So welcome welcome to our Grand Rounds series. It this is one of our special Grand Rounds, which is our visiting professor series We have a unique opportunity. I will not be Having me I will not have the honor of introducing John will leave that to Alan Crandall here in just a moment But suffice it to say that John is someone who is one of the bright minds in ophthalmology Beyond being a bright mind. He's also an incredible person quality of person I'm sure he doesn't want me to tell you this. He actually Just donated his entire honorarium for coming here to our resume education fund, which is quite an extraordinary gesture. So No, it's really a great honor for me to introduce John John has done some Even as young as he is has done some major major work in glaucoma Anybody that knows anything about the the astronauts at all every single astronaut has some form of Opinir pathology, whatever you want. I'll let you I see we're going to talk a little bit about that Related to being in space and and it's his Roll he went through thousands of of Records to discern how what's the problem and possibly how do we fix and make sure because if it if it was like It is now everybody would be blind by the time they got to Mars and Obviously, so there's a lot of work to do with his work with that in the central nervous system of connections Which will be very interesting for Judith. I hope she's yeah because he'll be talking about right up your alley So and also they have a great fellowship Our feet is Resident Russ who's up in up in? Up in Montana They've they set up an office for him up there and they take great care of their fellows And also their patients. So it's really a great honor to have him here to talk about the future Very interesting stuff. So we thank you very much And before we get started One of the things that I'd like to say is this place is incredible you guys have some of the most Accomplished most caring teacher mentors of any institution in the United States and as a from a fellowship director standpoint I think that the best training of residents occurs here and the University of Iowa of any place in the United States And so for those that are in training. I said this when it was just our small group, but I'll say it again You have a responsibility to our profession. That's bigger than just going out and doing a good job That's the absolute ante for you guys, but being at the best residency program in the best Specialty within medicine and medicine is one of the best jobs in the world in the most prosperous company or country in the world Is a is a real? Responsibility it's a it's a little bit of a burden, but it's really an opportunity and I'm really excited to see what the great things that all of your trainees do and and you've got like I said some of the best people in the world So this talk might be a little bit different than some of the talks that you've gotten in the past But how many people have heard the phrase the dark side of the moon? Not just the best Pink Floyd album ever And it's got special significance now because China just recently landed on the dark side of the moon What is the dark side of the moon one of the residents tell me what the dark side of the moon is what does that mean? So it's the side of the moon that's facing away from Earth. That's right. Most people that's right Most people say that the dark side of the moon is the side that doesn't get any sun That's incorrect. It's the side of the moon that we never see from Earth So it turns out that the moon's day and the moon's year So the day is how long it takes to do a rotation the moon's year is how long it takes to do the revolution? They are identical so it does one rotation in Exactly the same amount of the time that it takes to do one revolution And what that means is the same side of the moon always faces the earth and has Forever and I think that glaucoma is not unlike that We as ophthalmologists quickly forget that the eyeball is connected to the rest of the body and We spend all of our time in our one cubic inch of the world And we don't think about it in terms of the greater pathophysiology And so I'm gonna make an argument that The dark side of the moon is analogous to the dark side of the optic nerve and we need to think about that Here's my financial disclosure. So, how do you take some? crazy idea that you have and Actuated Ideas are really really fun and they get your juices going and there are One maybe if you're lucky 2% of the work and they're the fun 2% of the work The rest of it is just work and most of the time what happens to a brilliant idea is it ends up like this Once the work actually starts how many have started a research project that you're excited about and Four months later after you've you know Written down a paragraph of the proposal. We haven't made any progress right that kind of stuff happens and the other thing about ideas and taking Taking a stand on something is that it requires real risk not fake risk but real risk reputational risk risk of how you view yourself if you fail and you thought that you were brilliant and unstoppable and Risk of other people's dollars that have invested in you Especially if you're doing that from a venture capital standpoint people invest millions of dollars and you did you deliver on that? Trust that they put in you But what happens in academia better than anywhere else is that you have an opportunity for lightning to strike If you're just going through your day from cataract to cataract to cataract to cataract to cataract plus makes to cataract There isn't an opportunity for that conversation with a colleague for lightning to strike another thing that happens in a university setting is you've got specialists that are Not in your field that can give you ideas. I think that most of the ideas in medicine Get translated are discovered and if we can apply them to us or we can take Discoveries we made and apply them to other areas of medicine There's huge opportunity there. I remember when I was a medical student at Mayo Pediatric oncologist came and told me that he thought for retinopathy of prematurity That may be some of these new anti-veget, anti-cancer drugs Could be helpful. This is in 2002. I'm like, I don't get it and you know, and that's I don't know how far along they were Before they were injecting medicine in the back of the eye But the point is that there is somebody somewhere that's thinking Across specialties and if you can take that and translate it somewhere else you can find real big Opportunities so my idea came when I was scuba diving. This is my family. This is taken last year Not when I had the idea, but this is my son Who's tennis my wife and that's me And so I'm down scuba diving and I'm down under the water And I'm a first-year resident at Duke at this time and I'm thinking What's going on with the pressure inside my eyeball if I'm down 30 feet underwater? How many scuba divers do we have in here? How much This isn't a pimp type question, but does anybody know at 30 feet how many millimeters of mercury your pressure the water's putting on you 10 meters what? One atmosphere at third at 30 feet 30 meters would be three atmospheres. Yeah So one atmosphere of pressure. Does anybody know how many atmosphere one atmosphere of pressure is how many millimeters of mercury? 760 somebody said it but didn't want to get credit for it because they whispered it They're gonna be really accurate. They would have said it's about 610 in Salt Lake in Salt Lake City So 760 millimeters of mercury of pressure pushing on my eyeball Now if someone comes in today with the pressure of 60, we're gonna drill a hole in their eyeball today, right? So how can I be experiencing 760 millimeters of mercury of pressure on my eyeball and And not have glaucoma. How can I profuse my eyes? So I'm sitting on my one vacation I get during my first year of residency And I'm thinking about this and my wife is pissed because this is what I'm thinking about on the beach instead of enjoying a corona and paying attention to her and so When we're confronted with Something that we can't make sense of I think we have to zoom out and think about the perspective And I like this picture because this is true. You shine a red light from over here. This is true If you shine a whatever color this is aquamarine light from here This is true, but it does not represent the totality of truth And if we can zoom back out and start to make the puzzle pieces fit together We can get a broader view of what Is so the common belief is that glaucoma is a one-pressure disease the pressure inside the eyeball The more likely truth is that glaucoma is a two-pressure disease Or at least I believe the more likely truth is that glaucoma is a two-pressure disease a balance between the intraocular pressure and The intracranial pressure Okay, so when you look at the optic nerve head and you do a histology slide and this comes from Yoast Jonas Here's the intraocular pressure. There's the lamina Croprosa Here's the cerebral spinal fluid pressure bathing the optic nerve all the way to the back of the eye and we've spent a century talking about this pressure that affects the optic nerve and Very little time talking about this pressure the CSF that bathes the optic nerve We'll talk about one millimeter of mercury difference here And what's happening at night and all of this stuff when the disease occurs here at the optic nerve head? How is it possible that this pressurized fluid doesn't matter? You know that it matters You know it does because what do we see in high CSF pressure? That Vladimir the optic nerve bows forward it swells excellent will transport gets stuck on this side of it What else do you see? That looks like papillodema in high intra-cranial pressure papillodema. Hi potty the optic nerve swells Right if this pressure differential is one where CSF pressure is higher than IOP the optic nerve bows forward it swells If IOP is higher than CSF, what would we expect to see? cupping and The optic nerve gets pushed backwards right so This is just basic physics if you have two equal and opposite forces those forces cancel each other out No net force is generated Nothing happens, but if you have a force on one side That's higher on the force that's higher than the force on the other side cupping can occur glaucoma can occur So when I'm sitting there scuba diving what's happening? Yeah, my eye pressure went up 760 millimeters of mercury But so did my CSF pressure so did my blood pressure so did my tissue pressures all the pressures work in lock steps so to the point of having it having atmospheric pressure being 610 millimeters of mercury in Salt Lake City a 150 millimeters of mercury less than it is in San Diego people in Salt Lake City still get glaucoma even though the Absolute pressure in their eyes 150 millimeters mercury less It's got to be absolute. It's got to be relative pressures that matter not absolute pressures that matter But that's not how we think about glaucoma We think about it as an absolute pressure inside the eye and that's not actually the truth when we measure the pressure across the Cornia we're measuring a relative pressure We're saying what's the pressure inside the eye? How much force do I have to add to the cornea to flatten it? Aplenate it and that's the pressure and so we should really call IOP We really should call it the trans laminar cornea pressure difference, so I go back and I Go back to one of the other glaucoma specialists at Duke and I say hey, I have this idea I think that it might redefine what glaucoma is He says you're wrong go back on call So I do just what you learn to do with your parents. I find it different professor And I say hey, I got this idea about what I think glaucoma might be and And he says well, I think you're wrong go study it and that was Randall and him and so he's one of my six heroes in Ophthalmology because he took a risk on this with me and he was a wonderful mentor and he just died earlier this year And so so I'll cherish