone, welcome back to figure fantasy. So this morning, I had four matches in PVP. This is only a single PVP that I really lost to. I think they are free to play PVP teams that I think you should invest, especially for those who are beginning the game. For those who don't want to spend, I think these teams are worth your investment. So let's check out the Brawl Club that I was. I really had a bad, you know, had a bad beating with this team. So I had, as you can see here, I had four attacks, one, two, three, four. And let's take a look at this one. This is, I think, the most, not this one. This one was the most, you know, the most free to play team that I've ever seen in so far in the battles that I've done. So the keys here will be Yuki, Sapphire, Erixia, even Zephyr. The last person or the last figure in, you know, in this row, Chris, can be interchanged. But Chris himself is really free to play friendly, even because most of them are already three-star Peach and one-star Peach for Riksha and Chris. The other lineup that I had myself beat was Yuki, Erixia, Zephyr, Zerola. So again, the course there, Yuki, Erixia, and Zephyr, Zerola will be replaced Chris, while Astaroth, if you don't have him, you know, he is actually interchangeable with Sapphire. The other lineup is this one. So as you can see, almost similar as a lineup for what they call this with Chris. The only one that replaced him here is Zerola, which is an upgrade for me, I think. And most of them are at three-star as well. And the last team that, okay. So Yuki, Sapphire, Zephyr, Zerola, and the one that's not here is Erixia. But again, I think the most important combination to consider is this one in terms of if you want a cheaper or the cheapest alternative to any free-to-play PVP lineup is this one. Because the keys here to survival are 1, 2, 3, 4, and 5. So Chris is interchangeable, but these two are actually, you know, they are really hard to kill. Even if I had Megan and Cruces, I had a problem with them. So I'm gonna take you through a match with this one. I'm gonna have a rematch and to see how I'm going to lose to this team. I'm gonna lose badly, I tell you. Let's have a rematch of that team. My team is leveled up, as you can see here. So this was my original team that I used. So I had to change. But again, so let's try this first. Again, I'll be having a hard time, you know, finishing off. I have 1-80 already with Megan. But again, this team with Erixia being in the middle, share health is going to give me a headache. So as you can see there, I can barely crack their HP. Barely goes down. And as you can see, Cruces is down. Cruces is down. So again, I'm actually considering reinvesting some of my, you know, some of the lower characters or lower figures. As you can see, I'm decimated by this team. So again, I'm not ashamed that I lost. It's actually, I also wanted to share with you guys what you can build with a free-to-play, almost free-to-play lineup. So that's one. Let's have another match up so that you could see and then let's have a discussion on more or less who to invest on. Okay, we'll just go with this one. So this is the one that I think is similar, except that Zerola was promoted to, uh, Chris was promoted to Zerola. So let's have a rematch for this one. This is more of a headache because again, Zerola is going to hit more than Chris. So again, let's do this. If you can see here, both Cruces and Megan look like, you know, they're like paper. And even Cruces cannot keep up with Sapphire. So as you can see, I cannot deal a lot of damage, really having a hard time. Even Eriksha is distributing damage.  As you can see, I'm down to three. So again, this lineup is going to be, you know, it's going to be wonderful for free to play, for beginners, for PVP, they can really climb PVP with this lineup, not my lineup, but the opponent's lineup. So, and it's a good thing that we, you know, the game is pretty much balanced in terms of characters. So let's go first with the first one is going to be Yuki. Yuki is pretty solid, solid, very good damage. This one is reducing the damage taken of yourself and all teammates. Crazy, crazy skill for a super rarity. So that is what makes her good. As for Sapphire, I have a Sapphire here, but not leveled up.  She's pretty much very tough, grants shield to all of your figures to start a battle for each, each battle for 10 seconds. The shield will be adjusted by the figures max health.  The one that is actually important, both by the way, Yuki and Sapphire are easy to get, easy to level up. The one that we are, most of us got for free is Riksha. So Riksha for her, it's plainly just, just shared health. That is why I cannot take out some of the units there.   And you have here Zephyr, which provides healing and provides energy. Again, crazy team. I suggest you guys build it. You know, it might help you run your PVP or at least level you up in terms of your placement in PVP. But again, this is the best PVP lineup with Yuki. You have Sapphire, you have Erixia, Zephyr, and Zerola or Chris. Okay, so I hope that helped guys. So again, I took a beating. So I'm considering, you know, shifting my approach right now for PVP. But for you guys, I hope that tip helped and hopefully you can climb up PVP, especially for those who are new to the game and especially for beginners and free to play. Anyway, guys, take care. Stay safe. This is the Warden and I'm out of here.


I can't remember if I mentioned it in previous showcases, but the project that I'm working on for this increment is creating a starter course so that when a person first creates their Moodle Cloud site, that they can see a course already in there. The idea being not necessarily that they will go through and complete it step by step. But in this case, just it really is a demonstration just to invite them to start editing a Moodle Cloud site and to start seeing the power of how well it can be customized, particularly in creating courses. So what you're seeing here is just a user flow of how that future state will look. We already do have Intercom, which is in step two in this year one. Intercom is already live, but the other things that we'll be adding over the coming weeks is the welcome block and the block giving information about the free trial. And also at the bottom, there'll be a course in there by default. So like I said, this course is not intended to be comprehensive. It's not intended to replace Moodle Academy or anything like that. It's just to really give that taster and to invite people to experience Moodle Cloud. So Julie has been really helpful in creating just very succinct little bits of content in the example activities that we've got there in the introduction, just to give people an idea of what's possible. If you go to the next slide, there's just a slightly bigger version of this. The nice thing about this project is I didn't have to bother actually designing it in Figma, I just did it straight in Moodle. So it's already built. It's just doing some final tweaks. And then once it's all approved, it should hopefully be a fairly straightforward process to then include it in the template, which gets replicated for all new Moodle Cloud sites. So it's not something which is gonna require a ton of building effort either. Things crossed. So yeah, that's the plan and that's how it's looking so far. I know there was a little bit of interest in this project. So yeah, if you have any feedback or ideas based on this, I'll always happy to talk through it.


My name is Avery, I'm from Germany and I'm studying at Sowas University of London. My initial plan was to remain in Germany and study politics and language there, but I came to London in a gap year and enjoyed my time here enough to change my plans and stay for university. I'm studying the foundation here at Sowas and will go on to study a course I'm passionate about at a university I never thought I would have got into. Without the clearing process, this would not have been a possibility for me. I had not applied to UK University using the regular route before I applied through clearing. I had almost given up on getting into a good university in the UK as I realised too late that, despite Brexit, I would not have to pay overseas fees. So when I realised clearing was still open, I felt I just had to at least give it a shot and luckily I ended up getting into Sowas. Given my pool of interests, Sowas was a natural choice for me regarding my university pathway with the excellent politics and language departments. After my successful foundation year, I will now go on to study politics and Korean from October. It's always stressful to find a place to live in London, but seeing as I could not afford student accommodation, I might have found it easier than other clearing students that relied on student housing as I chose to live with my friends. I have definitely enjoyed my time at Sowas and especially in my course. I feel I made the right choice applying on such short notice and doing a foundation year is definitely even worth it. It has made me really excited to progress onto my bachelor's course the coming academic year.


