What do you, you talked yesterday about trying to take that next step to be there. How do you get that translate to the offense? You had the spark last week. What do you have to do to be better there? And I don't think just the offense. I think, Teresa, this is a critical time for us as a football team. We are four and four. We've won two games in a row. There's no buy this week. We are just like every other team in the national football league, I would say, operating at less than 100%. It's a vicious game. And so there's a fine line between trying to improve on the practice field, which is what you have to do and work on the practice field, and make sure that our guys are ready to play, that we are trying to take care of the guys that need to be taken care of, but also improving. You know, offensively, there are definitely signs. And it was inconsistent, and it was tough. We knew sometimes that the run game was going to be tough sledding, but we also knew that if we committed to it, that we could potentially break a couple, which we did. We were on the post-safety three times at a 42-yarder that got called back. And then we weren't able to secure the football. We made some good throws. We made some really great catches. But then, and there were some good pockets. And then there were other times where there weren't. And so trying to just be more consistent with some of those plays and not have the negative runs or that put us behind the chains, the penalties. But we overcame a first and 20 on a huge drive at the end of the game with some good checks, some good throws, and then ultimately touched down there with AJ. So we've been able to score. We took advantage of the game, really came down to the red zone. I was proud of defensively what we were able to do. Could have been better, but making them kick-field goals early. And then what our offense did, to be able to throw it in to the end zone, and Jonu making a fantastic catch, and AJ and everybody else, Tajah, so it was good to see. Why is it that the offense is so much more efficient in the red zone in the last couple of weeks? Well, we made a huge commitment to it in the spring when you have the passing camps, the non-contact OTAs, that you're trying to establish a base foundation and then work some plays off of it maybe each week that you feel like are a scheme play. But I do think that the players are comfortable in what's being called and what they're being asked to do. Tajah, we continue to practice. I mean, Tajah's had good weeks of practice and did a great job on the fade ball. A route that we worked with AJ over and over to try to have a lot of confidence in it. And then, in Jonu's case, a player that ran a decisive route, it was a little behind him. He made a great catch. And I think there was just good timing on that route. On the fake, what made that idea of Brett getting 10 yards more appealing to you than the offense getting to? Well, and I think that certainly appreciate that concept. You see that a lot if teams run speed option on third and one and they dish it back, balls at seven yards, then you have to gain eight. It really came down to where we were on the field, having the look that we had practiced for, that wanted to run it against. So that decision did not turn out to we didn't execute it. And so we have to continue to move on, give our guys all the credit in the world. In all three phases, we had a really nice kickoff return. We have to fix the punt return. But I felt like we kicked the ball well. The defense, being able to create turnovers, take advantage of those things when James gave us a chance to give our offense great field position. If that play is executed correctly, does it work in your mind? Yeah, I mean, Jim, I think that if any play is executed correctly, that it's going to work. Again, it go back that there's a lot of decisions that occur during the course of the game, guys. And we make them, they don't work. We're trying to win the game. That's what we're trying to do in each and every opportunity that we have to make a decision. How much did you win the game? Someone was supposed to block Devin White on that play? No, Devin White made an absolutely fantastic play. So we need to execute it better in order to get it. It didn't work. It was a play we can sit down and there's 168 snaps into the game. And there were plays that we made and that they're going to coach. And there was plays that we didn't make that we need to coach. When you were getting super aggressive on that play, where you say we're trying to win the game, which you seem to try to do without one call, where you say, this wins the game because we maintain possession and we end it. But then the general offensive game plan seems conservative. And I'm trying to come to terms with the two things, where with the one play, you're trying to win the game with the big punch. But with the overall thing against the past defense that hasn't been that good, and we ask you about it, you say, well, they played good defense. Well, they really did. I mean, and so the opportunities that we left out there and the game plan, I think that that's where you, I've always kind of, as a player, I think as a coach, whatever the call is, it should be played and executed. And we should play with the same energy and finish and effort, whether if it's a cover two defense or if it's an all out blitz. So that's the mentality that we hope that we can instill, whether it's an inside run, an outside run, a shot to Khalif or a deep pass, any of those. I think that's the mindset. I think that that's where I don't ever want to kind of coach, like, oh, this is just a base defense and it shouldn't be aggressive. And this is a blitz. And so now we should all of a sudden play faster or this is a play action pass or this is a screen play. I mean, they all need to be executed with the same energy, excitement, fundamentals, the effort, all the details that go into every play. So we have a game plan that we think can help our players take advantage of their skill sets, try to work and mix in different runs against a very good run defense. And again, not very consistent, but in times that we needed we were able to execute in some critical situations. When you analyze after the game, you analyze the whole team and you look at some of those decisions that you've made that have worked and that haven't worked and you brought up yesterday how you hear questions on the ones that don't work and not the ones that do work. How much do you analyze yourself watching the film saying, OK, was this a good decision that wasn't executed right or should maybe I have thought the other way when going back and looking at yourself? Every single minute of the day, I mean, I think that it starts with me. It starts with how I lead this team, how the message that I have, the keys that I think are critical to win. I was just going to be typing. It starts with me and how I can get this team to operate and function and understand how we have to be great in critical situations because the games are going to be close. That's where the majority of the games in this league are. The decisions that we make on the calls that we make, the calls and decisions that I make, I mean, obviously, I mean, it's probably not much fun, God bless her heart.  That's all I do. Think about it, analyze it, try to get better and then come back the next week. I was proud of the players, the way they played, the effort, Jarrell and how he attacked that last play on fourth and one, Nate hanging in there, Jamal Davis hanging in there against two werewolves, man, two massive inside players that are talented and good and he's battling. I mean, that's what I'm most proud of. And then we do that all the time. I do that all the time. We do that with the coaches all the time. I mean, that's not just something like we're just like, OK, we would say, how will we do this differently? Do we like this call at the end of the game with the defense that we were playing? How much time that they have, they threw it in bounds. We had to keep them in bounds. And when we did that, they ran 18 seconds off the clock and gained 12 yards. So those are things that we're trying to tell our players that, hey, that's great. We're executing the situation. So we always analyze it. To answer your question. So many felt teams that kind of enlisted analytics companies that can help situationally. What are your thoughts on outside help with analytics? Is that something that Titans do? Would they ever do it? I'm sure it would be something that we would always consider. We're always trying to consider things, whether that's at a consultant level or finding somebody to put on a staff. I mean, I think that any time you can use numbers to your advantage, you have to try to do it. You also have to try to make some decisions when the numbers are close. But I don't think that crunching numbers is going to go anywhere. It's something that allows a lot of people to be involved in a game that's very unpredictable and they try to make it predictable. What percentage of the time in the league do you think of hard count on fourth down results in the first down? I don't know. Has it worked here? Oh, I don't know. I know they jumped three or four times earlier in the game. That'd be different, correct? You know, I wouldn't be able to tell you either way. I mean, if you're asking a question with already knowing the answer, I couldn't tell it to you. I just know through the course of the game, they were either called for off sides or were off sides. And weren't called for it. So, you know. Just negative rushes