this picture You know with him forever me making some argument about some crazy idea and him seeming to buy it So I went to the Mayo Clinic. I talked my way out of one week of my glaucoma residence or my glaucoma rotation I went to the Mayo Clinic in January. I looked at 55,000 lumbar punctures over a 20-year period with Doug Johnson Doug Johnson was also one of the great people and glaucoma specialists and he died a year after we did this project from liver after having a liver transplant and And boy, he was one of the good guys. So our original paper has me Randall and him and Doug Johnson And I'm all that's left and that really rocked me a little bit. Our time is short Make sure that you're spending it on things that matter with people These were people that I cared about so we looked at 55,000 lumbar punctures and We found that indeed they have a low CSF pressure the patients that have a glaucoma glaucoma have low CSF pressure I'll talk about that in a second. So we get the paper submitted. I We submit it to ophthalmology. I'm here in this building interviewing for fellowship 10 years ago and It was the day I learned that I was not tough enough to be an academic Because it's the day that this paper got rejected And I remember getting the email saying There's not a whole lot you can poke in this thing and I was Dejected, I mean I was like, oh my gosh two people Anonymous people have this much power over me and my day And and I was I knew honestly no kidding. I knew in that moment that I wasn't tough enough to be an academic I'm interested enough to be an academic. I like to do it But my underbelly is too soft to take that kind of rejection for so for those of you that are tough enough to do that kudos to you because it really was It really was hard on me and so I went back to Allingham and I'd whined to him that I thought that this should get Accepted and he called up Henry Jampel and said how about you have one more reviewer look at it and it ultimately did get accepted in ophthalmology Peer the peer review process is not quite as Unassailable as you think that it is And it ultimately did get accepted to ophthalmology and was the lead article in their journal And so here's what we found we found that patients that had um That were normal had an average CSF pressure of 13 millimeters of mercury and people that Had glaucoma had a CSF pressure of 9.2. That was lower and so Highly statistically significant We then went back and said well, what about Ocular hypertension what about normal tension glaucoma right doesn't this explain all of it? Because 30% of glaucoma in the United States is normal tension glaucoma 70% of glaucoma in Japan is normal tension glaucoma and 83% of glaucoma in China is normal tension glaucoma Most people that have a high eye pressure don't get glaucoma Many people that have normal eye pressures do get glaucoma What's the big picture that we're missing? So if it's this that normal is eye pressure say 15 or 16 CSF pressure of about 13 Glaucoma primary open-angle glaucoma is a high eye pressure a little bit lower CSF pressure You get that pressure differential across the optic nerve Normal tension glaucoma is a normal eye pressure, but a bottomed out CSF pressure an ocular hypertension is a high seat without glaucoma a high eye pressure and a high balanced CSF pressure So that's why they don't get the disease So we went back and looked at that and that's what we found indeed the patients that had normal tension glaucoma had a lower CSF pressure patients that had ocular hypertension had a high CSF pressure and so I bring this back to Dave Epstein who was the chair at Duke who also you know passed away a year and a half ago and And and it was so fun to have a chair that would Light up and take joy in your successes and he was And so he would have these rounds Monday night and he poke at me about this stuff and he ultimately came to believe So then the questions start flying once you have this insight. What happens to CSF pressure with age? Are there diurnal CSF pressure curves does BMI affects CSF pressure? What about experimental models? Can we raise CSF pressure? Can we measure CSF pressure not invasively without doing a lumbar puncture? So what does happen to IOP with age? How about some of the residents? Let's start with an easier question This is maybe a PGY to question What happens to glaucoma incidents with age does it go up go down or stay the same? Answer the easy question first because they only get harder Goes up Okay, make sense right what happens to IOP age if say it goes up residents. How many people say it goes up? How many people okay somebody saw somebody raised their hand they said I'm following Raise your hand if you say it goes up Raise your hand if you say it goes up raise your hand if you say it stays the same Raise your hand if it stays goes down raise your hand if you don't have hands Okay IOP Increases with age to the sixth decade after which a decrease in IOP is seen with further age IOP really doesn't go up That much with age even though glaucoma in incidents is going up with age. That's curious, right? After adjusting for blood pressure there was a trend for IOP to decrease With age Okay, so IOP Stays the same if anything it goes down with age That's curious since glaucoma goes up with age. No doubt about it What happens to ICP with age? How many people say that it goes down? How many people say that it goes up? People say it stays the same. Okay, so you're right. So this is a paper that we published in I OVS 14,000 points make up this curve Here's what's how here's what happens to CSF pressure with age When you're young and you know these little babies getting taps You know, maybe they're sick or something like that, but basically it stays really really flat until about age 65 And then it falls off the cliff So CSF pressure no doubt goes down with age and not only we're not the only ones that That showed that other papers show that ICP seems to decrease with age across all ages Okay, what about BMI? What happens to CSF pressure with BMI? CSF pressure goes up. This is another paper that we published Luke Aswale published a paper in ophthalmology showing that obese women were protected from glaucoma even if they had a high IOP So glaucoma is one of the few diseases that it's good to be chubby. Enjoy your cheeseburger I think we've all seen the reverse of somebody who's had stable glaucoma and it loses a lot of weight And and the glaucoma just goes just that's right And we were talking just yesterday about when you see normal tension glaucoma patients How many of them are slender females a Lot of them are slender females and it starts to tie this story Together so here's past Wallace paper among women high BMI was associated with a lower risk of primary open-angle glaucoma Low BMI low BMI was associated with an increased odds of glaucoma Okay. Now, um, I didn't show one other study. I don't think maybe I'm showing it later Where mainly Wang from Beijing Tongren Hospital He did a prospective study looking at this and did spinal taps on patients that had That had glaucoma and he found the same step out that oculohypertensives were the highest and controls then glaucoma then normal tension glaucoma He published that in the very prestigious Chinese Journal of Forest Experimentation And That's the kind of prospective study that you can get away with but not everyone believes so so I just enjoy this study And this is where reputational risk comes out and this is fun This is where you get in the arena and you get to fight for what you believe in don't take offense Get in there and fight for what you believe. Sohan. Hey ray has a his from the University of Iowa He has a history of writing pretty Pointed letters to the editor. So we publish our letter to the editor. He's also an iconic last He doesn't mind taking shots he's 92 years old he still goes into the office And so I published we publish our paper in ophthalmology He writes a letter to the editor to ophthalmology. They don't publish it So he writes a letter to the editor to graphe's which he's the editor-in-chief of which is kind of not the typical way So I just happened to come across this and he's saying, you know that he thinks that I'm wrong So let's go through a little bit of this He says a recent study claims CSF pressure may play an important contributory role in pathogenesis a glaucoma But in that study the difference in mean CSF between the groups was only four millimeters of mercury the concept that a Translimiter pressure difference of only three point eight millimeters of mercury produced by low CSF is strong enough to call bowing back the dense compact Connective tissue has little scientific credibility So he comes at me with like a jab. That's probably the nicest one that he's ever written I reply with a little harder jab and say we appreciate and recognize the tremendous Contributions that dr. Hey ray has made to ophthalmology in particular is understanding the ha optic nerve Thus it's with humble respect that we disagree with his conclusion This is the jab scientific validity is assessed by a well-controlled study to address a hypothesis not expert opinion He replies with a roundhouse This is this is him now saying this is speculation and simple armchair philosophy I just love this and sorry to take so much time bird on colleagues site Yablonsky in support of the hypothesis in 1978 dr. Yablot 40 years ago dr. Yablonsky and I discussed this at a conference He told me that the entire concept of the pathogenesis of optic disc and demon rays CSF was based on my studies He wanted me to Wanted to ask me about the concept of optic disc cupping in glaucoma He told me that if rays CSF pressure causes optic disc swelling the naturally a fallen CSF must cup Cause the reverse I tried my best to explain to him that this was not true at all Because the pathogenesis of optic disc swelling was totally different However, he was not prepared to accept any scientific evidence contradicting his belief He presented a paper on this at Arvo, but that was never published Birdall and colleagues states none of the colleagues dr. Hayre sites are designed to address whether a chronic pressure difference across the lamina cabrosa would lead to glaucoma disc cupping I do not waste my precious time researching topics that have no scientific logic in merit in conclusion therefore It's evident contrary to the hypothesis by birdall and colleagues that there is no scientifically valid theory that CSF pressure Plays a role in disc cupping It's what Thomas Henry Huxley called the great tragedy of science the slaying of a beautiful hypothesis by an ugly fact But the facts are what we need even if they are ugly and unwelcome. I have tried to present in this editorial facts Okay, so how much fun is this we get to try and establish truth And if you're gonna try to be a truth Establish her you're gonna have to fight for it Nobody has ever not had to fight for it when they're changing how people think and you know all we care about is truth If we're wrong, we're wrong and these kind of things test us and help make us better There is a little bit of disconfirming evidence. So our see it our ophthalmology papers been said you know 300 times down with only a couple of papers that have shown that maybe CSF pressure wasn't low This one actually got there's one that got published in ophthalmology that showed that Norm and the title of it was that CSF pressure is not low and normal tension glaucoma And what they found was that it was lower by a millimeter of mercury in a prospective study of 11 people And so it was lower and for their title was that it's not low And so there's um, you know some disconfirming evidence, but I'll tell you Hey Ray wasn't alone. If you ever want to be humbled apply for an AGS grant So I was applying for a young investigator grant. It's for the people that are in the first five years of practice that have Outside of the box idea. So I feel like this qualifies and so I apply for the grant