Let's go ahead and get started. Welcome to, this is Pediatric Ophthalmology, Stout ran around. We're gonna do case presentations. And first up is Dr. Dries, who's lately become quite the expert on superior oblique dysfunction, surgery and everything associated with it. He's gonna share some of the wisdom that he's gathered. Thank you, Bob, and good morning, everyone. This morning, I'm trying to present something that will interest you with quite a bit of information and fairly quickly. So, what if I told you that the superior oblique muscle was not just one muscle, but rather two? And indeed, it kind of is. There are muscle compartments in multiple extraocular muscles. And this morning, I'd like to talk about the compartments of the superior oblique and what that means clinically for diagnosis and surgical management. Thank you to Dr. Joseph Deemert, UCLA, and Steve Archer, the University of Michigan, for helping me with figures and multiple discussions over the more recent years. Here, you're looking at the histology of the superior oblique muscle belly with multiple cuts starting posteriorly and then the cuts march anteriorly. And the two colors correspond to two branches of the trochlear nerve. This green color innervates here, purple-ish color here, and here's a reconstruction of selective, separate innervation of the two compartments of the superior oblique. Separate innervation makes sure that it has a totally separate oblique. Yes. So, what does that mean clinically for diagnosis and surgical management? Well, we do need to talk just a bit about motor physiology at the superior oblique. As we all know about the axes of rotation, the superior oblique is an in-torter, an abductor, and a depressor.  This is the vertical axis about which the eye rotates horizontally that gets you oriented as to the position of the superior oblique tendon with regard to that axis, and you'll have to think about the other axes, sagittal and horizontal as well. This is in primary gaze, and it makes sense that this muscle has those three functions. What about in down gaze? Well, it does change a bit. It's a better in-torter, an abductor in down gaze, and that's in large part because, simply put, the muscle just pulls harder, but the superior oblique does have this unique anatomy we all know with an origin at the apex of the orbit, coursing anteriorly and curving around the trachelea and then tendon fibers fanning out in the globe, and in down gaze, here, actually here, this is the eye in down gaze. You can't see the cornea very well, and it's kind of hard to understand why the muscle's a better in-torter and abductor. So, let's view the eye in down gaze 30 degrees forward. If you saw the movie, The Matrix, they were fighting and they would freeze and then the camera would pan over to a different perspective. That's what this view is like here. So, the eye is in down gaze. Look what happens to the relationship between the belly, the superior oblique, and the tendon. This is more or less perpendicular. Here, it's more acute, and if you look at the vertical axis, you can see the position of the tendon has changed with regard to that axis, making it a better abductor in down gaze, and the tendon is more at the equatorial position, giving it better in-torsion in down gaze. The contribution from this unique anatomy is only about five to 15% increased in-torsion and abduction. Mostly, it's that the muscle's just pulling harder. So, what does this mean clinically? Well, what's it like to have torsional diplopia? This is what it's like to have torsional diplopia. This is a 55-year-old photographer who supplied this photo shot, photo of what it's like to walk down stairs at an apartment complex. And I would just like to show you in this diagram the compartments of the muscle. There's a lateral compartment of the superior bleak and a medial compartment. The lateral compartment, its tendons insert on the posterior fibers of the tendon and the medial compartments inserts on the more equatorial anterior fibers. So, the lateral compartment has more depression, and the medial compartment has more in-torsion. The case here is a lady, mainly with tons of torsion, okay?  One could speculate. She has lots of torsion, eight degrees in primary gaze, much more in down gaze, 15 degrees. Really makes sense that those anterior fibers are affected, right, in the medial compartment. And look at her vertical deviation. It's really not that big. It's really quite small, and there's not much incomitance in down gaze. So the posterior fibers of the tendon probably are less affected. Probably the lateral compartment is less affected. So what surgery would help her? Because she's suffering. Prism isn't gonna work. Well, let's go back to the 20th century and talk about the Harada Ito procedure. Initially devised by Japanese Dr. Harada Dr. Ito just to anteriorize the front tendons of the superior bleak, but later fells modified it by splitting the tendon and transposing these fibers temporarily and anteriorly on the globe, giving them a better mechanical advantage to in torsion. How did it work? Well, quite well. Her extorsion is two in primary gaze, six in down gaze. She still has her hypertropia. Initially she fused two weeks out, but three months later, she did have trouble controlling her dyplopia again, especially in down gaze. Luckily, a small amount of vertical prism and she was fusing and she liked spectacles in the first place and she's happy. So does she have a selective medial compartment superior bleak peresis? One can speculate, but we really don't have dynamic MRI that will really tell us this in these patients at this point. Let me just talk about one more case. I think this is bilateral and maybe even a bilateral medial compartment trochlear peresis, a 60 year old female director of medical directors at the University of Utah, torsional and vertical dyplopia with a small head tilt going back to the teenage years, but a worsen recently after she had cataract surgery, which often happens with clarity of vision in patients with preexisting strabismus. She had dyplopia when driving and when reading. Let's look at her exam. Bit more complex than the last one, but look at how much torsion there is. 15 degrees in primary gaze, 16 degrees in down gaze. That is a lot of torsion. And let's look at her exam. Again, a hypertrophy that's not large without much incompetence, which would argue that the posterior tendon fibers at the superior bleak and the lateral compartment probably are not as affected. She does have a V pattern in an esotropian primary gaze. She doesn't have classic three-step Park-Spielczowski testing for superior bleak peresis, but I think she probably has a mass bilateral superior bleak peresis. When patients are this complex, you gotta break down the deviation.  A superior bleak tuck might have been a good choice, but it chose not to do that because she had such little incompetence of her hypertropia and her hypertropia was small in down gaze. So instead for her hypertropia, a contralateral inferior rectus recession is my procedure of choice, the yolk muscle of the predic superior bleak. She also has the esotropia with the V pattern. She needed a meteor rectus recession, one half tendon with infra placement for the V pattern, but keep in mind, when you transpose recti muscles, you induce torsion and if you infraplace the meteor recti, you're going to make her extortion worse. So she had a bilateral herata ego, bilateral with the goal of creating 15 to 20 degrees of mechanical encyclotorgen under general anesthesia, which we can do with a Mendez ring. The refractive surgeons know what that is and the stupasma surgeons are beginning to learn about it because you can mark the lid, mark the limbis, do your surgery, change torsion and measure how much you got mechanically. There are other ways to do this, but this seems to be the most convenient easiest for me. So how does she do? She was fusing in all gaze positions except for extreme down gaze. Her extortion was five degrees in primary gaze, five in down gaze. So she did very well and mainly the point here is, could she have a bilateral medial compartment superior oblique peresis? So what if I asked you, does the superior oblique muscle have two compartments? Well, you'd probably say yes. Thank you. Next, Terahan, resident currently on the PDF got home initially about our next patient and then I'm gonna have some comments as well. So this is an 18 month old boy who at birth developed infantile spasms and was noted to have unilateral hemimegalencephaly, which is an enlargement of one cerebral hemisphere. He had a left hemispherectomy, but despite this he had persistent seizures. After a vagal nerve stimulator and starting the ketogenic diet, this helped, but he still has about 20 seizures per day, which is better than about a hundred that he was having before. His mother had a normal pregnancy, normal ultrasounds, no known infections during pregnancy and he was born full term. There's no family history of seizures, no neurodevelopmental or genetic diseases that run in the family. And his developmental history, as you would expect, he's developmentally delayed. He's able to sit with support, he can throw objects and he likes toys that have lighted buttons. He can't say any words, but does communicate his likes and dislikes with sounds. This is a list of the medications that he's on. As you can see, he's on Sabral or by Gabbatron and we'll be talking more about that. Because of his use of Sabral, it was recommended that he get eye exams. Unfortunately, the first exam that he got was just VEP and ERG without an EUA. So the first time that we're seeing him is in April of 2018. In the clinic, he has wandering eye movements and XT and then for his EUA, his pressure is 712 and this is a cycloplegic retinoscopy. And so as I said, in 2017 he had a VEP and ERG without the associated EUA. So we do have a comparison point and that you can see that his P100 amplitude is slightly better back in 2017, but this wasn't under anesthesia, so probably pretty comparable. And this is single flash ERG and you can see that he has decreased B wave amplitude. And this is 30 Hertz testing the cones and he has a very poor cone response bilaterally as he did back in 2017. All right, so this issue of Vigabit, the question at this point with his child when he came down here from Montana was, is there evidence of Vigabit or toxicity? And we typically do an exam under anesthesia, do electrophysiology. It turns out that many years ago when this drug was studied, Don Creel and I were among the investigators that participated in gathering data that brought to the fore the issue of Vigabit or toxicity in children. And in this child, that is definitely an issue. And the thing that was striking with our exam under anesthesia was these changes depigmented areas from mid peripheral retina out to the periphery. The optic nerve notably looks healthy. We, because of issues getting test accomplished did not get an OCT during our recent exam under anesthesia. And what we did do the electrophysiology that you saw and the thing that struck me with that electrophysiology was that the cone ERG, the flicker response, which is predominantly a cone response, all we saw were stimulus spikes. That was a grossly abnormal electroretinogram. The manufacturer of Sabral has recommended that testing be done every three months, including electrophysiology and all children on the medication. We have held the line in doing it here every six months recently incorporated doing OCT. It turns out that retinal nerve fiber layer thinning has been identified as another component of this toxicity. In looking into this, there are a couple of things with this kit and I wanna show you some of the pictures. These are these areas of depigmentation that are present and fortunately the posterior pole looks relatively normal. One of the questions here is, is this Sabral toxicity? And I apologize for the flashing. I have no idea how to operate this when it works, let alone how to troubleshoot it. So if anyone has a clue, please jump in. Any of the residents, as far as is, if we were to consider other things, what else should we consider? You've got an abnormal electroretinogram in an infant who's got borderline poor vision and some pigmentary retinal changes. RP could be some sort of retinal dystrophy. The other question in a child who's got abnormal neurologic function is, in my mind, was is there some evidence of a metabolic disease? It turns out that we have him scheduled to see Dr. Longo, who is our pediatric geneticist metabolic specialist. So we will hopefully have answers on that. In the interim, the plan, quite forcefully to pediatric neurology, was let's taper him off of Vicabatron while we were sorting this out. We are going to bring him back at our next exam. We will do an OCT and we'll have more information. In terms of looking