in the league. Well, what's maybe going wrong there? To try to get to them the line of scrimmage so they don't count as negative runs, I wish I could tell you it has to be better, obviously. Because you break them. When you can break them, you get them to the second level. We've got to cover guys up and make good reads. Get the play started. That's critical when runners, especially Derek, can try to get into his fourth or fifth step. It's a little different than a guy with a different skill set. And everybody's very aware of what his skill set is. And if we can get him into his fourth or fifth step, we feel very confident in his ability and in our ability to gain meaningful yards. But if we can't do that, that's hard to ask him to make some of those cuts that a smaller, quicker back would make. It's like Correa flashed a little bit yesterday. There was one play where he had a good rush, but what did he need to do better there to get Winston on the ground? Was just something changing his technique slow down a little bit, or what would you say on that play? Didn't make the play on the quarterback. Quarterback, pump, I mean, pump faked it. And then coming out of there on a boot, and if he slows down, he just probably dumps it over his head. And he's coming. He's going hard. And he wasn't able to make the play. And then I think we missed the tackle. Corey Davis need more snaps, or was that maybe a result of the illness he had earlier in the week? Corey, I don't know how many snaps did he play. 46, if I remember correctly. I think that those guys, I think Tajik deserves snaps. I think Hump deserves snaps. And Corey, I think they all do. So we'll kind of see where it goes based on each week and how everybody feels. Could you tell that Temple was making a preparation form based on what they saw in that first game? I don't know if they would have known consistently where he would have been based on 21 snaps. I know that that was a talented, rested football team. I think our guys battled. Very proud of how they played. I would say that he felt better today than he did last Monday. So that would be probably the most positive thing that I would take from that, that after his second NFL game, coming back from what he came back from, that he feels better today. So that just means he's getting used to it and understanding that there's going to be some bumps and bruises or soreness. And so he felt a lot better today. Mike, you're guys' first two games at home. You played fourth quarter games that you couldn't come up with to play at loss. Now the last two weeks, you've won it basically with last minute, last second stands. Is there a value in being able to flip that switch? And I don't know if it's learning how to win, but to win those types of games? Well, I think that to appreciate playing in close games, being up in that game yesterday, being down in that game, battling, coming back, and being up and then finishing the game off, that's why I'm proud of this team. Because I don't think we have front runners that only are soaring high when we're up 14 to 3, that they battled and came back and were able to withstand the ups and downs of the game and the highs and the lows and just that journey you take throughout the course of a game and trying to go back out the next series and do something a little better. Would you, John, who'd done to be successful when called upon this year? Just continue to work. He's a tireless worker. He's got a great attitude. Comes to work every single day ready to learn, ready to improve. He's focused in meetings. Todd's worked. Todd Downing's worked very well with him, one-on-one. They get a lot of these one-on-one meetings sometimes. During special teams periods, when Johnny can get some extra time with Todd. And so it's just been, it's always refreshing to see good things happen to great people. I think Johnny's a great person, great player, great teammate. In the last two weeks, you guys have had two of your long. What is it, obviously a team game, but what is it that Ryan Tannehill is doing to keep this offense on schedule and just efficient like that? Well, I think the biggest thing that Ryan did probably yesterday is he got us into two great checks. He got us into two Blitz 0 checks that allowed us to protect it just long enough, understand, when they're in Blitz 0. However many of you guys have block and they're going to have one extra, right? And so you just have to kind of keep adding guys to the protection to force the free guy to be as far away from the quarterback as possible. And he did that twice through a great pass to Humphries on third down, through a great pass to Jono, excuse me, Tajé on third down. So you're going to have to pick up some critical third downs along a 10 or 12-play drive that comes down to dropping back and finding the guy open pretty quick. What are some of the things that is throughout a game going to the decision-making process of personnel groupings and snap counts? Is it a stamina thing? Is it we like these guys together versus these guys together? Can you walk us through that?   Are they playing them in base? Are they playing a nickel? What coverages do you get out of certain personnel groups, which would all be analytically based? But then you come into the games and like, OK, this is how they're playing us. And those numbers quite don't add up to where they were before the game. You're like, OK, this is how they're playing us. And so we're going to have to try to adjust and make adjustments. And then as far as players go, I think there's certain plays that guys have that they're in the game for, that maybe that play might be designed for them or not. Sometimes guys do need a break. Sometimes guys need a rest. And then they'll all determine when they're out there. Correct me if I misunderstood, but I think you said something yesterday about as you got to water level being pleased that you managed to get to where you were last year. But the whole theme of the offseason was that last year wasn't satisfactory. No, it wasn't. My point, again, I'm not going to try to correct you with whatever you understood. I just was saying that the NFL season has begun. Like it's November now or whenever it's going to be here. Now we're playing games. Every game going on forward from November is really when the NFL season begins. And we're in a position to do something with that going forward, is all I've said. After the way we started being 2-4 and now being 4-4 to start this push, I guess that's all I was alluding to. Saffold, I guess, in concussion protocol movement? He is. Was he able to show his speed of what it could do for you a little bit? Yeah, and just again, the guy has the ball. The quarterback has the ball, and he's got to make a decision on what he feels the ball needs to go. But Cleave had a nice return. It was well blocked. There was a lot of great efforts on that kickoff return. And then the few plays he had in there, I thought he was running and showing some speed. If you make the fake yesterday, still about three and a half times left. Two timeouts, and then, yeah, right. And hopefully that takes them down there under two and we're able to score, kick the field goal, give them the football with no time and everything else with the situation. So the big hope there was to take the timeouts from Tampa by getting the ball? The big hope was to go get the first down on a play that we really liked. The play that we've worked for a long time against a look that we wanted, didn't get it, didn't execute it. And so again, I want to credit to the players for finishing the game. For finishing the game, defensive stand. Evans was having a day, talented receiver, caught some amazing passes. Caught the back half of the ball. Over there, I thought Kenny was in pretty good position. And you just got to see his length and his hands. It's what the National Football League is about. And our guys made some good adjustments and were able to take him out of there. But he was having a day. Did you see Mr. Clear Wild Boy there, yeah? Again, I just try to worry about the calls that we have the opportunity to challenge. They blew the whistle. Again, there's a lot of plays that go into the game on both sides. Were your early thoughts on the Panthers? Well, they probably have one of the most dynamic running backs in the league as far as from a rushing and a receiving standpoint. Looked like Allen had got off to a really good start. You got to see through some interceptions yesterday. Not sure where Cam will be, but obviously, based on his health and his ability to throw the football and to run the football, any defense that has Luke Keekley on it, is going to be a very good defense. Just enjoy watching him play from an instinctive standpoint, production standpoint, and a leadership standpoint. So again, every challenge is every week is a challenge. And I need to do everything we can near to get started on Carolina and getting our players ready to compete against them. And on the fake, did you know when they ran out there that the fake was going to be run? Or was it, hey, if Brett sees this look, then it won't fit. Yeah, there are some different things that go and evolve with a lot of plays that we have on defense, special teams, and offense that you have the ability to get in and out of place. And so that's what we try to do. We try to give them the best opportunity to get into the right play, whether that be Brett, whether that be Ryan, that be Kevin Byard. And in all three phases, we're trying to give them options to get in and out of the correct play. Thanks, guys. Appreciate it.