and Um, and here's what I got in response It would be unethical to proceed given the complete lack of scientific evidence that would be achieved based entirely on flawed judgment And my favorite rabbits wouldn't wear goggles. How do you who says? Rabbits wouldn't wear goggles. Okay, so so let's think about this for a second What type of disease is glaucoma? Is it a mechanical disease of vascular disease of metabolic disease? A combination what is it and when we don't know we always say it's a combination of a bunch of things multi-factorial to me that usually just means we don't know So Harry Quigley and Doug Anderson wrote a classic paper And I think that this was in 1978 as well looking at axonal transport and monkeys and This will reveal how geeky I am, but it's really fun to go back to some of the real old You know 40 year old literature and read it because how they wrote was way different then and it was often much more Speculation was allowed and and it really is fun to to read how these papers sound different And we're looking at axonal transport and what he showed was that indeed if you raise eye pressure in monkeys Exonals transport stopped at the level of lamina crebrosa Okay, and and then the apoptotic mechanism occurs but what he also showed which was really interesting was that if you lowered the eye pressure for just four hours for one hour about half to seventy percent of the Metabolic accumulants were gone if you lowered it for four hours. It was 100% gone So what I wonder and I don't know that I'm right about this, but I wonder is glaucoma really a 24-hour disease Or is it a disease where if you can normalize that pressure gradient for a period of time You allow axonal transport to resume you deliver the metabolic needs you remove the metabolic waste. It's like Getting a breath.  No problem Kind of like just the salmon swimming up the river If the pressure in the eye is higher or the pressure in the brain is lower It's a little bit harder to get up that pressure gradient But you get there, but if the eye pressure is really high or the CSF pressure is really low Then axonal transport is stopped. It can't get up that pressure gradient the accumulants Backup the metabolic needs aren't met the apoptotic signal descent and the optic nerve dies and the same is true in reverse With our ortho grade axonal transport If CSF pressure is high the axonal transport can't get up into the eye and that's been shown and now it's been shown in more and more studies experimentally this is an experiment An animal experiment where they showed that indeed if you lower CSF pressure Axonal transport stops the level of the optic nerve Even more so than if you raise IOP the same amount So there's lots of studies that have been done. This has been done This was done by Bill Morgan in Australia He showed that indeed there is a pressure gradient that exists across the optic nerve Had he cannulated the vitreous then the anterior optic nerve Lama crebrosa the posterior optic nerve the subarachnoid space and showed that indeed there is a pressure gradient that does exist There this is an experimental study in monkeys showing that if you lower CSF pressure, there's thinning of the optic nerve and neural retinal rim thinning this is that study by Rujan Ren and Ningli Wang showing similar data to what we have in their prospective study On on this in humans that they lower CSF pressure Optic nerve sheet diameter has been shown to be smaller in glaucoma patients Indicating that perhaps the retro laminar CSF pressure is lower there and so When I think about all of this work I think back on some of these people that that believe that we should try to find out if it was true or not Even before they did and the risk that they took on So I come out of residency and I'm feeling really good and I remember actually sitting in in Dr. Olson's office Talking about this and he said you seem really passionate about this and I was and and that meant Something to me and he said you can tell a difference between a research project Where somebody is just doing it to put it on their CV and a research project actually Because they're interested in trying to accomplish something. Okay, so I get done with residency. I'm feeling pretty good I'm applying to fellowships.  He's one of the real Amazing people that you'll ever meet he is loyal and he is Smart and he cares about the good and sometimes he takes some arrows because like you because You don't have to take any arrows because everybody loves what you do but but But he cares about what's doing right and because he's such a big person in our profession He he does take those arrows, but he's amazing So I sit down with him and I put together this ten minute PowerPoint to make the argument the CSF pressure matters in glaucoma And I get done and he says in his really deep voice John. I think you're right What are you gonna do about it? Like what do you mean? What am I gonna do about it? I'm gonna get credit for it people are gonna think that I'm smart And that's what I'm gonna do and he says well I live in a world where we like to take these scientific discoveries and translate them into something that can actually help people And I said well, I don't know what I'm gonna do and he says that's okay Opportunity favors the prepared mind be prepared for when that opportunity presents itself So what so what am I gonna do so I go through the next four or five years thinking what can I do to? Help treat people that have glaucoma because they've got a low CSF pressure And so I'm laying in bed one night, and I'm reading the Wall Street Journal on my iPad And there's an article that says astronaut shortage, and I say I'm always looking for a job I wonder what the skinny is, you know, why are What's the problem and they talk about how astronauts are losing vision up on the International Space Station during long-term spaceflight and I'm like and they talked about you know the path of the demon I say I think I know why It's because their CSF pressures high because there's no gravity pulling their CSF pressure down So it's amazing what you find in Google I find the highest ranking persons at NASA's email address that I can find who's in charge of astronaut help And and I email and I say hey, this is John from South Dakota. I think I can help you and No kidding he emailed me back and so we set up a call and then Ultimately, I got invited to be a part of the vision from ours program So I get to go down and meet all these astronauts and so this is the that syndrome. It's now called sands It used to be called the IIP and it's really four things. It's Coroidal folds. It's a hyperopic shift It's globe flattening and it's papillodema So what does that sound like? Sounds like hypoteny, right? Well hypoteny If you look at it through the lens of CSF pressure is just when IOP is lower than CSF So it's that same kind of scenario So this is what the this is one of the astronauts eyes after he got back and these are the four things That you see in that so what would be a treatment for that? gravity would be a great treatment Or raising eye pressure right so that it balances out CSF pressure So I was luring or lowering CSF pressure something like maybe Diamonds but diamox will also lower IOP. So maybe maybe a differentially lowers it Ventricular peritoneal shunt Could maybe do that maybe astronauts don't want one of those So and they're pretty particular about experimenting invasively on astronauts while we're up in space So the idea you know is really a simple one It's this as we're all sitting here our CSF by gravity is pulled down into our caudal spinal column CSF pressure at eye level is Lower in space. There is no gravity pulling the CSF down it redistributes up And so at eye level CSF pressures higher they never saw it on short-term space flight because it wasn't enough time to cause the problem of the accumulance of metabolic and external transport But I'm up at three months in space about 50% of the astronauts are experiencing some of these Symptoms women less likely to experience it than men Probably because they have lower CSF volumes a lower Column of fluid because they're shorter and they have lower CSF pressures to start with okay so we go down to NASA and we We get a hundred thousand dollar grant for this crazy idea that I have about raising eye pressure And we'll talk about that in a second and we publish a paper in this journal and I would highly recommend this journal I love this journal the Journal of Medical Hypothesis because you don't need any data To publish in this journal all you need is a hypothesis So you can come up with your idea try to support it That's what this journal is intended for and and I really I really do like it So I'm sitting in my office and this is my partner Vance Thompson And these are the planes of South Dakota with the Missouri River in the background The answer is one of my other heroes and ophthalmology and one of the really really good guys and for your for residents That are choosing a job we talked about this but join somebody like him Join somebody who is going to take as much joy as in your successes and be rocket fuel for your career Like he has been for me not someone who wants to suppress you And so we're sitting in the office and we're talking about all right What can we do so what that the CSF pressure thing is there and we were talking about astronauts and Says well, what if we just put them in a pressurized room and we pressurized the room and I said well Vance That's going to pressurize their eye, but it's also going to pressurize their CSF so it'll move and lock step That's not going to work. He's like, okay What if we use a helmet and pressurize a helmet well Vance It's gonna pressurize the eye and it's gonna pressurize the head and they're gonna move and lock step and so I say well What about a pair of goggles? What if we could just pressurize the eyeball, but not the CSF? so That's what we did.  We got $450,000 to study it from friends family and fools that said hey I'm willing to invest in your crazy idea And and we're on the way to a company that we've now raised 17 million dollars for and if you think that there's Pressure in academia from so on. Hey ray writing that so nice things about your idea in a paper try taking 17 million dollars from venture Capitalists that's real pressure. So the idea is this atmosphere is like a cosmic thumb pushing on our body It's pressurizing our entire body okay, and So all we're gonna do is release a little bit of pressure over the eye by drawing a vacuum now The atmospheric weight is not pushing down as hard in our eye But it's pushing down the same amount everywhere else in the body if I pushed my thumb on your eyeball will go What happens to your eye pressure? What if I release my thumb what happens to your eye pressure? Goes down Pretty simple concept, right? I mean it's really really straightforward. So the idea is this if you think about it in absolute terms Atmospheric pressure is 760 millimeters mercury the eye pressure is 16 millimeters of mercury higher than that 776 an intracranial pressure say 12 so that's 772. We think about it this way ambient is zero I pressure 16 CSF pressures 12 you got a pressure different differential right here of four no big deal you put on Glaucoma and that 16 goes up to a 22 that 12 goes down to a 9 Now you have a pressure differential here of 13 millimeters of mercury and the optic nerve doesn't like that and it slowly Deteriorates so if we took an applied negative 10 millimeters of mercury to the eye take that 22 down to a 12 Leave the CSF pressure at 9. We've now normalized that pressure gradient Pretty straightforward Okay, so the first thing that I did is I went and went over to Germany And there's a company that has wireless eye pressure sensors inside the eye We took my kind of Amazon garage created once we went over there We dialed the pressure down two millimeters of mercury it went down two millimeters of mercury Dialed down two more and went down