into this, what have we learned and what have I learned in putting this together for you? It turns out that Vicabatron is an irreversible inhibitor of GABA aminotransferase. And when you have increased GABA, you have decreased seizure activity. Where is it most frequently used? At least 90% of the patients that I see this medication used in have tuberous sclerosis. Why is it the magic bullet for seizures and T.S.? That is an unknown. Now, the ERG changes that Dr. Creel identified years ago include a decrease in the cone B wave, decreased in flicker amplitude. And the thing that most people remember is absence of oscillatory potentials, those little spikes you see on the elevated portion of the B wave in the electroretinogram. Nasal optic atrophy and nasal retinal, kind of segmental retinal atrophy were described by Ray Bunsik at hospital for sick kids in Toronto back in 2004 for monitoring, again, electroretinogram, fundus photos and OCT. Now, one thing I learned that I was not aware of is this has been associated with a cumulative dose greater than 1500 grams of drug. So we're going to need to start recording that when we see kids. We've not been doing that. The other issue is question of does this have long-term implications? And there are at least two papers suggesting that it indeed does. In adolescence, with documented sabral toxicity early in childhood, when they were seen later, when one could do a goldmine visual field and do OCT, looking carefully at nerve fiber layer thickness, there are abnormalities seen in adolescence from documented toxicity early in childhood. This is years off. Years down the road. And this is really opening a can of worms. And then the other issue is these authors, and this is a French group of investigators published in pediatric neurology presented VEP and ERG stimuli to selected parts of the retina. And what they found were that there were issues in the peripheral parts of the retina that they were abnormal when presenting these flashes, both VEP and ERG in school-aged children who had been exposed years earlier. And these were school-aged children who had been on the medication that did not have documented toxicity. So there's real question about this and reason for us to be following these kids closely. And so, now, setting that aside, I wanted to think, you're in clinic, it's very busy, you get a text. And the text is from one of your radiology colleagues. And the text basically just says, what is this and do you need to see the patient today? And here is the scan. And this is the only image I got. And yes, it was this fuzzy on my cell phone. And you see what looks like a lens here and not much of an anterior chamber. And so I'm wondering, is this a child with anterior segment dysgenesis that they've discovered? Say, tell me more about the patient. It turns out that the patient is a healthy 12-year-old girl head injured CT from an outside hospital reported to have perfectly normal eye exams, good visual acuity by mom. And this was an artifact. And I don't know in retrospect whether he sent this to me as a joke or seriously asking a question. But when things don't look right, you wanna wonder about the source of the information. And back to the first case, questions, comments particularly from our retina colleagues in neuro-othemology as far as this issue of bi-gabatron toxicity. What percentage of all patients on this medication do you think end up having toxicity? We talked and this is an extremely rare occurrence. This is a rare occurrence. It's a rare occurrence. When we were doing, they're doing the initial treatment trials and we were doing electrophysiology, they were using much higher doses. The doses they're using now are much lower. And I have, this is the first patient in recent memory that I have recommended that they stop the medication. Almost all the other patients we've been on have had good electrophysiology and we've had good stable electrophysiology. And again, the issue with this first ERG to understand is when you put a patient under general anesthesia, it suppresses the EEG. When you suppress the EEG, you decrease the response that you're gonna get with electoretogram and particularly with the VEP. So that anesthesia can alter it. So comparing an awake study to an asleep study is not necessarily a good thing to do and draw firm conclusions. Yes, not that I am aware of. Clearly the RPE looks like it's being impacted. Yeah, this is, if this is due to Vygabitrin, this looks like RPE. The other thing I'm gonna do when we go back next with this child and they've gotta come down from Montana and we have to coordinate care is I think it'd be wise to do an FA. We can easily do that now with a RETCAM. And Glenn Jenkins has been very good about coming to do FA's for us and helping us through that, both with PEDS Retina and Pediatric Ophthalmology Services. And doing an FA I think would help sort out where this is. The other thing I thought, as far as the metabolic disease of this, could it be gyrate atrophy or something like that? And, but there you've got loss of Choroid. This does not look to me like loss of Choroid. It looks like simple loss of RPE. I've never seen anything look just like this in any of the patients that I've either seen in person or published with Vygabitrin toxicity. So I think the important thing is the finding that this indeed can be a permanent change from a permanent loss of Daner. So, who knows how advanced that could be if somebody doesn't pick this up and then just could extend it very well. Well, the other plea I would make is that rather than having someone order the test, I think that having someone look at the eyes carefully and thoughtfully is highly desirable in terms of trying to sort these things out. Yes? I mean, the hard thing I think about Sable is it's an amazing drug for a lot of kids. And so it's not like, I mean, in some cases you have to have the discussion with parents. Would you like to take them off this drug which is the only drug that can control their seizures or the trouble I've had with this drug is that when I put them under anesthesia and do these repeat ERGs, sometimes they'll get a little lower, sometimes they're a little higher. And some of it a lot of it has to do with under anesthesia, they're a little bit different and it depends on how light the anesthesia is. And so I have trouble sorting that out and these are usually very delayed children that you can't get much of an exam in clinic. And so it's hard to know that, but it is, you know, it's really getting lower and you look at their exam in clinic and is it really worth putting these kids under anesthesia because these are kids with lots of other developmental problems. But this is the only drug that controls their seizures. It's a very difficult drug to deal with. What I said, I'm impressed how kids with uncontrolled seizures just are developmentally stalled or regressed, they're in a vegetative state. And if you can't get the seizures under control, their life expectancy goes to the teens. So this is often the option that parents have. So I find that the parents are often very comfortable with the risks of vision loss because their child for the first time is developing their brain, is not seizing and they're starting to hit milestones. So it is, it's a very complicated situation. But then they say, but you can put glasses on and fix that. Right? And that's the issue because this issue of having a brain that functions is important and it is a night and day difference. Dr. Warner. At the analyst last year, one presentation discussed a prospective trial of by Geltrin and doing baseline prior to taking medication and a very high percentage of the patients had abnormalities on RFL, on electrophysiology, visual fields, and. Prior to. Prior to. Exactly. And they had the study go on for a couple of years and they didn't see any statistically significant changes in the visual fields or RFL. Maybe the RFL actually increased a little bit and no patient had lost immunity. One patient developed visual field constriction. So I mean, I think that that's sort of called into question because a lot of the studies are done way later after the exposure. Yes. And it's, you know, understandably a lot of patients were very young at enrollment and couldn't have done a pre-treatment extensive testing. Right. But it's been somewhat controversial as to the really frequency of how often this really occurs compared to the potential benefit of the drug. It's a tough call. We try to get pre-treatment testing, you know, whenever possible. And this situation we're in here unusual for me where I've never seen the child and the very first time I see them, they've been on it for a long time, supposedly been tested and things don't look good. And we're trying to sort out whether it's old or new, which is exactly the case. And I also think of the point of the syndrome kids who, you know, there's often a reason why they have intractable epilepsy and end up on pre-treatment. That may definitely include a potential retinal issue that's related to their own disorder rather than their drugs. I'll bring additional info back. Dr. Bernstein. Yeah, just as a plug, we do have a genetic counselor that we're hiring as of July 1st. You need to do genetic testing on a patient like this because you're bringing up the idea could this be a retinal disc repeat? Yes. A retinal disc repeat plus a toxic drug and all sorts of disorders, so to say. And the genetic testing prices are coming down, so compared to a lot of other testing you're doing. It's, they're plugged into genetics already and hopefully we'll get some sort of answer in terms of an overall, better overall diagnosis. All right, next, moving on. Number three, oh, Dr. Young. Dr. Young's gonna talk to us about a very interesting patient that led both of us, I think, initially. So I'm gonna present a case of a kid I actually just saw in clinic last week, Tuesday, and the kid came in and I kind of started to discuss it quickly with Bob and he said, oh, you should present that case. So this is a six-month-old kid who was in my 930 slot last Tuesday, came in because he had some left orbital swelling. He had been treated by his primary care doctor with a course of augmentin. After he'd been on that about two days, mom felt like it got worse and she went to the emergency department where they saw him and said he has a little bit of injection of his conjectiva, some swelling with erythema of the upper lid, thought the pupils were equal and reactive to light. They thought he looked around, looked fine, told him to go home and come back and see his primary care doctor in two days or follow up with them if things got worse. But nothing got better and so they were a little bit concerned and talked to their primary care doctor and decided that they needed to come see ophthalmology. His past history is pretty insignificant. He was born full term. There was no family history of any eye problems, no past medical history. On exam in the clinic, he would follow things with his right eye but would not follow anything with his left eye and got mad when you covered his right eye. His pupil on the right was round and reacted. The left, I had a hard time seeing but it certainly didn't seem to move at all. His pressure was normal in each eye which I was able to get with the eye care. He had pretty small palpibral fissures. He was a half Asian kid so he didn't open either eye a lot but the left eye barely opened at all. The anterior segment exam on the right eye was clear. When I could get the left eye open, he had a very, not a very, but he had a hazy central cornea there and it was difficult for me to look at the anterior chamber. So at this point, I was a little bit concerned that he had kind of a fuller, it didn't look so much like a swollen orbit to me but it made me concerned that mom was saying that it was swollen. What's going on here? That in addition to an eye with a cloudy cornea that I can't see to the back, couldn't really dilate the pupil and the pupil was unresponsive. The bad thing that I was really worried about was is this retinoblastoma with extracular extension and that's why he's got some orbital changes. Mom said it kind of comes and goes. I looked at her phone and it didn't look like it, she said it wasn't there right after birth but had come later and I was wondering if maybe this could be something like a lymph angioma which has kind of a course that comes and goes but that didn't really go with the cloudy cornea. Could this be a tumor like a rhabdomyosarcoma? Something else that's very worrisome but always thinking of. Dermoid cyst, we see these commonly but that also wouldn't go with the cloudy cornea norwood congenital ptosis. Always think about congenital glaucoma in any infant you see with the cloudy cornea but his pressures were normal and that kind of rules that out in a kid. Or is this a retinal