Hello everyone, I'm going to take a picture of this apple and the cork ball behind the apple is going to be removed from the picture and that's what I'll show you today. Hello everyone, this is Amit Dan of amitdan.com. Today I'll have another episode of Pixel 6 Pro camera video and I'll talk about how you can use Magicazer to remove unwanted things from your picture. So if this is your first time or if you visit, thank you for your support on this channel. I'm always trying new and different ideas. If you appreciate variety, please go ahead and subscribe. So today I have Pixel 6 Pro camera right here and what I'll do, this camera has a very nice feature. So it's called Magicazer. So you can take a picture of something and if in the picture an object or something appears which you do not want, then you have the capability to remove it and that's what I'll show you today that how you can do it. So you're looking at the camera of Pixel 6 Pro right now and let's take a picture of this apple which is right here. You can see that there's a kind of cork ball behind it. So we'll just open the camera app and we'll take a picture. So let's take this picture here. So we took the picture and I'll just remove this for now. Let's put the camera on the stand. So here we have the picture and you can see that it takes a very good quality picture and you can see the cork ball behind the apple. So if you'd like to remove that then you have to go to edit and then once you click on edit then it's going to give you some options.  So if you click on here then you can see that you know it's telling you on top of the picture that circle or brush or erase. So what you have to do you have to just you know use your finger to kind of erase that. It's like you know erasing with a rubber eraser. So what I'll do so let's just try to erase this and you can see that you know it's kind of getting white and it's just erasing that part.  So I'm going to just you know erase a little bit more and you can see that it erased more and looks like I have something slightly more here. So I'll just use that here and here a little bit more and let's just erase this a little bit more. Now if you take a look at here then you can see that the cork ball is all gone and you're looking at the apple that's the only thing you're looking at. It doesn't even look like you know there's a cork ball behind it. So that's how you use the feature magic eraser on your Google Pixel 6 Pro phone. And just another note that you know once you finish erasing you can just you know click done and then it's just going to give you option to save a copy. So just you know click on save a copy and it's going to save a copy on your phone. So thank you for watching this video. There will be more videos coming up and I'll see you shortly.


Hello and welcome to the session. In this session we will discuss the following question and the question says, how many subsets do the following sets have? List them as directed. First part is, A is equal to letters of the word Chicago. List all proper subsets with one element. Second part is, the set A is equal to the set containing the elements 5, 10, 15. List all proper subsets with two elements. Third part is, the set B is equal to two digit numbers between 5 and 13. List all proper subsets with three elements. Fourth part is, the set P is equal to the set containing the elements A, B, C, D. List all proper subsets with five elements. Before we start solving the question, let us first recall how many subsets a given set has. If a set has n elements, then the number of subsets of the set is two raised to the power n. Now let us review what is a proper subset, the subset of a given set except the set itself is called a proper subset. So this is the key idea for this question and using this key idea we will solve the question. Let's start the solution now. The first part is, A is equal to letters of the word Chicago. We will write the set A in roster form since the repetition of the elements is not allowed. So set A is equal to the set containing the elements C, H, I, A, G, O. The number of subsets of A is equal to two raised to the power 6. Since there are six elements in the set A which is equal to 64, now we have to find all proper subsets with one element. So it's proper subsets with one element set containing the element C, set containing the element H, set containing the element I, set containing the element A, set containing the element G and set containing the element O. So this is our answer for the first part. Now the second part is, set A is equal to the set containing the elements 5, 10, 15. The number of subsets of A is equal to two raised to the power 3. Since there are three elements in the set A, this is equal to 8, we have to find all proper subsets with two elements. Proper subsets containing two elements are the set containing the elements 5, 10, set containing the elements 10, 15 and set containing the elements 5, 15. This is our answer for the second part. The third part is, the set B is equal to two digit numbers between 5 and 13. Numbers between 5 and 13 are 6, 7, 8, 9, 10, 11 and 12. Now from these the two digit numbers are 10, 11 and 12. So the set B in roster form can be written as the set containing the elements 10, 11, 12. The number of subsets of B is equal to two raised to the power 3. Since there are three elements in the set B, this is equal to 8. Now we have to find all proper subsets with three elements. The only subset of the set B having three elements is the set B itself. Since the set itself cannot be a proper subset, so there exists no proper subset of B which has three elements. This is our answer for the third part. Now the fourth part is set P is equal to the set containing the elements A, B, C, D. The number of subsets of P is equal to two raised to the power 4. Since there are four elements in the set P, this is equal to 16. We have to find all proper subsets with five elements. Since the set P itself contains four elements, so there cannot exist any proper subset of the set P having five elements. So we can say that as the set itself has four elements, therefore proper subset having five elements is none. This is our answer for the fourth part. With this we end our session. Hope you enjoyed the session.