two more. I got the phone call. I wasn't there when they did it I got the phone call at 4 a.m. Laying on my couch saying we can dial and I'm We presented this paper for this data for the first time at the AAO conference this year Here's what we saw. This is 51 patients in a consistent cohort One eye with goggles with vacuum one eye with goggles that didn't have vacuum as a control Pressure was 16 millimeters of mercury beforehand. We dialed in 25% of their baseline So think of this as we're dialing in 25% of that minus 4 we take their 16.2 down to 13 Control eye stays more or less where it was We dial in 50% so dial in minus 8 we take it down to 11 and a half We dial in minus 12. We take it down below 10 millimeters of mercury And so we just can dial in the eye pressure To where we want it to be After you take the goggles off the pressure goes back up to normal in a week later. It's normal interestingly We've been seeing this kind of positive after effect Of a little bit lower eye pressure afterwards I don't have a good way to explain it if I'm not willing to hang my hat on it But I am willing to hang my hat on the fact that we can lower eye pressure So we believe that this technology will be helpful during a vulnerable time Which is nighttime night times the time where IOP goes up medications and surgeries don't work as well Blood pressure goes down and it's a third of our existence. So we think that this will be an adjunctive Treatment to glaucoma or especially for hard to lower IOP somebody that's had it to Somebody that's got normal tension glaucoma and they're at 13 and they're still getting worse and we think what a CSF pressure Do during the night? You'd think it would go up. It does Go up a little bit at night Just like IOP goes up and so I think about CSF pressure and aqueous, you know cerebral spinal fluid and aqueous as very similar Embrilogically, they're similar compositionally. They're pretty similar and they have a tendency to go up and down together I thought CSF during the daytime was about five and at night it's about 15. That's a three-fold increase Yeah, so CSF pressure during the day is about 12 millimeters of mercury and it raises an interesting And it raises an interesting point One thing that you could ask is why haven't we thought about this before? Usually what are the units for CSF pressure measurement clinically that we use? centimeters of water or Millimeters of water one of those two and so here we have millimeters of mercury and so because we were comparing units that weren't Comparable we maybe didn't see a connection that we would have seen otherwise, but CSF pressure during the day is about 11 to 12 millimeters of mercury Okay, so when you're trying to take an idea and execute it What do you need what you need to Solve a real unmet need and we think that there is an unmet need here We think that we have good control of IOP We're going to be able to monitor this in the future So the pump has a 4g antenna built in to monitor clients and also to monitor whether or not People are actually getting worse over time. So how often do you have to wear it is eight hours a night? Meaningful or is it not? So this is where we hope to end up But once you get bit by some of these ideas, it's hard not to keep It's hard not to get bit by these ideas so we've got a couple other companies That we've started and I would encourage you to go after these things because it's really fun and icing on the cake One is really easy. This was a stigmatism fix. I was a math teacher and When I was a fellow Dave Hardin said you're a math teacher. I've got a torac lens that's misrotated figure out where I should rotate it to Okay, so I put together this big ugly wonky spreadsheet with a lot of arch tangents in it And and then I got sick of emailing this to everybody And so we put it on the website for free or put it on the web for free in a thousand surgeons a month Go and it's a real issue is is residual stigmatism after cataract surgery So a thousand a month Alcon licensed it. They're potentially going to put that in some of their New diagnostic devices. This one's kind of fun too. So, um, this is the MKO melt What it is is versed ketamine and sofran underneath the tongue for sedation for cataract surgery So we don't start an IV in 98% of our cataract patients We just give them this the ketamine is really nice because they have a tendency to gaze and stare at the light They get a little analgesia and they get a little euphoria And they don't have to have an IV and so This is going to get spun out of imprimise into its own Company and they're going to go for an FDA approval and we're really excited about that having meaningful impact Not just an ophthalmology, but maybe in the emergency rooms or minor surgical procedures elsewhere And then the final one is this thing that we just started which is a way to get online second opinions Um And so right now you have a person in rural wherever and their local doctor says you got foods dystrophy And you should have cornea transplant, but they didn't have a good connection This um tries to introduce a marketplace to medicine where you can say I want an opinion from alan krandall and it costs acts i'm pretty sure you would probably charge five bucks because Maybe that's a little steep because i'm giving you are but really say I want access to some of the world's best doctors I want them to review my records. I don't want to have to travel. I want to be able to get in with them doctors set their own price Patients choose which doctor they want and we're going to see if we actually get people to transact or not So when you're thinking about how you start your own company There's a couple of things that you need to look at you need to look at a market markets are real And so if it's going to be a company it has to have a market Um, how are you going to protect yourself? What's your motivation? What are you really doing this for because it's hard get mentors that are going to help you? And ultimately you're going to have to have some capital And i'm going to squeeze through the last five minutes really quick because I think it's the most important stuff And this is usually the favorite Talk that I give it's the next parts with my dad usually but he couldn't be here today So my question for you about whatever ideas that you have is don't be a dwi That's a doctor with an idea be a doctor that does something with it and execute So what are you going to do about it? Okay So when's the last time you felt vulnerable all of this stuff is because We serve patients. So when is the last time that you felt really Vulnerable, you know, we're all kind of bulletproof, especially the younger trainees But when did you feel like something beyond your control? could Shatter your life And so my dad Came in to see me when I was a first year resident and I was at the VA at Duke And I did an eye exam And I'm just staring at this thinking I'm not sure that I know what I'm seeing here, but I'm pretty sure you have fuchs dystrophy So dad you have fuchs dystrophy. You're probably going to need a corny transplant someday This is my dad and I think this is interesting insight to what patients do. He said he's never heard of fuchs dystrophy So he goes home And he says Am I the only person that has this obviously not because it has a name And who are other people that have this Mandy Patinkin? Is one of those people that had a cornea transplant. He had it for care to come And so he was diagnosed in fuchs dystrophy and then in 2010 he was hired by our local eye bank to evaluate corneas And um, that's when things became real because every cornea. He was evaluating He was thinking should I would I want this cornea? in my eye And so his vision wasn't bad only 2025, but he's driving around at night and now he is The outreach coordinator, so he's driving around the state of South Dakota at night And he can't drive and my mom's with them He's writing his tests down to 2400 fuchs dystrophy is the poster child for visual acuity not being a complete measure Of visual function because a lot he's seeing his acuity is good, but he can't function And so I say dad are you seeing okay, and he says no I'm not We need to do something about this so I'm going to talk real quick, and I'm going to move through it quickly So we're done by nine, but I'm going to talk about three people my dad my mentor and my father in law And so when so I end up Saying dad you want me to do this surgery or do you want somebody else? And I'll get you to The best people in the world. He says no. I want you to do my surgery. So does anybody know who this is This is Felix Baumgartner And he held the record for the highest From space to earth And when you're about to do surgery on your dad it kind of feels like this when you're going to do a cornea transplant And right about here you feel committed To the plan that you have but uh, you know, especially to the trainees Rely Rely on your training Take that plunge do things that make you feel uncomfortable But acquire the skill to get comfortable because inevitably things will start spinning out of control And when they spin out of control you have to be able to control yourself in order to end up with um With a happy landing and and that's what ultimately ended up for him So i'm not going to show you his his video. This is his eye, but his cataract surgery and cornea transplant went great And um, and this is what he looked like one week afterwards And he's got this tiny little partial detachment. So we put an air bubble in this is what his endothelial cells looked like After his d-mech. That's what they looked like before his d-mech So the second time around you could tell how nervous he was. He had gotten one of those mko melds and um, you know He uh That's before surgery And he's just sitting there snoring away right before going into the operating room So he ended up 2020 minus 2. I'm corrected. I actually did the second eye with a little bit of mono vision Um, so he doesn't need glasses for intermediate or distance. He just needs them for up close Um, I'll skip through a couple of these things a little bit But as the outreach coordinator, he reaches out to all of the recipients and he got this card one day Listen, I opened um I opened two gifts this morning. They were my eyes. What we do here is sacred and people value that And this is a letter that he got from one of One of those recipients and I am going to read it quickly first and foremost. I'm deeply sorry for your loss I send my sincerest condolences to your family. So these go get distributed through the eye bank to the donor family I've been legally blind since I was 15 with care to conus. I'm 32 years old now and over the years My vision got very bad. I recent a recent turn of events led me to look into eye surgery before then I was in a hopeless state of mind and just never In may of 2016 I underwent my first cornea transplant and to date it has been very successful I still have ways to go before I get my right eye done Needless to say my hope has been restored and I'm working on turning my life around I will be completing my GED soon and entering the work field. I am told 32 years old I'm told that there's a chance I will be able to drive after my next surgery I can't express enough how forever grateful and thankful I am to your family It goes without saying that if at all possible, I would give this all up For you to have your lost loved one back. I wanted you to know that with this opportunity All of this will not be for nothing. Thank you so much for helping restore my hope And I will do my best to make the most out of life In the daily grind of what we do This is lost a lot of times and reminding ourselves of how sacred it is His 32 years old didn't have a GED didn't have hope. He got his life back Because somebody made a donor and so eye banking is really a special Thing that allows miracles to happen and there are unsung heroes and ophthalmologists are not part of that We are sung heroes, right? We