detachment with the pretisical eye and that maybe it's not really a swollen orbit, maybe it's just a small eye that doesn't open up as much. I was thinking about those things while I was letting the kid dilate and I took a brief look at the dilated exam in that right eye and thought it looked pretty normal but was quite concerned about the left eye. I couldn't get a view at all, couldn't get that pupil to dilate at all and fortunately that day I was at primary so I was able to send him over to see Dr. Harry for an ultrasound which showed a total retinal detachment and interestingly an axial length in the normal eye of 20 millimeters and an axial length in the left eye of 14 millimeters so I thought, oh, this is PHPV. This is a smaller eye with the retinal detachment. You know, it just, maybe a little bit of a and the eye is smaller so it just doesn't open as much. This, you know, doesn't have anything to do with it being swollen at all and kind of started to talk to the family a little bit about it. They were understandably quite upset but I also recommended that we do an exam under anesthesia just to get a really good look at the right eye to make sure we weren't missing anything else but I was pretty sure this was what was going on. They were quite concerned that we, you know, although there was a retinal detachment here that I didn't think we could fix that retinal detachment but I said, let's just get an EUA. I have OR time tomorrow and then we can have a better idea of things. So we put the kit under anesthesia here and these aren't the greatest photos but the right eye has a nice clear cordia. The left eye and a normal anterior segment. The left eye here, there's a haze here in the middle. The pupil is, you know, about a millimeter big and the iris is all the way up to the endothelium and I think that's why the cornea is cloudy. It's just starting to. The anterior segment doesn't look particularly, doesn't probably look like corneal. No, no. The anterior segment actually looks pretty normal. It's just that the, there's no, there's no AC. It's about a half millimeter difference in corneal diameter in the OR. Yeah, no. It's attracted to pressure, 17. Yeah, it was 17, normal. Yeah, pressures were normal. And we rechecked it in the OR and it was, it was even less, it was like 13 and 11 or something like that, very normal. I took a picture of the kit under anesthesia and you can see that this was at the end of the case but apart from the lid speculum marks, it doesn't really look like a swollen eye. It more looks like, you know, it's, the orbital swelling was just kind of a red herring. This is just a smaller eye that doesn't open as much. We also did some electrophysiology and electro ERGs here and you can see that in the right eye looks pretty normal. Single flash here in the left eye, almost nothing. And VEP is, you know, very abnormal as well. So at this point, we were, you know, I was, we kind of looked around inside the eye and taking a little closer look now that the kids are under anesthesia and, you know, Bob and I both took a look here and we could see that there was this depigmented area here which made us a little bit, take a little pause and think a little bit more about what's going on with the retina. Also, if you look, you know, a little more closely here, you can see that the vessels don't seem to completely go all the way out to the edge but at this point, we were, you know, still kind of thinking about it and kind of still thought it was a PHPV until we got in the floor scene. Glenn was nice enough to come over at the very last minute and do a floor scene for us but you can see very nicely which, I don't know, you can't, the lights are on a little bit here but this showed up much better on my computer. Yeah, if we can hit those lights off here. Oh, this picture up at all. It shows up much better on my screen here but the vascular retina ends right here. And this all branches out into fans which showed up much nicer on my computer here but pretty, and as well down here, you can see a little bit. It just adds a little bit of a... Very dramatic. Very dramatic. The vascular areas in that eye. So pretty clearly looks like something like fever now which we were completely thrown off until we, you know, did this under anesthesia. There's no leak, you know, these are the later frames here at two minutes. There doesn't seem to be any leakage. It's just all peripheral abasca retina here. You can see it just kind of fans here into a, you know, ear pattern. Looking here. So, very glad, you know, you can also see it from here as well. We put this kid under anesthesia to kind of answer that question a little bit better. So just to talk a little bit about fever which is something I didn't see so much in residency or fellowship but have seen a couple of cases and picked up on a few cases as in attending. It's characterized by peripheral abasca retina in patients without a history of retinopathy and prematurity really kind of looks like ROP. Can be very asymmetric and has variable patterns of inheritance and penetrance. This is actually one of my patients here who had kind of a similar story born with retinal detachment in the other eye. This I actually was initially doing much better and then, you know, just suddenly took a turn for the worse. You know, when the kid was a couple of years old and started pulling more and more and more although she had many times been lasered. So certainly can have a course that's very unpredictable and can change very, very rapidly. There's a paper in Ophthalmology in 2014 done by Mike Tracy's group that suggests that the prevalence of fever is quite underestimated. They looked at 74 subjects of 17 families and found that 58% of asymptomatic family members had stage one or two fever and 21% had stage three, four or five. So our patient would be a stage one just because they just have peripheral vascular, avascular retina. Stage two is, you know, when they start to have, you know, can start to have some exudate and a little bit more concerning. So 35% of these asymptomatic people had stage two which is kind of that stage that can really take a turn and start causing a lot of problems in terms of retinal detachment and macular dragging and things like that. So the question for me is how do you pick up on these kids, you know, when you see them in clinic and when can you identify them? I mean, this is one of the few retinal dystrophies that we can do something about and we can prevent vision loss. So what are things we look for? We can look for straightened vessels. We can ask about a family history but that's not always so helpful unless it's positive. If it's negative, it doesn't really help rule this out. We can look for some vitreous opacities or things. This is actually one of my other patients who was seen by another pediatric ophthalmologist in town. He had a little bit of nystagmus, had a Chiari I malformation, had actually seen neuropa at one time for his nystagmus and his Chiari and questions about whether they wanted to decompress that. He came to my clinic because the other pediatric, he had a head turn and they were considering doing a Kestin bomb so they came to me for a question of whether we should do surgery for the Kestin bomb and I said, well, what is your ophthalmologist or what have people said in the past about that tough to vitreous that's in this, you know, right over as an optic nerve and the family said, well, we don't know what you're talking about. And I sent this patient up to Emmy and it turns out this kid has fever and the nystagmus was probably due to the Chiari and he probably had both things but he ended up getting some laser in the periphery. Vertical stribismus, I have a couple of fever kids that have kind of funny vertical stribismus but we often see that too in kids who are dragged in RLP. So these are kind of some things that I kind of think about when I'm looking for these kids. The other thing that, you know, is a huge part of our exam, sometimes the biggest part of our exam is the retinoscopy and so I always kind of think about when I see kids with really high refractor, oh, sorry, this should be mine, yeah. Do these kids have fever? I have a couple of kids with fever who have really asymmetric, you know, this is a case report that was actually written by my mentor, Boston Children's, where they was published in 99 but looking at, you know, this kid who had some anisomatropia and this is actually the eye with the worst fever and they conjectured that maybe the disease could be associated with this axiomyopia. I have seen this in a few cases. I have at least one kid who's a minus nine with fever and one eye and nothing in the other eye but I also, you know, this other kid here is that I showed as a, you know, Plano in each eye. So certainly doesn't always have to be that. Also high myopia, kids with really high myopia, I kind of wonder about that as well. This is, there was a Taiwanese study that was published in 2002 that looked at kids and said that all of them had, they looked at nine patients actually with fever that they saw consecutively in their clinic and all of them had myopia greater than five diopters by age eight. This is another kid I saw who came into my clinic just after failing a vision screening and maybe a little bit of straightening. This is from his first EUA but he was 19 months old and had this refractive error. Also had a little bit of exudate here and I sent this kid up to Emmy and ended up having fever as well. So bottom line is I think it's a lot more common and I think sometimes we miss it and I think it is something that we can do something about some of these really sad cases like it can cause devastating vision loss but I think we're missing some of these cases. It's good, you know, this is the, one of the reasons I'm so glad we have our pediatric retinocerous with Dr. Hartnett, I mean the issue with this case that she presented is that without knowing the diagnosis, this child's only eye is a significant risk of vision loss. We're gonna go back and do a combined EUA for pediatric retinocerous. That I will probably get laser treatment to the abascular retina. So this is making a big difference and these are cases, it was tough to sort this out that we likely would have missed years ago and so I think that this is a clear case we're having a pediatric retina specialist that has brought this disorder into our consciousness and made us a lot more aware of it. So the question is, in the left eye? Yes. Is it feeding, this was bilateral fever? Yes, yes. Or was there a PHPB in the other eye? No, I think it's. So is fever sometimes associated with that mark difference in regards to overall globe size? I don't know the answer to that. If, I mean once you have the, this is an eye that probably didn't thrive and had retinal detachment very, very on. So, okay. And in vascular development. We know that can affect globe growth. And that's what I attributed the very short eye to was that it probably, if we don't have a prenatal ultrasound, what would be fascinating is that they had one to go back and look and see at what point in development. So this thing could have been attached potentially even to the uterus? Oh I think it did. Yeah, oh it did. I think it did. So that's what we would, I think it's a size difference too. I think it's a pretty tight funnel in there. I think it's been there a long time. So the other thing you're telling is you look at these signs but it sounds like in these mild cases, the only way you can know for sure is a fluorescent angiography. Am I not right? No you're correct. That's right. And if you hadn't had a fluorescent angiography. No, and I almost didn't. Cause to me it looked pretty like a, like it looked like a PHPV to me. You know, and that with, especially with the globe size, I almost didn't do one. But then I just kind of been thinking and I've seen kind of, I have a collection of these fever kids now and I'm thinking about it more and more. So yeah. You're right. Cause even in the or looking at the peripheral retina, she and I agreed, something isn't quite right here. Let's get an F.A. And the F.A. night and day difference. So. It was just that one depigmented area. And then the vessel, it just looked a little funny, but not really straightened. I mean, you can, it didn't, it's not advanced enough. It was just themselves. Okay. Sorry. I wish the advantage. You're not better. This is great. Thank you very much. Next, we're going to hear from Dr. Owen, who's going to talk to us about new onset esotropia. Sorry. Lost on the list. No, that's okay. We only have a few minutes. So I'll just go through kind of quickly. I don't want to delay anybody today. The patient that I'm presenting was a previously healthy two year old girl. She was born full term, no prior medical problems, not a patient of our clinic previously. She was initially presenting to the