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Thank you to have you join us on our flagship news tonight. I'm Laura Tatyogo. The Speaker of the House of Representatives, Femig Bajabiamila, has insisted that commercial banks are obliged to continue to receive phased-out notes until after five months of the change in the design. The Speaker quoted sections 20, subsection 3 of the Central Bank of Nigeria's Act that compels the CBN to also redeem the phased value of the recalled currency upon demand even after the expiration of the recall and withstanding the deadline imposed by the CBN. The Speaker also stated that the duration of the exercise should be between a time duration of two to five months. Bajabiamila was reacting to the failure of the CBN governor and his officials refusal to honor the House's invitation to brief it on the scarcity of the new notes to Nigerians. The Central Bank Act under section 20 allows the Central Bank to change the legal tender but it also says that after the expiration date such Naira notes change will no longer be legal tender but it says that even five months after, three months after, two months after, even in June, any old notes presented to the bank shall be redeemed by the bank. That point needs to be made to the Central Bank and to the public. It has not been made.


McPawn Mike Stevens visited the Pacific Northwest as a part of his zeroing in on excellence initiative and commented on the examples that sailors are setting in the fleet. There are sailors and leaders alike doing great work up there zeroing in on excellence controlling what they own focusing on good order and discipline and also developing leaders. I was so proud to have the opportunity to interact with them during the week-long visit that we had in the Pacific Northwest. Stevens also noted the importance of instilling leadership in sailors. Well I believe this I believe everything we do all starts and stops with leadership. Our ability to lead and to provide leadership is essential absolutely essential to the total success of our Navy. From the Defense Media Activity I'm Petty Officer Matthew Halls.


I'm Laurie Slater, I've been photographing Toronto for probably a couple of decades now. I love the city, I love pretty things but I like the gritty, probably a little bit more. I like everyday items and I see all these little details that I find so fascinating and beautiful about the city. Well when I first started going to the shows I actually framed things and that kind of went over like a lead bloom. Because framing is quite expensive so it adds so much to the cost. And so I was searching alternative ways and I came across resin so I gave it a try and I was amazed. It gives such depth to the photo, makes a colors pop and then of course it gives it that shiny exterior and people love it. It's a great city, I love the city, I get told that it comes through in my photos and I think the resin really helps that too. It's just something really special about it. It's the best way that I've found to display my photos.


Studying William Shakespeare's play Romeo and Juliet, let's look at key quotations relating to the character of Makishio. In Act 204 he is presented as very bawdy and dismissive of love. He says if love be rough with you, be rough with love and the repetition of love essentially shows how dismissive he is towards love. Furthermore the repetition of rough shows that he sees falling in love as a sign of weakness. The alliteration and prick love for pricking shows that he sees love as something to be deflated, something to be defeated. The verb beat to describe how he would beat love down shows his violent nature. The alliteration of E in Give Me shows he takes Romeo's heart break as a joke. Visage is a noun, however in this case it means face and it's a mask that he's placing on his face. Also, a visor for a visor is an inflammatory sentence. Here it's really interesting because he's talking about a mask. In many ways what this shows is that he never really truly trusts intentions of women even if they say that they're in love with him. He sees that just as a mask.


So, I guess we start. Thanks everybody for showing up so early. I guess we are the first talk today on the IoT Village. I still need to get this somewhere near my mouth. Okay, so I'm Daniel, this is Hiska and Caroline and we will present our work on Fitbit fitness trackers. Our talk is called Fitness Firmware Hacking, the Current State of the Heart. And this basically summarizes our research from the last few years. And all the work we are presenting was done in the secure mobile networking lab. So, a brief motivation. A few years ago, I guess like 2017, there was this article in the telegraph which talks about privacy in the Fitbit fitness trackers. But that's not so important. What's more important here is this comment from this guy who says basically, please modify my Fitbit so that I run 10K every day. And we thought why not help this poor soul achieving his goals. And also, if you look like insurance companies, you will get like up to here, Mill mentioned like 1500 bucks like bonuses if you can, if you like upload your fitness data to the insurance companies to show them that you are healthy and stuff like this. So, let's start with the version comparison. So today, we are going to show you several issues and hacks and modifications that are applying to very different versions of the Fitbit. So, we started with the Flex as a simple tracker and also the Child Change R. But Caroline did a lot of work on the Fitbit Ionic. So, there will be very different things on top of this because the Fitbit Ionic has different interfaces which she will tell you. Apart from this, all of them are ARM based. So, the architecture is definitely similar for the Flex and Child Change R and somewhat similar for the Ionic. Yeah, the Fitbit Ionic is the first device within Fitbit's product portfolio to be marketed as an actual smartwatch. And this is because it introduces a number of new functionalities and interfaces. So, for instance, it does not only have GPS or Bluetooth, it also has a Wi-Fi interface and NFC and it has something that is called Fitbit Pay which essentially allows you to contactlessly pay with your watch and you can develop your own custom applications in JavaScript using, for instance, an online IDE called Fitbit Studio. And, of course, it synchronizes data over Bluetooth energy using some form of application, for example, on a smartphone or computer. And, of course, it has a number of different sensors for capturing the user's fitness data. And you can store music files, download radio station playlists, for example, from Deezer or Pandora, and connect your Bluetooth headphones. And the Hungry Cat marks the parts of the Fitbit Ionic that we thought were the most interesting in terms of security research. So, I'm now going to introduce the communication between the Fitbit and the server and this part is very important for you to remember to understand the remaining part of the talk. So, you have a Fitbit fitness tracker and this is connected over Bluetooth LE to the smartphone app and this connection is not that secure. So, it's not that important that it's not so secure because the app is only forwarding this traffic over HTTPS to the server and the traffic is, and to add encrypted with a device-specific symmetric key. So, each Fitbit will have its own key, 128-bit key during fabrication of it and it will be used for encryption. And this encryption only has been on recent records only which means, well, recent, I mean, we started some years ago so any model introduced after 2015 has encryption enabled by default so you cannot disable it but on the orders you could and then also there was a memory attack that was not patched in all trackers. It was only patched in October 2017 on all trackers so there were some possibilities in all the trackers to analyze this communication in plain text. So, what is happening? If you are running, so if you're Susie Fit here in the example you would run and then you have steps that are recorded on the tracker locally and this locally stored data could be something like a week of activity data but usually if you're connected to the smartphone app this data will be transferred to the server just forwarded and then it will be added to the activity database and this activity database has this data then in plain text but you need to actually log in with your smartphone to see this data in JSON so you would get summaries like all the steps of the last week or something in JSON and the mega dumps itself so the binary format from the tracker will also