get so much credit, but there's people every Night they get up in the middle of the night drive through snowstorms to recover tissue So that we're not annoyed that we get it five minutes late when we're in the operating room And it's really really Special the work that they do So as we transition to this I get an email from Dick Lindstrom A few years ago at john in his deep voice. I would like to come and see you do d second d mac I especially want to see how you use sf6. I still have more rebubblings than I would like So time for you to be the teacher. What days do you operate if we planned ahead? Could you bunch up some cases would also be fun to see you in the or an action? Maybe send me your d second d mac op report and any reading you think I might find useful Best for me is a Wednesday or Thursday, but I can do anything I'm available October 7th 8 28th and 29th at those work Your friend tickle Okay, so I feel like I get an email from the king and he's coming to watch me and I'm so impressed with myself And when I got over myself three days later what I realized Is that this is a guy who loves the process of being great if someone doesn't need to transition from d sec to d mac It's the 70 year old dick Lindstrom But he says if he's going to do it he's going to do it as good as he possibly can and he came And he was the single best observer that I ever had in in the operating room. It was incredible And so now Isn't this amazing? My mentor teaches me a skill That I use on my dad And then get to go back and help him Become better and Alan was talking about how He's having a fellow that was trained by his son And and it is just this circle of life that we get to go through that is so Incredibly special and then I'll end with this And this is a little personal and a little Insane, so this is the most powerful thing that happened to me in medicine. This is my father-in-law. His name's tom dirks This is him dressed up He is a redneck and he delivered newspapers all of his life And and he was a great guy and he was the pillar of his community and a poor community and people just went over to him And and he would pay somebody to mow his lawn so that he could so that guy could pay his rent or get food This is my son Tommy who he's named after And so he died four years ago five years ago, maybe now and um And he died and my wife gave the eulogy and she gave an amazing eulogy and afterwards I go out and one of his friends is just bawling his name was Steve and Steve Um, I said, how you doing? I gave him a hug. He said i'm doing terrible. I miss tom so much I've just been sitting here all day long listening to the song spirit in the sky because it was one of his favorite songs I said i'm sorry So now fast forward a week later. I'm in the operating room And i'm getting ready to do full thickness corny transplant and I look at the donor sheet And on the donor sheet It's his cause of death and it's his time of death And it's his date of death and it's my father-in-law's cornea That I get to implant into somebody else and so he gets to live on through me Through that and so I sit down at the microscope And um and i'm sitting there And no kidding 10 seconds. Oh shoot the music didn't yeah, so 10 seconds after I start the surgery The song spirit in the sky comes on the ring And i'm like oh boy Is that for real and who knows if it is or if it's caught but what we do Is bigger than the moments that we're in every day. So don't let the grind in the moment um Delude the sacredness and the trust that patients put in so in closing Be committed to what you do like Felix Baumgartner jumping out of that You know space capsule Fall in love with the process of becoming great not greatness itself do the work to be awesome um You are a hero, but there are so many other people that are heroes And and don't forget the power that your words have and how you can influence somebody's day And finally what we do is sacred. So it's really a huge honor for me to see you guys today and thank you for listening So john that's fantastic and uh, obviously great lessons for us all to remember. We often get locked up in our detailed life Don't get back and get a chance to look at the bigger picture. So, uh Following only what you've said and there's boogie still here So when we do an optic nerve sheath fenestration, obviously because we're concerned about permanently lowering The um icp Do those people who have that then are they at greater risk for glaucoma? Is that an unknowable? We don't know that. I don't think we know it yet. Um, we do know that Ventral peritoneal shunts have shown acceleration of glaucoma after people have shunts And so actually when I was at mayo doing this study I call rand alling ham after I analyzed the dad and I say look he said I saw a patient yesterday I couldn't believe it. They had a vp shunt placed three months ago and their glaucoma fell out of the table Yeah, so it's randy those fenestrations. Of course you're going from an extremely high csf to a lower csf And ultrasound studies roger roger's here. We we published this a while ago. It shows that you get a filtration But then the filtration sees up So it's not like you're creating a witch you're not creating on an abnormally low You're just rigging back to a normal level. So the estimate was about three months It sort of sees itself off That buys you the time to get But but here we're inducing pressure from extremely high to a lower level John it's interesting when you talk about the astronauts captain kelly who spent a year in the space station Prover is a really interesting book and They have chronic problems not only with the button and I broke you but he says you chronically feel like your head It's totally full and you can't think and you have a chronic headache and they're putting them in pressure suits now And having them do exercise and he was saying that when they were doing that subjectively he was feeling tremendously better So it'd be interesting to see What that does to any kind of uh, you know an ultrasound or an oct of their optic nerves and their posterior That's right. And they also have negative pressure body suits that kind of create a negative pressure So fluid comes down and if you look at an astronaut before Before takeoff and five days afterwards. You will see that they look um, all almost like Well, they've got swollen faces and and they look like they're you know got too much steroid Right because all of almost cushionoid because all of that fluid redistributes upward And and you know interestingly, you know our valves and our veins and stuff You know, we have valves down below our legs, but not always up above and so we're designed for gravity We're not designed for no gravity That guy killer. I think yeah hans peter killer. Yeah. Yeah. Yeah. He did some really interesting studies of csf flow csf flow, but and the possibility of Lockulation and entrapment of csf around the optic nerve during elevated screen pressure specifically with regard to the potential Sort of nutrient stasis In the csf around the optic nerve. That's sort of an interesting Thing that has also not been kind of brought into this number two There is a phenomenon of people who have chronic papillodema Long term who get shunted for all the right reasons and then who rapidly go blind in one or both eyes over the course of a couple weeks Completely mysterious have no idea why that happens.  Eventually. Yes as with many Because their intracranial pressure is great The question is what the possibilities have been raised by this ICP iop thing is whether their iop their icp is too low Which as far as a neurosurgeon is concerned is not an issue Right why would low icp be a problem? But and a third thing is there have been a couple of cases of people who Their shunts for other reasons their shunts are over draining and it can get a progressive optic neuropathy And you can not reverse it but halt it by readjusting their icp And to me, I think that a lot of this is around the pressure differential You know another question is do we have a compartment syndrome going on? Is there a segmentation of the intra orbital part of the nerve from the intracranial part of the nerve? And if the csf pressure is too low, maybe it can't just get into that backwater area That's surrounding the optic nerve head and I think that Hans peter killer's work is really, you know fascinating But but I still think that it I still bet that most of this can be explained by what is the retro laminar tissue pressures And how much flow do we have there? sleep apnea Yeah, so sleep apnea has a Some studies show that it is associated with glaucoma and some other studies show that it It's not You know, it's interesting to me because you know, people are probably hypoxic and having issues But they're also probably large and would have a higher csf pressure So in my mind the jury's still out of what cs Sleep apnea and glaucoma is real association and that group in germany measured that during the sensors Yeah, they could measure what happens to iop During during sleep and sleep apnea patients and I don't know what the answer to that is And you know, you kind of wonder if they actually have balsalva a little bit when they're sure They have they can have profoundly Interesting and there are some studies suggesting a relationship between sleep apnea and elevated Thank you, sir


Hello, my name is Rathal Kumar. I am doing my bachelor's in engineering from Bangalore, India. My startup idea is called as Garberian. Basically, Garberian is a setup which focuses on smart management of waste by using sensor technology. We are using sensors in modifying a normal dustbin to a smart bin. By using sensors, we detect the level of waste in dustbin. Two ways of waste and reporting it accordingly. Humans have five basic sensors like hearing, sight, touch, smell and taste, which corresponds to primary biological sensors which are the eyes, skin, nose, ear and tongue. Using these sensors, humans are able to make observations and accumulate information. Our design philosophy is based on the same line so as to be interactive and intelligent. I am working out a connection for enhancing the technologies and business model relevant to market with the potential to generate substantial business impact and how we can manage waste in a smart city accordingly and curb the climate changes. At Garberian, we have a simple code. If you want something new, you have to stop doing something new. That is exactly what my project was about and it's named as the Garberian. Thank you. Do you want to give us a sense of where you are in the process so far? Yeah, I'll like in passing one or two months we'll be testing our product. We are incorporated with various microcontroller units in India who are helping us build a better dustbin. We'll be working on a website called as thegarberian.com by the end of March we'll be launching a website also. We have designed a new application also. We'll be launching that also with our new website. Basically, the application will be working on creating public awareness among people. Application is a part of our marketing unit. When we are doing our marketing and creating public awareness, if you're disposing your waste in a proper way, there will be a barcode of each and every smart bin. By scanning that barcode and disposing your waste in a proper manner, you'll be getting kind of like a reward from the government or from our company. The next time you go and buy a burger at McDonald's, you'll be getting like 20 bucks off or like 10 bucks off accordingly when you're disposing your waste in a proper way. As Laina had told us about choosing a co-founder, we even have found a new co-founder with myself and keeping your skills in mind and your key points in mind. I'm looking for one more co-founder at the present and how we can work accordingly and spread the idea of waste management in a smart city. So this is the point I have reached till now and possibly in one month after ITU Telecom World.