pediatric ophthalmology clinics from the primary children's ER. And she was seen there after a chair fell on her head. And the chief complaint in the ER, she had new right eye crossing with a face turn. And it was after this unwitness blunt trauma to the head. She did not lose consciousness when she was evaluated in the ED, which was initially the day after her trauma, she was sent home without intervention. She then represented to the ER several days later because her parents were concerned that her eye was still crossing, her face was still turning. They didn't understand why this was the case. At that time, we were consulted. We documented a right esotropia, but a normal dilated exam and the recommendation was made just to follow up as an outpatient. And so I saw this child six days after the initial injury in my clinic. And to highlight some of the pertinent parts of the exam, this was a two-year-old child, not reading the eye chart, but did have normal tracking abilities in each eye. But on her strabismus exam, you can hopefully see, it's a little small, I apologize. She has a right esotropia that is greater at distance. It's 25 at near, but 35 at distance. It's also incommitant on my exam, which is probably why she has at least a 30-degree head turn to get her eyes into the left gaze position where you can see she no longer has a right ET. And I did document aduction limitation in the ER, our evaluation felt like there was no adduction limitation, but she did have the face turn at that time, which is kind of a red flag for an incommitant esotropia or eye misalignment of any kind. Because generally a new onset face turn, why would anyone do that? To keep their eyes straight. And so that must mean there's some position where their eyes are straight, and by definition that means it's not incommitant. Because in a incommitant deviation, the eye misalignment is the same in all directions of gaze, therefore there would not be a position, a head position that would be advantageous at least to give you binocular vision. So these things were concerning to me. The rest of her exam was fairly non-focal. She didn't have optic nerve edema. Her dilated exam, I agreed, was normal. And she really didn't have a significant refractive error. She wasn't a high hyper-op. So I recommended that we scan her and the radiologist read is gonna be most informative, more so than my impressions. But essentially, this is the computer, that the radiologist was coming to us. All right, so they found these flare hyper-intensities that were bilateral. They had a specific pattern in the white matter. They didn't notice volume loss, but they essentially called this a picture of Luko Malaysia, but they weren't quite sure. It didn't look like anything that they could call specifically from the MRI, but it wasn't normal. The other thing that was really interesting to me is that they didn't feel like it looked very acute.  So I expected to maybe see an acute finding, but this didn't seem acute. So it was really interesting and perplexing, and I thought a neurologist would be better able to evaluate it. So I referred them to neurology and their findings, they did find a right six cranial nerve palsy, which is what prompted everything in the first place. She was maintaining her head position when she saw them in clinic, but they didn't notice any other neurologic deficits in their clinic. They were specifically looking, it sounds like, for things like spasticity that they didn't find. They felt that they were in agreement with her pediatrician and her parents that she'd been meeting all of her developmental milestones. They really could find no clinical evidence that would coincide with her MRI findings.  So it was really kind of perplexing. Their plan was to watch her carefully. They're gonna repeat a brain MRI in three months. It has not yet been three months since this was done. Sooner if she develops any other motor deficits. And then they're also doing some blood analysis to look for things associated with different leukodystrophies because their main concern was this thing called vanishing white matter disease that I had not previously heard of. So we'll talk a little bit more about that, but I think the salient points and the reason I wanted to present this is that when we see new esotropia in a child, we never know if they had a tendency previously that was unrecognized and that their disease process has worsened and this is just a manifestation of something that was already present or if this is truly a new phenomenon. And it has implications for what the cause is and if we should image the child, if we should look for any concerning underlying etiologies. So some things to watch out for if it's an incombitant esotropia, that's a big red flag that this should be imaged. And it can be difficult in a two-year-old child to ensure that all of their ductions are completely full especially in an ER setting. And so some things that can, it's certainly a induction limitation is going to help you determine if it's incombitant but a new head posture as we discussed earlier is also a sign even if you can't fully evaluate the ductions or feel like you might not be getting a true picture. If they have a new gaze position, a preferred gaze position, that is a red flag. In the setting of eye misalignment, it's a red flag for an incombitant eye misalignment. But if there is no eye misalignment but they still have a new gaze preference, that's still worrisome. They could have a new homonymous hemianopsia or something like that. So any time a child has a new head posture, it should be a cause for concern. And especially in the setting of trauma, even if you feel like the parents are poor historians, they don't know what they're talking about. This probably has been going on forever. In the setting of a trauma, you have to give the benefit of the doubt to the parents, I think. And so what if this was actually a incombitant esotropias I think was initially thought? Well, there's some guidelines for this, which we don't need to go into in depth, but people have studied this. And even a new onset, a comitant esotropia can be cause for concern. And they found in their study that out of these 48 children that presented with an acute comitant esotropia that about 6% did have an intracranial process that would account for that. And the things that were red flagged in a comitant deviation were larger angle at distance than near, which really suggests possibly a cranial nerve 6 etiology that's really a notice because that pattern because the lateral rectus muscles, which are innervated by the 6 cranial nerve are more important at distance and have more activity, we think. So common because it's bilateral? Comitant meaning it's the same in all gaze directions. The reason why a 6 would be comitant is because you've got one. I think it might have been missed. If there's truly a distance near disparity, it may be a missed 6th. And they may be calling it comitant when it might be, yeah. But obviously if the child has neurologic sign symptoms, they included optic nerve edema in this. If they have recurrence, like it gets better and then it comes back. Or if they're older than six years of age at the time they present, those are the things that correlated in their study with intracranial pathology causing the deviation. So even in a comitant esotropia that's new, there can be a reason to image those kids and those are some of the things to look for. So what do we know about vanishing white matter disease and why would that be causing this 6 nerve palsy and how is it related to the chair falling on her head? Well, we don't know for certain that she has this, but I think the reason neurology suspects it is that it is a stress-induced leukomalacia. And the MRI was substantiating the fact that this child had a leukomalacia. The chair, they feel like, could have been the stress that caused this chain of events. You can see here that there is, we won't go into detail, but there is a molecular rationale for why stress could potentiate this disease process. But essentially these children, like our patient, if this is an early childhood onset form of the disease, they do tend to develop normally. They may have some mild motor or speech delays, but they can be completely normal until you see evidence after a trauma of something like any neurologic deficit. In ours it was the 6 nerve, but it can be a taxia or spasticity. And you can see that there is some concern for life expectancy. It's an awful disease, you should read that. Yeah, we won't go, it is an awful disease, and it's really hard to fathom considering that she's a cute, normal two-year-old right now. And so for me, this is a conundrum because how do I treat her? Her head is like this. And so that is not sustainable. You know, for long-term. But it is allowing her to maintain binocularity, which is one of our goals. So I like that. I don't know how she would respond to strabismus surgery for a couple of reasons. Would strabismus surgery stress her in a way that could potentiate her disease progression? Otherwise, I don't know. And I wouldn't want, and it might not just be relative to the eyes, it could potentiate other manifestations of the disease, which I would not want to do.  I don't want to make things worse for her. And then would she respond normally to our traditional strabismus dosing and techniques because her neurologic system is not normal and that's what's causing this. Often in our accommodate abyssal tropes or partially accommodated abyssal tropes, if we're doing surgery on them, we feel like the innervation is fairly normal, the muscles are fairly normal. So we have some framework to believe that they're gonna predictably or somewhat predictably respond to our surgical dosage, but in circumstances where the muscles are abnormal, the innervation's abnormal, they don't respond as reliably and would a surgery be able to allow her to maintain a straight eye position? Would it be worth it to do that? I don't know. So we're kind of working through this now with neurology and with the family, but any thoughts would be appreciated.


news update. Good afternoon, folks. Steve Rhodes coming to you live from the shores of sunny delray Beach, Florida. This year, 1 p.m. Update curling. We have all the U.S. indices. In fact, most everything is trading to the downside. The Dow's off 329 points, a little less than 1%. One in 7 tenths percent for the S&P. That's 77 points and Aztec 103%. 460 points. The Russell's off one in three tenths. 26 points there, three and a quarter percent for the Summice. There are down 116 points. Trading out at 3480. You've got gold off for a buck. Silver down 34 cents. That's one and a half percent. Lights Recruit is trading higher by 35 pennies. She's trading at 8861 natural gas. Big move yesterday to the upside. Today, big move to the downside. Let's go take a look at our nine-panel market update chart. We begin by looking at the ES mini in the upper left-hand side. What we'll see here is prices, you know, this isn't going to really tell us where we're trading to. You'll have to tune into the Trader Z show and I'll show you all of the daily oscillator and change line levels. That's where price is likely targeting. Now, it could take those areas out. If it does, then in the case of the ES mini, we'd be looking at a move down to about the 4396 level. And that's a real possibility, while that spot follow tonics remains above its 50-day exponential moving average. That's currently printed at 2226. You've got the NQ point back, so it's back below. It's a daily profile, the top of the daily profile. If the move lower is just a counter trend move, setting up perhaps the C point of an A to B equals CDT upside, then where the NQ should find support is at the level of 14484. If you take a look at the US dollar index, we know it's got a TD9 count top. Price is pulled back. It's back below the bottom of its daily profile, which is 9560. It also is, I believe it's targeting a breakout area from 9105. I can't remember, but if you turn to the Traders Ed Show, we'll certainly take a look at that. Gold deluxe, although it's rejected the lows of today, you've got gold trading lower in terms of euros and pounds, higher in terms of yen, somewhat sideways in terms of dollars here. So gold's not going to get a whole lot of traction until it starts trading higher in all of the currencies out there. You can see Light's We Crew, there's a new profile that's attempting to form. Price is really trying to take out the quarterly profile level, and that's at the 8903 level. And if we do get above that, close above that, boy, we're going to see Light's We Crew will not have any resistance, at least from a profile scan. Folks, they do for the Traders Ed Show, we'll be back in just a few minutes. We're off to start for Thursday. Have a terrific one. We'll look forward to seeing you again soon.