be answered with some settings from the server so this is a different communication here what you see in JSON is a different thing than what you will see in the micro dump, mega dump and now there is a very interesting concept because let's say I have my current step count or my heart rate and I would like to see it in the smartphone app that would be very inefficient to send it to the server each time let the server decrypt send it back in JSON and so on so there is a live mode and the idea here is that the user is logging into the server, does a local pairing with the tracker and then there is a remote association so each time I would log in again I would see the data from this tracker and the smartphone app actually in this step also gets authentication credentials these credentials are only obtained once so that you can later use them offline so that you don't need the server for getting more data and in this authenticated live mode you would get plain text data so that is only the thing that you see as a summary on the display so it's only the total step count of the day, the current heart rate and so on and there was also the possibility for a memory readout and since you can reuse this forever even if you associate the tracker another time this is kind of a critical thing here but we can also understand why did it this way because it's for the offline usage so it's kind of by design that you can reuse it forever so Caroline is now going to tell you about the additions on the Ionix might watch so as I've said the Fitbit Ionic introduces new functionality and has new interfaces that have not been there in previous trackers and for this reason the communication paradigm has also been a bit modified what remains largely the same is pretty much things like so-called server dumps this is something that Diska already told you about it's essentially a generalization of micro and mega dumps and they are sent from the Fitbit service over the Fitbit smart one application to the Fitbit smart watch and also the entire communication on top of Bluetooth energy is very similar but there are also some new concepts for example something that we called app dumps that I'm going to talk to you about later on in more detail and the Fitbit Ionix Wi-Fi interface is used during the installation of a custom application mainly for web socket traffic also for downloading firmware during a firmware update and that's pretty much it everything else is still relayed over the smart phone application and the NFC interface is only used for the transmission of payment traffic to and from a payment terminal and of course as I've said you can connect your Bluetooth headphones using Bluetooth okay so one important step during our research was accessing the hardware you can start with disassembling the app of course or taking dumps from I don't know HTTPS but to get a whole picture we thought we also want to get access to the hardware itself so to quickly show you our threat model so we still have Susie Fit who stores her activity locally on her tracker and of course this tracker has a local symmetric device key but now what happens if Susie is not so active anymore and likes to modify her own data or get her own data so our goals are to access the local data storage and to get the encryption keys so first stuff you do of course is to search for ebay and buy all the trackers you get your hands on and so in our case the Fitbit Flex was pretty cheap already so broken ones you could get up into batches of 20 for $1 each and so here's a quick look at hardware and software of the Fitbit Flex so you have your main system on a chip you have which in this case is a chip from STM it runs a Cortex M3 ARM and the firmware consists of a few libraries which we identified they used so for encryption for example they used LibTomCrip and for BLE they used a library which is very similar to the BLE shield and of course apart from the main SOC you also have your Bluetooth chip which is from Nordic Semiconductors and an accelerometer and here in the Fitbit Flex example everything is connected via an UR bus so if you pry open the hardware so this is pretty easy on the Fitbit Flex you just use a heating gun, heat it up and then you can basically pull it apart and you will get to the PCB so here we already removed the battery and the vibration sensor or vibration actuator and so you already see that there are many testing points and the most important ones are these so a TP8 and 9 are used for SWD debugging and you can use just the ground from the battery to connect it to your debugger and apart from this there is also TP10 which you can use for resetting and yeah that's it you have everything you need to hook it up to a debugger and so here on the right hand side this is how it looked in our case we just used the ST-Link debugger from STM and in the breadboard basically and with this we were already able to read out all the memory so it consists of three big parts a flash, an EEPROM and an SRAM the flash contains of course all the firmware code the EEPROM stores all the data you want to get your hands on and the SRAM of course for firmware variables we have a closer look at the flash you will see that it consists of two big parts an app part and an BSL part Jiska will tell you more about these later but the important thing is that they can run independently from each other and the EEPROM as I said contains all your fitness data but also like the serial number of the Fitbit an encryption key and an encryption switch so with this switch it was possible to disable encryption completely but nowadays the backend will not accept connections which are not encrypted anymore so this does not work anymore so one important step also was to re-enable GDB access what we discovered is basically that you only were able to connect to the Fitbit to the reset before this and after this if you hit continue on your GDB the connection to the debugger will be lost so at some point in time it needs to apparently it remapsed the GPIO ports to something else but not like to something which we need for debugging so we thought why not reset them to something which we actually need and what we used for this is the Nexmo and patching framework so we already developed this for a previous project and with this framework we are able to binary patch the stuff basically and we adapted it for our needs of course our goal was to modify the firmware and enable the dynamic debugging so this is what the core graph looks like for after initialization so at the beginning GDB access still works and somewhere after the initialization it doesn't work anymore so I have no idea where exactly these GPIO ports are reassigned but I actually don't need to know so what we just did instead is to add an additional Bluetooth command to remap the GPIO ports to re-enable GDB access and for this we did this with a special Bluetooth command because we did not know which other use case they had for this GPIO and we just wanted to keep the side effects as small as possible and with this of course then we were able to have breakpoints and memory watch points and all the good stuff so naturally we also had to look at the Fitbit Ionix hardware and we did this by using two broken Fitbit Ionix smartwatches and the goal was for us to understand the hardware that is used and also to find possibilities for debugging and what you see on the picture below is the Fitbit Ionix main PCB being powered by its battery pack and it has 39 copper wires sorted to its back and is connected to a logic analyzer and since the Fitbit Ionix main PCB is rather small this entire setup always reminds me of the flying spaghetti monster what you see on this picture are all the hardware markings that we deciphered from the chips on the Fitbit Ionix main PCB using a microscope and what you see from this is that the Fitbit Ionix uses a Cypress Bluetooth chip a Broadcom Wi-Fi and an NXP NFC chip and also the CPU and the flash memory are manufactured by Toshiba and the CPU is custom built for wearables and smartwatches and it contains an ARM Cortex-M4 and it does not have JTAG interface but instead uses SWD which is short for a serial wired debug and on the right hand side you see a comparison of the Fitbit Ionix main PCB to the main PCB of the Fitbit Flex and what is noticeable is that the Fitbit Ionix has a lot more stuff going on on the PCB and it's a lot more densely packed and more complex so there's definitely an involvement there this is the main PCB from the back with all the different testing points there are 95 in some and we tested 39 of them using the logic analyzer under different conditions