Hi, my name is Skip Weitzel, I'm the proud parent of the UVM senior writer Weitzel, who's a history major at minoring in resort management, and this is why I think your son or daughter should consider the University of Vermont. What makes UVM so special to me is I like to say the whole is greater than the sum of its parts. There's so many great things about UVM, but when you put it all together, it's just a wonderful environment. There's so much to do outside of school. The quality of life up there is amazing. There's a place on campus where if you look west, you look at Lake Champlain, if you turn around and look east, you're looking over at Stowe and the Green Mountains, and you're right in the middle of UVM, right in the middle of Burlington. The faculty is phenomenal. Writers had a great experience with this faculty. To me, it's top-down. It starts at the very top with the new president, Aaron Mella, super guy, and what's been in place with the immediate past president, Tom Sullivan, he did a tremendous job. I had never seen a university in better place, in better shape. Academically, the caliber of students that they're admitting, the caliber of students that are graduating and the jobs that they're being placed in, I would congratulate any parent whose son or daughter has been admitted to UVM because I know it's very competitive these days, and that they should be proud of that, and that they should know that their son or daughter will get a high-quality educational experience at the University of Vermont.


So I guess the Ravens, they must have took Marcus Peters signing over with the Raiders a little personal.  On the day that we lost officially, lost the cornerback that we used to have, even though they probably ain't even have no intentions of resigning Marcus Peters this off season. But still, even on the day that they lost the cornerback that had a lot of heart and wasn't afraid to be outspoken, call stuff out. The day that they officially lose him, they decide to bring in another corner who was also outspoken and not afraid to call things out. Now, initially when I first saw this report that the Ravens were signing Arthur Mollett, I was naive to who he was. I mean, knew he obviously played for the Steelers, but I was naive to his game and whatnot. But let's, let's read the report first and then we'll get into it. Says, it came from Cameron Wolf, who works for NFL Network. Says, former Steelers cornerback Arthur Mollett is nearing an agreement to sign with the Baltimore Ravens per source. I'm like, okay, corner help. We've been talking about corner for a long time and the fact that we feel like, hey, it's a lot of unknown there at the position when it comes to the Baltimore Ravens right now. That nickel corner, that slot corner role, who's gonna feel it? Who's it gonna be? We just don't know. But the report also said Mollett played a lot of slot cornerback and special team snaps for Pittsburgh for the last two years. And now he could play against the Steelers twice a year. So boom, he played a lot of slot cornerback. You know what, that wasn't even a kicker for John Harbaugh. Harbaugh, he probably been looking for who's gonna be that slot cornerback. And he probably knows this stuff. Obviously he knows this stuff because he chose to sign him. But he played a lot of slot cornerback within the special teams part. That's when he was like, oh, bring me Arthur right here right now. Now, with him being signed by the Baltimore Ravens, that getting ready to be official very, very soon. I don't think that automatically makes him the slot cornerback guy. I don't think it's a given that all right, it's gonna go to Arthur Mollett. It could, it's maybe even be likely because he been around for a little while. But cause that's how he used to play for the Colts and the Jets. And then of course, the Steelers too. So he been around a game for a little bit, but I don't think it's a given that the job is automatically gonna go to him. So we'll see what happens with that. Now, when I looked up Arthur Mollett because we're talking about hard, talking about being outspoken, talking about accountability earlier. The reason I bring those things up is because he made headlines last year in October. When the Steelers, they played the Buffalo Bills and the Steelers, which obviously, especially as Ravens fans, we don't ever mind seeing but the Steelers got whooped. They got whooped 38 to three. They scored three points against the Buffalo Bills. And Arthur Mollett was somebody that was very, very upset and he called out his teammates in the locker room. And he said that they needed to show that they love the game. And that wasn't a display of it at all.  It don't look like you love nothing at that point.  Woo, we know Ravens done been there before quite a few times, but yeah, he called them out. So that made headlines. That was one of the biggest things I found about Arthur Mollett when I looked them up. And I appreciated that. I appreciated that because in anything that you do, you need people to be honest with you. In my opinion, honesty, it just, it brings out the best. Because if you have people, say for instance, you do anything, whatever it is that you do, for work, for fun, whatever. And people are always telling you how great you are at it. Oh, you're great, you're great. This is great, this is awesome, this is amazing. But you never have anybody correcting you. You never have anybody, hey, you need to do this better, hey, oh, hey, you could do this better. Hey, maybe you should try to do this. If you never have that stuff, can you really get better at whatever it is that you do? If nobody ever challenges you.  I mean, people do that regardless anyway. But anyway, but yeah. So with him, that whole incident, which wasn't a big deal, it's football. It's football, you need people like that. So Wild Ravens are getting the slot corner. Wild Ravens are getting the special teamer. Wild Ravens are getting extra help in the secondary. They also getting somebody who has experience with leadership. And leadership is something that cannot go. I mean, you can't underrate it because it's an important quality to have. It's an important quality, especially when you lead in a group of men. If you're with a group of men that, I can't call her, I'm not calling the Ravens lost because they're not lost, but you can never have enough leadership. So this is a, I'm with this move, I'm cool with it, and it's really a we'll see. We'll see. I ain't penciling him in for, all right, well, we got a slot corner back now. We'll see. That's what training camp is for. That's what training camp is all about. It's about that competition. It's to see who is going to win the jobs, who's gonna take over these roles, who's gonna establish themself as the guy for whatever the job may be, for the slot corner back role, for the nickel corner back role, for safety, for left, right corner, outside corners, pass or everything. We ain't gotta go down the whole list of all the different spots on the depth chart and what, no, we ain't doing that, but y'all get what I'm saying, man. Now, Team Keeper Clean, I did not tell you, subscribe to the channel. Subscribe, leave a like on the video and turn your notifications, look, I told you, I be warning y'all, man. I really do. I be warning y'all, I told y'all it's gonna be crazy. It's gonna be crazy. This is video number four today. Today. Subscribe and turn your notifications on so you never miss and leave a like on the video too.  You gots to be, cause I'm a lot of it off.  So you can't be no sane person and be no Ravens fan. Do you watch these Ravens play? Do you remember all them games? How crazy all of their games always are? Good or bad, they always bring craziness with them. Ravens don't, they hardly ever win or lose in a calm manner, ever. That's just not what they do. So yeah, man, you gotta be a little loony to be a Raven fan and a lot of loony to watch this channel. But I love y'all loony people. So shout out to y'all, shout out to Looney Tunes. But yeah, I appreciate y'all though a lot. I really do. So, hey, welcome aboard Arthur. I wonder what number he gonna get. Well, I mean, that ain't important cause he could have a number now in training camp but then once the roster get down to 53 men, somebody who lose that number, he could take theirs or y'all know how it goes. But yeah, the competition is he know, you know what's funny, I always talk about how timing is everything. We had just recorded an episode of question from subscribers talking about this very, very, very topic. When we talk about a bunch of other topics as well, but this very topic was the main topic or the starting topic of the video, talking about the slot cornerback roll. And we're probably gonna drop that tomorrow so y'all can look out for that video. But I just thought that was funny. This side, we talk about it in the video that we recorded that we're gonna drop later tomorrow probably, and then boom, they signed somebody as a slot corner. Now again, there's still Audarius Washington. There's still maybe Jaylenon or Davis, but there's Pepe Williams, but he's on the pup list right now. There's obviously, they could kick Maul and Humphrey in some times so that, and he obviously did a great job as a slot corner. But I mean, not to say he can't do it, but you're paying him to be outside corner. You paying him to take care of the outside wide receivers. So you wanna have a guy dedicated to that role. Like last year, they tried with Kyle Fuller. And a lot of Ravens fans are thinking, oh, maybe they might bring Kyle Fuller back. We don't know where he is with the status of his injury that he sustained on the Jets field last year. And week one, we don't know what the status is. So we don't know how his recovery is, anything like that. I'm sure the Ravens got all of that information, but they decided to go in a different route. So Ravens have a lot of cornerbacks right now. They have a lot. Like, and everybody ain't gonna be able to make the team. Like Maul and Humphrey, obviously a lock. Rocky scene, lock. Kiyu Blue Kelly, lock. You got Jay Leno and Davis. You got Pepe Williams. You got Ardarius Washington. You got Brandon Stevens. You got Trayvon Mullin. You just signed Arthur Mullet. So it's a lot of, you're not gonna keep all of them. So some decisions are gonna be made. Some people are gonna get stashed.   You know how it goes, man. It's gonna be a lot of transactions over this next month. Yeah, month. It's gonna be a lot of transactions because today is all tripping. I'm over here at Fast 4th in a month. Today is July 24th. So in a month from now, it'll be super close to when it's cut down day.  They doing from 90 to 53 all at once. So all on the same day, a lot of people are gonna be losing their jobs, losing their dreams and being told, yeah, you may never play in the NFL again. That's a very harsh reality, man. Again, 1% of people make it.  Oh, this guy's terrible. Oh, he's a bad, no. Nobody makes it to the NFL, man. 1% of people make it to the NFL. 1% of people, it's people that go out there, they get special training, they get in all these special classes and whatnot, these special programs and whatnot. They put so much money into it and effort and practice and all this stuff. And they don't even make it. So it's the 1%. So again, that's just a little reminder to just not call somebody, sorry.  He's terrible. No, he ain't sorry. Some unfortunate circumstances may happen, injuries may happen or they, the ball may just not bounce his way in the league, but they made it there for a reason, man. So that's the, anyway, I love y'all. I appreciate y'all. And just like Arthur Millet officially told the Steelers today, I'm out.