Any questions from the ones that I gave you to try or from the orbital mechanics homework from last day or from the gravitation The day before Any of these that you want me to go over now is your chance to ask yo from lesson five Number three love to so from gravitation lesson three. No from orbits lesson three Okay, find the speed required to orbit that high above the moon's surface Okay, I'm gonna do my work up here cuz I got room here Are we in orbit Okay, if they're talking about orbital speed or orbital period or orbital radius Caitlyn I always start out by going well Gravity is what's moving me in a circle and And gravity is gonna be big g big m little m over r squared Equals and since they want orbital speed I'll use the circular motion equation with the speed in it the v squared over r That okay so far and yay the mass cancels and one of the ours cancels in Fact I'm gonna get now. I got to be careful which numbers I use G is good still gonna be six point six seven times ten to the negative eleven. We're pretty sure that's constant throughout the universe We're doing the moon. So what's the mass of the moon seven point three five times ten to the twenty two Now I need the orbital radius of the moon. What they've given me is the distance above the surface Which is Seven times ten to the third But I'm going to add the radius of the moon to that that's the r that we're using here. Yes Oh, they gave it to me in kilometers. So 1740 times a thousand 1740 times a thousand and then plus Seven times ten to the third That's going to be my orbital radius I'll just keep that on my calculator So I should be able to go six point six seven times ten to the negative eleven times seven point three five times ten to the twenty two divided by my previous answer One seven four I'll write down the radius before I forget one seven four seven and three zero Square root of this Is the answer is sixteen seventy So why am I getting something different? I wonder if maybe there's a typo. I wonder if they meant to do seven times ten to the fourth Oh, it's kilometers That's also kilometers There I did the same thing. Okay, so the radius is going to be Seven times ten to the third Times a thousand but like fix that plus 1740 times a thousand That's your radius eight seven four zero zero zero zero. Let's fix that eight seven four and four zeros eight seven four and one two three four zeros and Now if I'm clever. Ah, there it is quick and then square root of that There it is seven hundred and forty nine I'll give you everything in meters by the way Silly mistake on both our parts, but don't you feel better because I did the same thing not sure. I feel kind of dumb that okay fine Any others? Yeah From this lesson as well. Sure So I talked about it last class, but I'll do it again. I don't mind when it talks about the gravitational field Katie it's talking about this which again is not on your formula sheet, but it's pretty easy to drive Okay, it's the acceleration that goes with mass And what they want you to find is this now how fast it's moving I just derived the equation with Caitlyn over there I think the speed in orbit was this big G big M over R And you know the mass of the earth Katie what we don't know is the radius of the orbit We're going to use this Don't move over here. So I have more room We're going to use this to find the radius because they told us that G is eight point seven five Big G big M over R squared Could you now cross multiply and get the R squared by itself and then square root and then that's what we'll go there G is six point six seven times ten to negative eleven mass of the earth both of these and you should be able to It's a two-step question. Okay, is that all right and The units are all good this time now. I'm going to be paranoid and check Any others so Connor let's pick up where we left off them two more questions Now we derived escape velocity. I don't actually memorize this equation I can redraw it if I need to how do I redraw it? I realize that out at infinity if we really want to leave the planet We want to have no more energy left and want to use it up just perfectly We want the fuel to have turned out to be just enough Kayla to get us to a potential energy at zero because that's what we Defined out an infinity and to have come to a stop at the edge of the universe. So your equation starts up by saying Your initial energy has to be zero Which sounds kind of strange, but actually no it works out Okay, because kinetic energy is a half MV squared your potential energy on the earth because we're going cosmic now I can't use Mgh is negative Which means when you plus it over you do get two positive answers What we're really saying is this all of your kinetic energy from firing the fuel all at once and one mighty burst Has to end up being enough potential energy to get to infinity and then cross multiply We get that So What is the escape velocity for the earth? well Escape velocity is the square root of two big g big m over r or r squared over r Can we leave the earth? Let's find out Which are oh, we're starting out on the earth surface. So it's gonna be the radius of the earth 6.38 times 10 to the 6th I think yeah, is it possible for us to leave our planet's gravitational field and get out to the edge of the universe What kind of a speed is the earth escape velocity? I get 1.12 times 10 to the 4th meters per second Or Caitlyn about 11,000 kilometers per hour. Can we do that? Yeah, actually we can space shuttle did it all the time It requires a lot of fuel and you just keep accelerating and accelerating and accelerating and accelerating and accelerating and eventually you're there And you can achieve escape velocity. It's what the Apollo rockets did when they went to the moon as well So it's doable, but it's a high enough number again. It requires enough fuel Joel that it's not easily doable, which is why Countries and multinational multinational corporations have satellites, but you know school district 42 does not have its own satellite Way too prohibitively expensive Would you expect the escape velocity of the moon to be bigger or smaller or the same? Think about it if you're not sure look at the equation and kind of ask yourself a little bit hmm Let's find out because B says for the moon Well It's still going to be the square root of two big GM over r Again not on your formula sheet, but easy enough to derive I think now it's going to be for the moon these I don't have memorized, but you have them on your data sheet So two six point six seven times ten to the negative eleven What's the mass of the moon? I know we just did it a few minutes ago, but I can't remember. I missed the first number Sorry seven point three five Okay, Brianna, what's the mass of the moon? 7.35 times ten to the twenty two Over and what's the radius of the moons? To the sixth that's going wait a minute. It's bigger than the earth now. I'm gonna cheat a little bit I'm gonna go backspace because All I need to change is the mass of the planet here is going to be seven point three five To the twenty two One Seven four times ten to the sixth square root Look way smaller This is why if the technology ever evolves The idea of putting a base on the moon would make much more economical sense if we're planning on exploring outer space because launching from there Here's the only problem. Is there a lot of fuel and oil on the moon? You'd still have to get any of the fuel from the earth up to the moon So I think actually the energy saving I mean no matter what you're still lifting that mass from the earth and burning the fuel to get it from the earth unless we found some way to Well, this is why they were interested in finding water on the moon because water we can turn into fuel We can break it up into hydrogen and oxygen pretty easily maybe Maybe in your lifetimes 2.37 okay 2370 meters per second So way smaller which makes sense because are you lighter on the moon or heavier on the moon? If you're lighter on the moon, I would assume it would take less energy to leave with gravitational field, right? Hasn't got a strong of gravitational field meteors Every day the earth is hit by dozens probably hundreds of meteorites They're called mirrors I think when they're out in outer space, but once they hit the atmosphere and start burning up They're called meteorites and most of them burn up in the atmosphere at night. We call them shooting stars and And there's two main times a year when there's lots of them because the earth is passing through Essentially a giant dust cloud. So we're clearing a path through the dust by burning it on our atmosphere I think in August and I think in December, but I have to look it up And have you ever gone meteor start shower watching at night sometimes? Sometimes they can be spectacular. I saw one a couple of years ago. I was out sailing and out on the ocean There's one took about six seconds to get across the whole sky and really lit up the whole sky Wow, that was that was way cool Is there anybody who has never seen a shooting star ever? Emily No, I saw that I saw you looking around and I don't want to meet you. So you've all seen them, right? They're not stars. They're meteorites. We call them shooting stars Did you make a wish? Because I'm sorry it won't help but still can Okay What's this question asking us to find Jacob how fast I'm gonna contradict you probably it's actually gonna be a speed We're gonna solve this probably with energies in all in all honesty Okay Now this is asking for how fast a speed, but are we in orbit in a stable orbit? Read the question carefully. How can you tell we're not in a stable orbit? Connor It's gonna hit the ground. Okay, so I am not I'll write this down. Don't write this down I am not gonna start out by going this Because we are not in a stable orbit Do we have a change in height? Yeah, and we have a change in speed This is a job for conservation of energy. This is a job for us to say The amount of kinetic energy at the beginning and the amount of potential energy at the beginning is gonna be equal to the Amount of kinetic energy at the end and the amount of potential energy at the end It says released. So I think my initial speed is zero is my initial potential energy zero. No Is my final kinetic energy zero in fact? I think that's gonna have to be final that I'm gonna solve for Andrew What about my final potential energy now if we were not going cosmic if we were using mgh We would define zero to be at the ground but because we're going cosmic Zero is defined at the center of the planet. So my final potential is not zero either.   Our initial is my initial radius up an outer space. Oh It's gonna be that plus the earth's radius now 6,300 Not really all that big. Let's drop it from a bit more serious height Cross out the six thousand three hundred and make it sixty three thousand sixty three kilometers up How fast will you be going and we're going to ignore air resistance? Oh? Nicole is there a little M in this expression? Yeah, is there a little M in this expression? Is there a little M in this expression? Yeah, what can you tell me what little m's then? Which is nice. They didn't mean to tell me how in other words the mass doesn't affect how fast it's going to be going on impact The mass affects how much damage it does witness the extinction of the dinosaurs What are we trying to find Jacob? that Okay, I'm gonna plus this over to this side Multiplying by a half on this side is the same as what over on this side Timesing by two Okay, so really I can go like this Vf squared equals negative two big g big m over our initial plus two big g big m over our final That okay our vendor And how to get rid of a squared? I don't think I'm going to try typing this in into one fell swoop So I'm going to type this press equals type this press equals add them together on my calculator and square root the answer Because that's a lot of typing. Let's plug in numbers first V final is going to be great big square root sign. Mr. D negative two six point six seven times ten to the negative eleven five point nine eight times ten to the twenty-fourth all over Now my initial radius was sixty three Thousand meters up, but then don't forget to add the radius of the earth Andrew right plus To six point six seven times ten to the negative eleven five point nine eight times ten to the twenty-fourth All over my final radius is going to be six point three eight times ten to the sixth negative two times six point six seven the negative eleven times five point nine eight The twenty-fourth divided by bracket sixty three thousand plus six point three eight times ten to the sixth that's how much I Was going to say it's how much potential energy I have up an orbit That's actually not true because we canceled the ends up, but that's this first number The second number is going to be the same thing, but ditch the negative Don't and delete the sixty three thousand Don't oh and Shawn. You know what I'm going to get really clever. Am I supposed to add these two together? Plus my previous answer. Ah Hey, that should automatically add that number to this number Square root moving pretty fast basically a kilometer a second one thousand one hundred One point one times ten to the third meters per second. Is it just a coincidence?  So are you saying that all of the potential energy that you lose Becomes kinetic energy that you gain and would that not make sense and are the our understanding of the universe? You know what? I don't think it's just coincidence. I probably in fact see this equation right here Don't write this down now.  What's changing anything? What's changing anything? But negative would be initial Mine is final Could I plus the initial to this side and plus that to that side and do I now have that equation? Oh Cool, I usually jump straight to here Because it's not a hard one for me to remember All of the energy before equals all the end after yeah moving pretty fast Now how do I know for this one that it's not a question? Do you notice there's a change in the height and we're running a final speed? It's not saying how much work How do I know this isn't an orbital radius fg equals fc question because a change in height and we're not in orbit How do I know Connor's gonna stay awake? I have no idea You're gonna make it. I Don't think so. Okay So What's your homework? I Already assigned one two and three try seven. I already assigned eight nine and ten try thirteen and Then here's the deal