and we wanted to identify which testing points correlate to the SWD interface unfortunately, Murphy's Law this did not yield the desired result instead we found that testing points 25 and 28 are responsible for SWD clock and input output respectively after we desoldered the main CPU so if you want to follow up on this these are the testing points to look for and this is what the flash memory and the main CPU look like desoldered so the first thing to note about the flash memory is that we were not able to find any information on the public internet about the manufacturer parts number on this chip we found one that was very similar that had just one letter exchanged essentially but it was bigger and this is why we think that it might be possible that this chip is even custom built for the Fitbit Ionix so the thing is that it is not that practical to open up a Fitbit to then change your step count or whatsoever so what we wanted to do is also to understand the wireless firmware flashing process to flash our own firmware that modifies something so the firmware update process usually works as follows you just have this same mega-dump synchronization with the server and the server realizes hey I have a new firmware and then this firmware is actually shown to the user and the user needs to confirm to do a firmware update and then again the tracker is sending a micro-dump and there is the firmware request to the server and the answer to this contains two parts which Daniel was already talking about a BSL and an app so app here is not smartphone application but the main application running on the Fitbit tracker and first the BSL is flash validated and so on and then there is a reboot to BSL and then the same happens to the app so the idea is that you cannot pre-create your tracker which means so if I cannot reboot to BSL then my BSL was wrong and then I can still boot the app so far so good another thing that you need to understand is that I still have a memory read-out attack but do encryption is how the encryption itself works so we did a bit of reverse engineering and found that the tracker is using lip-tom-crypt and with this it was also easier to find out how the nonce is used how the encryption key is used and that they have a Mac so the Mac also means that you cannot easily get a bit here and there to change the behavior because then in the end it will no longer match with the authentication Mac so you really need to understand how the format works and how the encryption works so if you want to flash a modified firmware first of all you need to get the encryption key or you have a tracker that is still in plain text you can achieve that actually if you buy one of the older trackers you can connect it to the internet so beginning of this year I was still buying trackers that could be modified but only the very old models and then you need to find someone buying one of those models that has never been unpacked so if you have the key you can then also read out the firmware if it's not already a firmware that we already have then you can copy the firmware modify it with Nexmon and copy it back to the smartphone app actually already has a few firmware images built in so if you just want to have one of the images that we provide you don't need to do this part but probably you are interested in binary patching and want to have your own patches and then you need again to format and encrypt the firmware and flash it back as I explained and yeah so the pre-compiled firmware that we have has a couple of funny features so the first feature we actually did when we had our first demo so when we gave our first talk and it is just returning the step counts times 100 so you need to do less points and it will still look somewhat realistic to the server so you could do some more advanced stuff here like replaying activity records or something but we just do the steps times 100 and another funny thing that happens so if you then are resetting the tracker to this patch and already have a high step count then it is like taking the square of this or something so it is getting super high numbers and this is really funny because then if you have a Fitbit account in your inbox you will have all the notifications of like you got the New Zealand batch of crossing all of New Zealand in one day and so on I don't know so that's really funny what happens if you do this and yeah you definitely can do this maybe you shouldn't do too much of this because if you have a health insurance and want to tell the health insurance I am doing sports and then they are like yes but you did like two billion steps then it might be strange so be careful with this and then beginning of this year I also ported this code to the Fitbit Charge HR which is also cool because the Fitbit Charge HR has a display and display means that you can take the smartphone app with you so you can just show like oh I did a lot of steps today I was doing sports before coming to your party and then you don't need to move a lot on the party because otherwise they will think like how did you do five thousand steps on the party okay so the accelerometer is one thing that we thought is very interesting to access because there is like or at least has been no good tools with trackers that are waterproof at accelerometer readings and there is almost no strings in the firmware so it's very hard to reverse engineer but one thing that is there is factory test mode with some basic console and luckily so one of the very few things that has a string is a command to test the accelerometer and with this we found out how the accelerometer is configured and the most important part is configured to make measurements with a rate of 100 hertz so 100 measurements per seconds I think this type of accelerometer can also be configured differently so to something like two kilohertz which would mean that you could also record or recognize some speed derivatives but the 100 hertz is totally sufficient for recognizing some gestures and movements actually already something like that would be okay so the question is could we get the readings of the accelerometer somehow out of the tracker with at least a rate of 25 hertz and the next problem is a bit that we are restricted in how to patch this because we do binary patching which means writing code from scratch aside it's easier to reuse existing functions so what we did is we made a switch into the live mode so we are using the live mode and then we are copying the XYZ values to the live mode and the rate of this is the blue to valley packet rate and so you can put out the readings with something like 66 hertz so it's like not as much as the original readings but it's still sufficient if you want to develop something that the use cases are various so for example you could now develop your own algorithms that do something with accelerometers so recognize I don't know some gestures on top of step counts and this you could do with Python or whatever you like on your smartphone and Java or whatever and then once you have all the logic of how to recognize those movements you can then see code with next month because putting out the readings over Bluetooth is draining the battery a lot so it's nothing to do forever but at least for development it's very interesting so the versions that you can modify is actually if you buy Fitbit one flex or charge HR that has never ever been updated so a fresh one from the internet something like it was never updated since October 2017 and the charge HR would also allow you to access the heart rate sensor so there's also some help commands with this but we didn't release a patch through this so far but if someone is very interested we can look into this of course so much about the trackers and now we are going to tell you about some of the insights that we gained during testing so as I already mentioned the most interesting parts of the Fitbit Ionic from our point of view are Fitbit pay the custom application installation capability as well as the way that the Ionic synchronizes data synchronization is very interesting because we found that it heavily relies on the old Fitbit ecosystem and reuses old functionality and we wanted to see whether all the old vulnerabilities are still present there one thing to know about custom applications is that the process of installing heavily relies on the Wi-Fi interface and for this Fitbit consistently uses TLS and sometimes for example during the download of firmware they even use mutually authenticated TLS using communication or modify communication so I'll skip applications and focus on Fitbit pay as well as synchronization in the next