Hi children, my name is Mansi and I'm going to help you solve the following question. The question says prove the following by using the principle of mathematical induction for all n belonging to natural numbers, 2n plus 7 is strictly less than n plus 3 the whole square. In this question you have to prove by using the principle of mathematical induction. Now before starting the solution we see the key idea behind the question. Now we know that the principle of mathematical induction is a specific technique which is used to prove certain statements that are formulated in terms of n where n is a positive integer. The principle can be explained with the help of two properties. If there is a given statement p at n such that first p at 1 is true and second if statement is true for n equal to k where k is some positive integer p at k is true then statement p at k plus 1 is also true for n equal to k plus 1 then e at n is true for all natural numbers. Using these two properties we will show that statement is true for n equal to 1 then assume it is true for n equal to k and then we prove it is also true for n equal to k plus 1 hence proving that it is true for all n belonging to natural numbers.


International Day for Biological Diversity, celebrated annually on May 22, is geared towards increasing the understanding and awareness of biodiversity issues. This year's theme, were part of the solution, was chosen to be a continuation of the momentum generated in 2020. Under the overarching theme, our solutions are in nature, which served as a reminder that biodiversity remains the answer to several sustainable development challenges. Organization of Eastern Caribbean States OECS's technical specialists in the Environment and Sustainability Division, General Gabriel, stated that humans depend on biodiversity for a number of things, including food, shelter and livelihoods, and sometimes it is hard to maintain the balance. We rely on these resources, so we need trees to build our homes, we need clean water to bathe and to drink, and so sometimes we have over exploited some of these resources, sometimes we have bad farming practices which deplete our soils of the nutrients which we need, it depletes it of some of those beneficial viruses and bacteria and microorganisms which we need. So our actions have sometimes had impacts on biodiversity and so that's why we can come in now and be the solution by changing our own human behavior. From nature-based solutions to climate, health issues, food and water security, and sustainable livelihoods, biodiversity is the foundation upon which humans can build back better. Acting Chief Forestry Officer in the Ministry of Agriculture, Fisheries, Natural Resources, Physical Planning and Cooperatives, Alwyn Donnelly explained that programs have been put in place to preserve biodiversity. The Forestry Department has had this program of selective harvesting, for example you know in the forest you know people who were into housemaking and timber production went into selective harvesting so there were certain criteria that we would use to be able to sell trees. If the species had been, we had found that it had been over harvested then you know in certain locations we would not remove remaining individuals you know. We would also look at the topographic area, how close it is you know to water sources and even has been so specific that if you remove one tree what damage that it will cause you know to the micro climate so we did those things. Biodiversity looks at the human well-being in the present and in the future and its rapid decline threatens nature and people alike. According to the Global Assessment Report on Biodiversity and Ecosystem Services in 2019 by the Intergovernmental Science Policy Platform on Biodiversity and Ecosystem Services at UNESCO, the main global drivers of biodiversity loss are climate change, invasive species, overexploitation of natural resources, pollution and urbanization. From the Government Information Service, I am Genelle Norville.


When I was a teenager, Frank Herbert's Dune was one of my favorite novels. For those of you who have never read it, it's a science fiction story that takes place on a hot, dry planet. One of the most intriguing things about this book to me was the way in which the protagonists of the story would don their still suits before they went down into the desert. To me, the most interesting part about the still suit was the way in which it captured the moisture and bodily wastes of its wearer and cleaned the water so that they could drink recycled water from a straw mounted next to their mouth. Twenty-five years after I first encountered Dune, I re-read it with my daughter. By this point, I was a professor at UC Berkeley studying droughts in Southern California. Rediscovering this treasure of my youth made me wonder, could we build a still suit for an entire city? When I pondered this question for a while, I realized that in some ways, we were already doing it. By passing water through reverse osmosis membranes, adding a small amount of hydrogen peroxide and exposing it to ultraviolet light, engineers in Orange County, California had been turning what used to be considered useless wastewater into drinking water for over 25 years. The difference was that after they passed the water through the advanced treatment process, they injected into the groundwater aquifer, where it spent six months before it was pumped out and returned to the water supply. Over the past two decades, this practice, which is called potable water recycling, has gradually spread from Southern California to Arizona, Texas, Georgia, and Virginia. And as the practices spread, our research team has developed state-of-the-art technologies for measuring chemicals that might sneak through the recycling process. We've also begun to open up entire sections of wastewater effluent receiving rivers to sunlight. The sunlight breaks down chemical contaminants, inactivates waterborne pathogens, and makes it easier for the downstream city to recycle the water. Now, in the early days, the skeptics said that as potable water recycling spread, and the public became more aware of the connection between their drinking water supply and the sewer, they would be repulsed. But that hasn't been the case. Researchers at UC Berkeley have shown that as the public becomes aware of the water recycling technology, and familiar with the professionals who operate their treatment plants, the initial fears tend to recede. Over the past decade, we've seen increasing interest in potable water recycling as droughts have emptied the reservoirs in California, and Texas, and Brazil, and Australia. In many cases, the interest in recycling disappears as soon as the rains return. But increasingly, we're seeing enlightened public officials who recognize that droughts are just a wake-up call to get us prepared for the hotter and drier conditions that will exist as our climate changes. But there's still a problem. Our still suits leak. Over half the water that we use in our cities doesn't return to our wastewater treatment plants. In a typical American city, about 20% of the water that we put in the pipes never even makes it to our homes. Now, if we were to invest more money in our neglected water infrastructure, we might be able to plug these leaks. But we'd never be able to completely close the urban water cycle. That's because we're always going to need some water to support trees and foliage that shade us from the sun, cool the air, and provide us with recreational opportunities. Now, it might be possible to refill our still suit by capturing the water that falls on our roofs and roadways and lawns and returning it to the drinking water supply. Here at UC Berkeley, we're developing cost-effective ways to purify rainwater and gradually percolate it into the aquifer to make up for the water that's lost through irrigation and leaks. But even if we were able to do this, it wouldn't be enough. There's still another problem, the location of our sewage treatment plants. As you might imagine when it was time to start building treatment plants, the most logical place to put them was at the end of the sewer pipe. That means that our wastewater infrastructure tends to be located on the waterfront where the effects of sea level rise and coastal flooding are going to be worse in the future. Here at UC Berkeley, we're developing two solutions to this problem. The first one is to use the water that remains after the recycling process to create a series of coastal wetlands that protect our flood control levies from storm surges. The other is to completely abandon our centralized wastewater treatment plants and build distributed recycling plants throughout the city. These miniature treatment plants will be equipped with many of the same technologies that we have in our centralized plants. But instead of having a staff of full-time operators, they'll be run remotely with sensors and actuators. When we come back and think about the stillsuit in Dune, we realize it wouldn't be a very practical solution for people living in a dry city. But an unobtrusive system of technologies that allows us to safely recycle water is no longer the stuff of science fiction. It's the future that we're building here at UC Berkeley. Thank you.


go. Aaron huge spot for a break you there in the 10 thing obviously what did you think of the way he was able to come in and shut things down what really impressed you about that. The confidence with which he pitched in with you know he right away you know even in his warm-ups I just he had a look of yeah give me the ball I'm ready for this you know he's he's done a great job for us all year you know we talked about that one outing in Tampa he responded from that you know he didn't let that you know get him down at all and you know he's come up in some really big spots for us here a couple of times in the last couple of weeks and and no tougher spot than that. What did you think of stop Higashiyoka made on the first pitch that he threw. Yeah I mean Higgie's Higgie's obviously very special back there so not surprising when he comes up with a good one. Obviously a tough night for Chad Green tough night for Zach Britton just how concerned are you with the state of the back end of your bullpen. Yeah I mean we're going through our struggles you know the reality is greening through the ball really well and and a great player got him on one pitch you know that doesn't take away from the way he's throwing the baseball right now. You know Britt Britt's going through a tough stretch tough time and you know even when you're great like him you know this game will do that to you and you got it you got to be able to battle through it and we'll be there and try and support him through this and and we know how important a role he's still going to play for us and you know but you know no question it's tough right now but the good thing is he has all the equipment to get through this. Marley Rivera you have the next question. Hi Anne and can you welcome to the decision of us using Britton in that situation. We spoke to him before the game and he was saying that he told you the conversation but he did not deserve to be in those types of situations. Well I mean we're now in extra innings and we've used a lot of high leverage situations so you know Britt's still a great pitcher and you know he was the guy for that spot and that spot of the lineup and you know we're going to have help behind him obviously but you know this is one of those games where you're using a lot of people. And when obviously when you see Commander again I'm sorry to sound like that. When you see Commander again in that position in this inning what were your thoughts. We got to get him out and and I like the way again Albert looked on the mound you know whatever happens there you know whether it gets get some or doesn't the good the one thing I felt good about was how he was throwing the ball and the confidence in the boys with which he was throwing the ball and then it's competition and let's go. Dan more new the next question. Aaron the way the judge has been swinging the bat and the way you know especially the last two nights. How much have you needed what he's given you. Yeah I mean man it's a it's he's he's getting locked in you know and that's that's exciting. I mean a couple of great swings tonight. I mean that first at bat going well I think it was a 3-2 count where he shot the ball the other way to drive in to drive in DJ was was just such a good at that such a good swing. You know the home run at bat and at bat earlier to get on. Obviously that the at bat that gets us a lead there in the 10th inning and then you know the field of dreams game. So good to see him really start to put some gather some really great at bats. You know we know what he means to us. And you talked about what your team can learn from games like this whether it's this game or a field of dreams game. What do you take from a game like tonight. You know what our team has hard and they're tough. You know this has not been easy this season for us at all. But they're tough and they they compete and they keep they keep grinding away and keep throwing punches and and we're going to continue to do that the rest of the way and look forward to going out there tomorrow and and trying to grab a series. But but this team showing me a lot of toughness is what they are. Brian hope you the next question. Aaron what are you starting to see with Joey Gallo. Any difference with him. Again you know I know you guys have asked me similar to what I've seen this entire time which is good at bats and now the last couple of days he's he's getting some results. Behind it as well. You know the walks there but his at bats are you know even when it ends in you know you know a strikeout or or a stretch of a few games where he's not getting a lot of hits. He's putting together really good at bats and you know that very much continued tonight. You know he's he's a tough at bat against a lefty. You know and obviously huge homer to give us a little bit of a cushion there. But kind of more of what I've been seeing only getting a little bit of results now the last couple nights.