If you guys fire me without any sort of legal way, then you know damn well over half this department is going to be lost I'm trying to build a police department. It's not about me. It's not about you. It's about all of us Yeah, when are you gonna start to buy in okay? I have sort of since day one. What have you started? What have you got in your together? Okay? That's why I'm asking you guys you think I put a gun to your back. I said, okay Do one more bullet for Sam pass I wouldn't have received for a treasonous comment a couple of nights ago.  This is not a question.  Thank you.  I feel like the there's people in the bd after me They're trying to intentionally misconstrucate and I don't know what's going on But uh, essentially there was a situation where we had like, I think six seven. It was it was somewhere between There's seven ish officers on a scene of a crime where dent there Donald bush the 23rd was running around stabbing folks all day and he got mag dumped So I put two in them and uh, this is the part that was excessive and I agree. I should have been dat for it I gave him an extra one. I said, you know one more for sam bass I mean because we're right outside great cpd. I don't know how well you do sam bass You know, they dat me five points For the one extra bullet. They're saying, oh, you could be charged for murder. You can do this.  Well, I mean if that's the case, they were six seven other officers there Wouldn't they all be accessory or excuse me accomplice? Everybody shot him. I just gave him the one extra It really depends like the like where they're at If you all had a clear shot if you're all guaranteed They really are Yeah, because there was only look there was only four there was only five gunshot ones. I documented the scene I documented myself and he only had five gunshot wounds Howdy slacks Howdy clues. This is captain slash from lsp. How you doing? I'm good.  Uh, bring my lord, okay If I can get ahold of them. Yeah, whatever attorney you can get Okay Uh, when at your earliest convenience is possible. Okay. I'll get there soon I'll uh, I'll see you soon and I'll explain it before you go inside.   How can I help you? I'll solve them for you. Yeah call call salman if you like Hey, molten. Are you there? Oh, this is uh, oh, this is awkward. I'm at mrpd Well, who else is mrpd? I'm gonna level with you come completely because I I believe you deserve the truth PD called me down to discuss a variety of things One of the which they they wanted my independent review on was the the one more for sam bass thing I I basically gave a very wishy-washy answer I I will say they do think they have a case against you If do they have do they have a case against me if I didn't shoot him in the head And he it was reported that he died of a gunshot wound to the head Uh, if you did not shoot him in the head, then I believe they may have a case for a lesser charge Here's what I'm getting at cornwood. Is this case they have a slam dunk? Absolutely not qualified immunity could very easily apply here if you are wanting to Uh discuss this case with me as your defense attorney for the purposes of this interrogation They want you to do I am more than willing to do that and fight for your corner in the interrogation room that they they want you in You know trial We'll we'll cross that that bridge if it happens But they do have a case against you you have a very a very strong defense in my my opinion though So if you want if you want me as as your lawyer for this interrogation I'm more than willing to to give you, uh, my what I feel Uh, if this case is going to boil down to okay, that sounds good I get get who you want.  Uh, yeah, they asked me to come down to mr. Pd. And I can bring my lawyers. So I'm I'm Are you are you with the max right now? I am with max. Is this happening right now cornwood? Uh, I'm I mean I'm gathering who I can Um, I might I might grab samantha sanders. She's a paralegal grab samantha sanders She was my protege cornwood and she knows how to take our gloves off samantha sanders Oliver's your prosecutor. She's a paralegal. She's in the yellow pages. It's no doubt what they're doing right now Wait, hold on. I said Oliver is there Oliver's there. He's the prosecutor. I'm calling. Wait. Is he not conflicted.  Make a buyer complaint Yeah, we made it clear afterwards. We gotta we gotta go get this cargo woman. Okay, um Um, all right, we just gotta wait for grace and then we're good to go. Uh, you need clothing store Where's the man at the sanders? She's in the trunk. Oh, I thought you were oh, I'm sorry. I don't think we've met before good to meet you, ma'am Here we go. All right. Let me open up the trunk. There you go. Oh god.  That's right. I'll be back.  Thank you Addy Horward they're trying to put you away from murder. Yeah What's going on? You need an attorney? Oh, yeah, you want to come join my legal team? Yeah, who's your legal team? Uh, zaver monro, samantha sanders, I believe Solomon walker Oh Yeah, you're doing the strat that i'm doing.  All right, so here's what you're gonna do All right, i'm giving you the strategy right now.  All right So you got to go to each judge and you like hey, I don't want to get your input on like this case What do you think I should do here? Right and boom once they give you their input you can that's our they're automatically conflicted so they can't even They can't go they can't They can't rule over And just tell everybody but murphy and then murphy will then have to force be forced to be the judge to take your case I'm the docket. I'm doing that right now as we speak actually. Let me call you right back. Okay, they're Sounds good. How you going today officer? How you doing today?   I don't know. They're we're all down here right now Okay. Hey, Liam. Can I hear you? Can you call you right this? All right, we'll see you Yeah, they uh turning this into a pink Cadillac. Oh, it should be white. Hopefully it's a wider pink I don't know. I think it should be pink though Uh-oh. All right. Just uh park it up. It should be good. All right. I appreciate it Okay, you any corn? Yeah, we'll see you Liam. I might be uh, I might not be around too much longer I don't know what's going to happen. They uh, they might be pushing a murder charge on me.  I didn't think they'd actually do it, but I was I was worried It's incredible to me that you're the first officer who they're trying to actually Do this too.  Kuro, I want to talk to you Yeah, sure thing I need to go talk to a I guess you can do this over here. Yeah. Hey, listen, I want to return this money that you gave me Hold on. No, did you take privileged information from me? And then hear what he had to say and then choose to return the money back to me oliver Mr. Kuro, I think you know that that was not privileged. I wasn't acting as your attorney I've never agreed to represent you in any matter, but after the fact is that okay That's all good. You agreed to it after the fact, right?   Like y'all and turn you against me What did I do the people love you cornwood?  What have I done?  I'm talking to everybody Slacks is the only one who at any point among all the captains has had my back And I'm severely disappointed in the fact that he is the only captain Who has any idea who I am up there in that meeting of that review earlier today There were two senior officers not a single senior officer who was a part of shift two or shift three that overlaps with me Like holy shit and at a certain point. Can we not can we not call a spade a spade? This is malicious prosecution period point blank end of discussion Please you know what's fucked up that meeting was probably scheduled around captain roost availability Exactly The person who's probably pushing this charge people who could have preached on here by hand A hundred percent of us my court case cornwood She was a very important partner and didn't show up as well. Judge was pissed, but somehow I still get It is completely unacceptable. She chose not to because she was scared I'm noticing a trend here slacks and you keep ignoring it.  Oh, here we go. Oh, here we go I didn't book the therapy session. Hope you know Okay, so we're not here for feelings for you for facts Yeah, we are here for facts and the facts are this is malicious prosecution Because if you guys fire me without any sort of legal way, then you know damn well Over half this department is going to be lost. You think I want to be here in this position I don't think I don't think you want to be here.  No, we got here because of bad faith And that is it There is not a single other ounce of anything other than bad faith Poor decisions poor leadership and a complete disaster of a police department After I'm told non-stop that it was a failure failed police department years ago All that shit after only two months this entire department has been nothing but a disaster This is completely unacceptable.  I have defended you I've stood up for you and I agree with you on a lot of things.  It's not true. She is she is how could you say that? How could you say that and you're gonna call me a murderer slacks?  You know all these problems you're talking about you were slacks You were the what let me finish rami You I took you in and I showed you exactly what's going on I tried to help you the problems you're talking about right now.   We do you guys self under review for excessive force. What was the vote like? Everybody voted yes I can't believe this I can't How do y'all not understand this at all? Okay, how do you not understand this?  Okay, and don't spin How come every every word that I've said has been spun Every single thing I have done has been spoken. What are you talking about? Everywhere I keep everybody who comes to me.  I love the pd. I wrap up. Oh, of course I love him too. Keep on going captain.  Why why is the only captain who's ever treated me fair here?  My now it's late. That's your opinion. Mr. K No, it's a fact.   How about that? No, no, we ain't done yet Slacks we wanted to have a conversation yet you jump to conclusions and you think that you're already guilty I know I don't think I know i'm not guilty I know for a fact i'm not guilty you told me in that meeting that he died to a gunshot wound to the head I told you I made a statement I don't know if it was written down when I was asked about it by a senior I said I shot him in the chest But in this conversation should be happening inside mr. Opinion it's out of it and that's what i'm trying to say I would rather have this conversation behind closed doors In a private setting The will of the people that you are trying to represent and protect with integrity It's fine for them to hear this conversation Yeah, I would want to be fair after that legislation. That is his business The mayor speaks That law is in place right now regardless of whether or not it is in that legislation tab You know what it looks like you posted an announcement to the rest of your cops. That is law Can somebody look up that announcement for us? I'll take it a step forward. I read I read it myself because captain slacks told me to check my announcements Captain rude had a statement in there that specifically mentioned She welcomes anybody who wishes to charge her for treason to do so because you know They're just upholding the law.   Okay, I don't think y'all understand what you do Okay I'm trying to build a police department. It's not about me. It's not about you. It's about all of us Yeah, when are you gonna start to buy in okay? I have sort of since day one When have you started?  Okay? That's what I'm asking you guys you think I put a gun to your back. Okay.