couple of slides so one thing that I've talked quite a bit about already is Bluetooth energy and as the name suggests it is closely related to Bluetooth yet a bit different because it has been designed for energy constraint devices it operates on the channels of which 37 are used for data transmission the generic attribute profile is another layer within the Bluetooth energy protocol stack and it groups related information into services and characteristics and the smallest bit of information on this layer is called an attribute hence the name generic attribute profile so the Fitbit Ionic uses Bluetooth energy 4.2 setting otherwise on the official website which is weird it says 4.0 on the website and Bluetooth energy is not known for being the most secure standard by design there is one pairing method called just works which essentially is the most unsecure pairing method that you could use because it does not use authentication and depending on the Bluetooth energy version you can also launch active and this is precisely what the Fitbit Ionic uses it enforces the use of just works pairing you cannot use anything else with your smart watch and we assume that this is due to usability issues because it does not require user interaction also the Fitbit Ionic exposes five different services on the generic attribute profile layer and two of those services are proprietary and these are used by Fitbit Ionic and the application layer protocol is what I'd like to dive a bit into in the next couple of slides some things are legacy and have already been present in previous trackers and some things are new and specific to the Fitbit Ionic so one thing Yiska already mentioned is the so-called live data which is the real-time fitness information of a user and this is still included and present on the Fitbit Ionic another type of data that is present on this application layer protocol is so-called command messages they either instructor receiving side to take a certain action or signal state and there have been modifications to previous ones or older ones from older trackers for the Fitbit Ionic and there are also a couple of new ones that have been introduced in the Fitbit application one thing that is new to the Fitbit Ionic are something that we called app dumps because they are exchanged between the Fitbit application and the Fitbit Ionic and they are encrypted dumps encrypted blobs of data they are encrypted using AES in EAX mode using a symmetric key of course and this key is derived using a proprietary session key of the Fitbit we reverse engineered this protocol and unfortunately for us we did not find a practical exploit but only a theoretical attack on this protocol because it has two independent stages and the semantics of the app dumps are defined in a construct that is called the Fitbit mobile data protocols which essentially is a set of XML files that define which bit and byte within a protocol about app dumps is that it is the first time that the application and the Fitbit tracker or smartwatch has the capability of exchanging encrypted blobs of data previously this was only present or possible between the Fitbit tracker and the Fitbit servers and if you are interested how all of this works I have a little Python script that demonstrates a little proof of concept to show you how app dumps work and how the session key I mentioned this server dumps are still present on the Fitbit Ionic there exchange between the Fitbit servers and the smartwatch and they are also encrypted blobs of data using a symmetric key and if you want to get to that data you either have to hack the Fitbit servers or your Fitbit Ionic because that's where the keys are it is completely transparent to the Fitbit mobile application and for the Fitbit Ionic and when I heard that you could now pay with your smartwatch I had really high hopes that it would be really insecure so I could find a lot of things you can use Fitbit Pay if you have a supported credit or debit card by one of the banks listed on Fitbit's website for instance the Bank of America is supported or the German Bundesbank Baden-Württemberg and all the payment traffic is transmitted on the NFC standard or EMV specifications and EMV is short for Europe International MasterCard and Visa and those are just three organizations that work together to create a common specification for credit card payments the credit card information is managed using the Fitbit mobile application and for this purpose Fitbit registered a new web API that is located under the domain Pables.co and to do this we used an app that is called NSCGate which has been developed within the Seymour Research Group the Secure Mobile Networking Lab and if you're interested in sniffing your own payment traffic using this very cost effective setup you can go to the link below of this slide which is NSC.wgf and what NSCGate does essentially is it creates a Wi-Fi wormhole so the first app on the first smartphone captures the NSC traffic on the NSCGate server that is also able to lock the traffic and from there the traffic will be relayed to the other NSCGate app where the data is sent via NSC to its destination which in this case is the payment terminal and vice versa okay so after analyzing and experimenting with this we found unfortunately for us that it is rather secure in terms of what is recommended in the EMV standard so for instance something that is called tokenization is used during payment which means that your credit card number is never transmitted in plaintext instead it is replaced with a so-called token which essentially is a pseudonym for your credit card number also a so-called authorization request cryptogram is used which is a Mac that is computed among other things over the transaction details like the card's master key and the transaction counter and what this does is that the transaction cannot be modified or replayed and last but not least a four digit pin is used as soon as you decide to set up Fitbit Pay which is supposed to lessen the probability of someone else paying with your watch and it is also used during a process that is called consumer device cardholder verification which proves your identity when paying with your Fitbit Ionic is pretty much the same than paying with your contactless plastic credit card yeah okay and next I would like to dive a bit into all the vulnerabilities that we found on the Bluetooth interface which is something that we dedicated a bit more time to and for this purpose I grouped all the vulnerabilities who identified in two categories on the right hand side you see all the vulnerabilities that are new to the Fitbit Ionic and have not been present in previous trackers and on the right hand side you see the vulnerabilities that are due to legacy implementations and have been known to be present in previous trackers and what is pretty obvious is that the right hand side is much larger there's much more vulnerabilities and this is because Fitbit relies on its old ecosystem and has a need for backwards old vulnerabilities to still be present instead of explaining each and every one of those vulnerabilities I'd just like to point out the main points of criticism that we have here and that are or that essentially cause all of these vulnerabilities so one thing that I've already talked to you about of course is the weak Bluetooth or energy pairing that just works pairing method and also we found that Bluetooth or energy security is inconsistently enforced this time between your Fitbit Ionic and the smart one application Bluetooth or energy or pairing does not instantly kick in instead it takes some time until pairing happens and during this time all of your data will be transmitted in plain text which of course is not that great so our recommendation would be to use secure connections whenever possible which is present in Bluetooth 4.2 and use a pairing method that uses authentication also Yiska already said authentication credentials for live data and this problem is still present on the Fitbit Ionic so if an attacker through whichever means acquires those authentication credentials they will forever be able to request live data from your smartwatch and of course this is also something that you do definitely not want so the reuse of those authentication credentials should be prevented for example by associating them with a validity period or if that's not possible maybe just plainly without that often. Another problem that persists is that live data is not protected on the application layer and this is a problem if you use a weak Bluetooth 4.2 pairing method as the Fitbit Ionic does or if at the beginning of each connection