So we're here with the HZO. So who are you? My name is Ryan Moore. I work in the marketing department. HZO is a company that they waterproof electronic devices. We work with manufacturers to help protect their devices from water, from sweat, any sort of corrosion. So it's submerged, it's waterproof, right? Turn this on. These have been in here all day. Is this a real or did you modify it? So this is a real Samsung Edge that we purchased and waterproofed ourselves just as a demonstration device. You can see the water actually gets inside of the device, but it's everything on the inside that's protected. There's no coating or anything on the outside. So water can actually get in. You can see the bubbles. Water can get in the device. It just drains out the bottom with no problems. Alright, so what are you showing here? So this is a test that we did. This is a 48-hour salt fog test. Salt fog is very corrosive as you can see. So after 48 hours the unprotected iPhone 5s had all this corrosion on the inside of the device. Here in my left hand is the HZO protected iPhone 5s that we have our coating on there. It's a clear transparent coating. So we wouldn't even know it's there, but you can see there's no corrosion and it's able to preserve the phone. So are you already in mass production and products? Yes, we are. So here's an example of some of them here. We will feature on the Motorola Surround. It's a new Bluetooth headphones that came out this year to help protect against sweat. Also the Nike Feel Band were featured on. The NaviLite wrist compass. And over here we have the Toleno eReader Vision 2. This was the number one eReader in Europe. And we're also featured on the one that just came out, the Vision 3 as well. Nice. So is there another company P2i? Are you similar or is it a different technology? It's actually a completely different technology. There's more of changing the contact angle and making things hydrophobic. Ours is a physical barrier to keep the water away from the electronics. So the benefit of that is you can do prolonged submersion. These have been in all morning with no problems at all. Is it a process where it's like you put in an oven and you can make it like this? So how do you make it compatible with your technology? How do you put it in there? So what it is that we work with manufacturers, we have equipment that has large chambers so we would assemble a PCB into an assembled board. We put it into a machine. The machine releases the gas and the gas forms a thin coating around all the circuitry of the device. And it's done at room temperature and then you would finish the assembly of the device basically putting it on the outer shell. So all the protection is on the inside of the device and when it gets in through one of the ports, everything inside is protected. And it stays on if you touch it later or you scratch it, does it make a hole in it? No, I mean, if I scraped this really hard it would come off, but I mean, again, it's all contained on the inside of the product and so no problems whatsoever.  Yeah, definitely. I mean, we're still a pretty young company. We started around 2012, but I mean, we've made some great progress. This is a cool thing here. This is a Raspberry Pi computer. It's been running our demo reel all morning since 9.30 this morning. All the coating is on here and it's running our video right here. Nice. And there's never any leaks or any, because if there's a small hole in it, it could be an issue, right? Yeah, exactly. So we're able to help protect them. The coating that we use is very robust. It's able to keep water out and not let it in. Cool. Could it be combined with the competing P2I or it should be one or the other?  ARCHIS offers a very robust solution so that you can do things like prolonged submersion. So in 2016, everything should be waterproof, right? That's the goal. That's what we're shooting. We're shooting for an HDO-protected world. When you buy a Samsung, it should just be by default with all this... Yeah, you should be able to put it in the water all day.


I remember a few years ago when I was sitting with Pastor Lee in a coffee shop talking about orphans and Pastor Lee said to me, Abraham I would like to build an orphanage for you. We built three orphanages, two schools and here I am to ask you to help me to build another school in one of the most needy places in the nation of India. And this school would be like a lighthouse bringing education to the illiterate backward communities of that area. It's going to cost us about $110,000 to be able to build this school and make it run. So I wanted to pray with me and I want you to help me and we want to thank you. I want to thank not only Pastor Lee and Jane but also the whole church for being so generous, for so giving and being so much part of us. And I pray that God will bless you abundantly and the year 2020 will be an amazing blessed year for the moment of radiant churches and God will bless you real good.


Layered double hydroxides, LDHs, also well known as hydrotalcite-like layered clays, have been widely investigated in the fields of catalysts and catalyst support, anion exchanger, electrical and optical functional materials, flame retardants, and nano-additives. This feature article focuses on the progress in micro-slash nano-structured LDHs in terms of morphology and also on the preparations, applications, and perspectives of the LDHs with different morphologies. This article was authored by Ming Dong Dong, Silang Su, Fajie Zhang, and others.


For our second recipient, we are excited to recognize Dr. Michael Brandon. Dr. Brandon joined NCSSN's faculty three years ago and has quickly become an outstanding teacher and colleague. As both a team and solo instructor, teaching American Studies and the highly requested Black Studies course, Dr. Brandon creates an active, lively, collaborative classroom atmosphere in which students are challenged, engaged, comfortable, and serious about their learning. In Dr. Brandon's classes, students experience the joy of investigation and discovery. Keeper of the Dream work is hard work, but I mean, I'll tell you.  You gotta have a boot for it. Dr. Brandon's well-organized lessons, rich in content that ranges across areas of study, challenge and empower his students to think critically and creatively, to work together, to apply their knowledge and understanding to real-life situations, and to think and act as informed, engaged citizens. For example, in one of his classes, he requires students in his class to research and present a current event from human trafficking to local government to the environment, making students more aware of their responsibility to the world around them. Elizabeth Moose, Dean of Humanities at NCSSN, shared that as a teacher and as an academic advisor, Dr. Brandon recognizes his students as complex, whole human beings, and he supports their growth not only as students, but also as people. Beyond the classroom, Dr. Brandon passionately invests time and energy in extracurricular activities that promote and facilitate students' engagement with civic issues and the world beyond NCSSN's campus. Dr. Brandon serves on several committees, including the Mental Health Committee, the Campus Cultural Climate and Diversity Committee, where he serves as one of the three coordinators who are helping our campus with our diversity efforts. This year, Dr. Brandon is sponsoring the Civic Engagement Club, the Teen Court Club, and NCSSN Socialists, all of which grew out of a campus advocacy project that he and his teaching partner implemented last year in American Studies. Service learning also plays an important role in these clubs, as well as in the new civil rights-based mini-term course Dr. Brandon is sponsoring this year. Several students nominated Dr. Brandon for the Keeper of the Dream and had this to share about Dr. Brandon's work with the Teen Court Volunteer Association. Dr. Brandon serves as the catalyst for this project which partners with Durham Teen Court in an alternative justice program that provides first-time juvenile offenders who have admitted guilt to misdemeanors as a second chance. Through the work of this program, we are exposed to an important social dilemma. We have the opportunity to look at the educational disparity between students in Teen Court and their peers. In addition, the program also established a new tutoring program. Whether it's driving students to Teen Court sessions on Thursday night, or helping out on various nights or weekends, Dr. Brandon has stepped up without hesitation to provide this opportunity for NCSSN students. In addition to his busy life as a teacher, advisor, and club sponsor, Dr. Brandon continues to grow as a scholar through his ongoing research, writing, and publication. Last summer, Dr. Brandon worked in Mississippi as a senior scholar with the Samuel Proctor Oral History Program's Mississippi Freedom Project, sponsored by the University of Florida. It not just as Dr. Brandon gave a presentation of social justice pedagogy at the City's Museum of African American History and Culture, just miles away from Richard Wright's boyhood home. He also gave a presentation on pedagogical approaches to black studies in Vicksburg at the Southern Cultural Heritage Foundation, and moreover, he joined University of Florida undergraduate and postgraduate researchers in service at the Watkins Street Cemetery in Vicksburg and at the Emmett Till Historic Intrepid Center in Glendora. Lastly, he had the privilege of interviewing Mississippi State Senator Willie Simmons in Cleveland for the program's archives among other fascinating interviews. Dr. Brandon called his work with the Oral History Program an invigorating, productive experience that has not only led to plans for a new mini-term trip, but also new approaches to integrate public and oral history into his African American studies and black studies curriculum. Students who nominated Dr. Brandon wrote that it's hard to capture in two pages in a few hundred words the passion and energy that Dr. Brandon exudes. All we can say is that if anyone on campus wants an intelligent, engaging discussion on race relations or basketball, Dr. Brandon is the man to visit. That if anyone wants to drive hundreds of miles to march against inequality, Dr. Brandon is the man to visit. And that if anyone wants to understand what it means to unyieldingly dedicate oneself to improving a community, Dr. Brandon is the man to watch. So please join us in recognizing a true keeper of the dream, Dr. Michael Brandon.