Everybody forced here picking XR and elements hobby six box football mixer here a multi-year mixer random teams You can find these results on your screen anytime a late in sports cards calm Let's go ahead and get started. Yeah, I'm excited for and or season two and Sewer to see where Mando goes in in the assoka series because rebel series was not as good as Clone Wars was still good It took me a while to get in the rebels, but the more I watch it the more I'm like, okay Yeah, definitely. I like it more every time I watch it. I gotta I gotta catch one bad I don't know when I don't know when Donnie. You're not much. Oh Yeah, I'll get there. All right, 19 XR. So we're 19 XR Elements first I'm already got the XR doing this one. I might go back and forth. We'll do 19 XR first Do it by yours? Well XR is 1920 21 elements is 2021 22 It's only one box at 19 and one box at 21 or 22 19 XR I Think that's our last box of 19 XR. I think it is. Let's Got a drew lock recated to 49 Denver with a Bradley chopped to 199 Denver Hakeem Butler triple Jersey rookie audit to 199 Cardinals Yes, he's moving far away. I am a moving Very close by triple Jersey David Montgomery to 75 for the Bears And rookie Marquise Brown Ravens Got rookie Tyree Jackson to 199 Buffalo and an Edelman to 249 Pats. Oh, look at that one of one triple patch auto printing plate Lions TJ Hawkinson Nice, that's pretty nice. Congrats Detroit Detroit Lions Matt age Congrats Matt. We'll get that mad for you. This is Kyler's here, right? Yeah Kyler Daniel Jones Perceivers like DK McLauren AJ Brown. Yeah, Hawkinson's a decent name too. Very nice Hawk. We'll get that one magged They're Hawkinson exponential potential one of 49 Lions the insert an AJ Sternberger to 22 elements, we'll do 22 elements now I'll finish with the 2020 boxes for sure I'll probably alternate honestly probably goes 21 elements than 21 XR Got Pickens to 99 Steelers rookie. I thought the nuggets one the other day Vaughn Got Xenon TJ Watt number to 54 Steelers Cross the hall the presidential suite dude. I wish Randy that'd be nice. I'd be great Victor if that's your prediction I think Herbert 27 on the patch card chargers Electric there's an electricity parallel and on our topic this year. Yeah, that's Sam says, you know Very typical we can't we can't let him break it Sauce all work every shift rookie a sauce garden a rookie auto for the Jets 20 out of 15. There you go Jets Sauce and a Jamal Charles Steel signatures chiefs Pretty cool. Hey, everybody loves Jamal Charles to 35.  I don't know which one might make a playoffs Michael Thomas at 27 Cobalt Saints Both those teams ain't the playoffs zero percent chance Rookie Auto Gold Travis at CN jr. Jaguar 7 of 79. There you go Jags. Nice hit there Tray Davies white neon signs bills to 125 Cardinals rookie Jersey Ron Dale Moore to 199 Superchar anything else Cowboy Super Bowl never say Cowboys and Super Bowl again Gold Jared Goff said 250 for the Lions Don't give Lane hope like that I'll say Chiefs and Why not redemption You're right Panthers against I mean, I don't feel and said it Panthers in Houston No, I'm not Houston Panthers and the Panthers and Jets The most unlikely circle matchup like ever if you're to travel back in time like six months This is 21 XR Got a Raheem Mosher to 249 Niners rookie. Oh, did you do what at the 199 for the Cowboys and A vintage moments to 99 Raiders Charles Woodson. He said go to the Super Bowl not win the East Got Terry McLauren patch auto four of five Commanders There we go player Warren very nice commanders patch out of four five Terry and McLauren reverse Terry You haven't seen that okay, thank God, I was gonna say to you happy I'll stop the break right now show show Reverse God Raheem Mosher at number two 199 for the Niners Calvin Joseph to 75 Ricky Cowboys Travis Ntn junior Jersey card to 75 Jags Said player warning say game one. I'm not sure what's going on with the smudge there Ron Dalemore rookie Jersey auto to 99 for the Cardinals WR1 Didn't they draft a receiver? Oh, it's a Cormo. I don't even remember all I know is like the first hand It's to 2020 elements in 2020 XR last few times. You said most of its last name with ice and mustard Raheem mustard. I got really confused 2020 elements in 2020 XR here we go It's good Yeah, I could see the jets going far and like just not making it in the chain in the championship game You'll see that they're also an inexperienced team outside of Rogers Rogers brings experience. He's like hey experience of losing Experience of losing in the Big moment. What's going on here? What is this? Okay? Here we go. I don't know what I'm doing Jacob Easton is 79 rookie for the Colts. This is our manager Antonio Gandy Golden rookie Jersey to 199 commanders 200 points around to everybody at the ends and Gold rookie stainless signatures here to 79 Clyde Everett's a lair chiefs doing pretty well in the elements boxes Go looking car there for the chiefs ever delay Think force is gonna take me off breaking duty or top-loading duty would take you out of job duty. That's you No way, dude, donnie's donnie's here to stay I gotta watch I'm gonna have you break Sam five nights a week.  You know what Lakers and seven little Lakers and seven little Lakers and seven I'm changing them up Bonnie said Lakers sweep. Yeah Get your amount out of here Ross Blacklock Texans rookie darn thing to 99 Kyler gold to 10 10 to 10 Cardinals We what do you think Steve? And a an extreme rookie entered a 25 to a tongue of a low a dolphins Yeah, my my brain says warriors. My heart says Lakers like I want to see that Lakers team like When you know what I mean like I don't know like I feel Chase young rookie excellence autograph swatches going to the commanders here again. This one is expired by Little over a year You'll have to get with beneath to see if they will honor that or You know whether they try to like give you something else in replacement. That's it's up to the manufacturer commanders chase young and a rookie Cole McDonald had a farm This is a thick pack pack down here. I don't think that's a five game series I think the Lakers are a little a little too good for that Brian Edwards rookie for the Raiders Daven Cook numbered to 249 for the Vikings 75 Uche rookie for the Pats And Earl Thomas and 99 Ravens nice rookie patch one of five Justin Herbert Congrats to the Chargers one of five Justin Herbert rookie patch card There we go nice x-ray on the patch ribs right there, too. Whoa. Oh my god crazy He's got this is like the image you got that dog in him And Antonio Gibson rookie luminous endorsements auto to 49 pretty cool design there Alright, let's go ahead and run them off the points card here So you send her points right to everybody to 12 on the points again, this is getting creepy Whoever's up top gets the points one two three four five I Ten 11 and 12 the points are going to the Broncos. Oh my god Vaughn's right Go into the Broncos the points All right recap here we had relics Uh Vantoneo gandy golden at TN Rondale more Herbert David Montgomery autos of Antonio Gibson Redemption commanders chase young this is expired. You will have to get with me to see if they'll honor this or if there's another Another thing that they'll offer instead Edwards. You layer Rondale more McLauren to five for the commanders three color patch auto it says Oh It actually has the game day. I'm sorry. I missed that before it actually has the game date, which is cool So October 11th 2020 it is game worn and it has the exact game. That's very cool for the commanders Grats congrats Tray Davies whites Travis at TN Jamal Charles sauce Gardner Hakeem Butler x-ray patch to five Justin Herbert chargers and Printing play triple patch auto one-of-one rookie Lions TJ Hawkinson from 19 XR That's a really good mixture actually just being six boxes. Thanks again. You all talk to you in a sec