the traffic is not instantly protected so our recommendation at this point would be to encrypt live data with a similar mechanism that app thumbs are protected with real-time data would not be entirely real-time anymore but security has never been convenient so and last but not least I also found some testing commands to be present in production for example I found a command that allows you which is one command to request a very large test dump it's just meaningless test data but it's rather large and I was able to keep the Fitbit Ionic sending for 45 minutes straight longer and what it does is that it drains the Fitbit Ionic's battery quite quickly and for whatever reason the UI becomes very sluggish and unresponsive so you can't really use your smartwatch anymore and that's just pretty much unnecessary so our recommendation would be to employ a process that ensures that all your testing code is not rolled out to production which is probably something that is standard to our talk we have three major points which we want to point out so in general we can say that Fitbit products improved a lot during the years which we observed them in general they have the problem of compatibility for older trackers so the app still needs to have this legacy protocol which needs to talk via Bluetooth and in general it seems that Fitbit just likes to implement encryption in weird ways so that's it from our side thanks for your time and I guess we have now some time for Q&A questions so the question was if we already looked into the app right so do you want to talk about this so we looked into the app so Caroline did it and me too for understanding for example how the firmware slash and so on and we patched the APK and made some debug prints and so on to get an idea of what is going on so the question was with the secure connections and the pairing how it works and why it kicks in later so I do not know why but I would expect that you pair or use a secure encrypted connection smartwatch and the application that this just doesn't happen they exchange data for a couple of seconds and then randomly pairing starts I don't know why but I've seen this quite a lot when testing so the question was if we also looked into other smartwatches so actually another group at our university initially did a study on fitness trackers in general 17 trackers, different kinds and what they found out is that most IoT fitness trackers do not even encrypt the data so we actually picked Fitbit because we thought it's like a very interesting ecosystem they have encryption and so on so it's like we are hacking the strongest implementation but yeah yeah so the question is there is some Fitbit with GPS I think it's the Fitbit series or something but that one has been produced after 2015 so it's encrypted and then it's harder to do it so that's why we just went then straight to the Ionic to see what changed I assume that some stuff would be similar so if you would open the PCB and so on then you could maybe extract the firmware again with the one encryption key that is on this very same tracker and that's a lot of effort for just hacking one device okay then thank you for listening we will be around here for a bit more if you have any questions also on how we patched the firmware for example that might be interesting for some of you yeah thank you


Alright everyone, what is going on and welcome back to another reaction video. Today's video, I'm looking at the number 91st best player in the NFL. Can you imagine that? He's in the top 100. He's almost in the top 90, but not quite. His name is Grady Jarrett. He's a defensive tackle for the Falcons. We haven't seen any DTs yet, so I'm excited. I want to see exactly how ruthless and how massive this guy is on D. And with that being said, let's get into it. That is honestly, I can't cuss because I can't tell you exactly what we call that right there. It's called check what, that's what we call it. Oh man, that's just Grady being Grady. Wow, okay, I gotta get some stats. That guy just swiped past him like, he was absolutely not even there. Grady Jarrett, I guess it is a kind of, what, 185? What, the 6 foot? We're going to call him 6-1. 6-1, 300 pounds. That is a low centre of gravity. Got picked up in the 2015 draft, picked number 137 in the 5th round by the Falcons. He's still there and he made the Pro Bowl last year. What a yard dash of 506. 33 reps on the bench. Alright, no wonder he's swiping past people.  I need a sip.  So I just gave him a little, gave him a little sugar. I'm watching the wrong guy. This is Grady talking, isn't it?  So I just gave him a little, gave him a little sugar. Ah, little step to the right. So he's coming off his left. He's stepping to the right. Once he sticks his right foot in, he's swiping over with his right hand.  With that, a swipe of the right. And you're through. Let's see if it happened. Let's see if it happened like that. I don't know. I'm certainly no, no, uh... Hang on, I want to watch his feet. Let's watch his feet, guys. Okay, so he's off his left. He's off his left. He's taken a slight step with his right. His right goes down. And with that, his left arm swipes through. So he sort of spins his body to the side to make it obviously that much thinner. So he's literally, he's coming around the side, isn't he? Swiping him through with his left hand. Interesting. Interesting. That's vintage gritty right there. Just disruptive. And he's low, he's probably going to be a little bit lower than some of these massive offensive linemen.  He ran a 5 second 40, but I don't know. Oh, so there's just a great play by that man, Grady. He hit him with the doubles. Who said the most dumbest thing ever?   Honestly, yeah, I really shouldn't be looking at that too often. 300 pounds. And that's down. He's hard to stop. Oh, you can try to hold him. See? See? Okay. 78, he's doing all he can, right? So he's done that same move, but it didn't quite work. Look at the size of 78. No wonder it didn't work. What's going to happen here? He doesn't give up. Oh, okay. So that guy was holding, was he? He was holding. Look at him. He's fucking... Of course he's holding. He's like, no, I didn't do it. Grady.  How many sacks did he get last year? He got in 16 games. I combined 69 tackles, 38 of which was solo just over 50%. Seven and a half sacks to bring his career total in five years to 21 and a half sacks in the regular season and three in the post season, which he... Which was in 2016. Three games in the post season. I don't know how far they went. Did they win the Super Bowl? No. Okay. Let's keep going. This would be so disruptive. This quarterback just doesn't want to get sacked again. He just throws it up there. He throws a lot of pop. Having somebody like that, it's fun to play with. Oh, that's what you want, man. That is definitely what you want. You just, yeah. It's like... It's like, literally like the coach is the general of the army. He's like, right, I want you to try and do this. I want you to try and do this.  He's a mint. He's absolutely a mint. Oh, look at that. Get that! 74 was lucky. He's the one that led him through, but he's the one that recovered the fumble. Or this one. I mean, where are you going, bro? This guy? Like, seriously? Or this one. Look at 74. He thinks he's coming up against someone that is not going to move laterally. Come on, bro. It's Grady Jarrett.  I love the Aaron Donnells and Fletcher Cox's and those guys, which they deserve to do diligence, but Grady is right there. Like, right there. Absolutely, especially Aaron Donnell. I'm gonna get there. There for sure. Yeah, I believe you will. Funnily enough, I think Grady Jarrett and Aaron Donnell are pretty much identical as far as body size and shape goes. I wouldn't say identical as far as quickness and agility because Aaron Donnell is just a hybrid. I mean, it's unbelievable. He does things that most humans can't. And that's why he was the number one player in the NFL last year. Now, in the next one, I'm pretty excited. We're gonna look at Kyla Murray. The first time I looked at him was probably about four weeks ago. Literally the very first time. I saw in the comment section a fair few of you guys were quite excited. The fact that I actually looked at a Cardinals player, because I apparently hadn't. There is one other Cardinals player that's pretty decent. His name's Larry Fitzgerald. And once again, I can't wait to see him come up on the list. You know, that's why this list is so good. I'm gonna see all the players come up, but if I do wanna look at anything, look at their stats, look at a particular play, I can do it at the time, you know? So we're gonna have 100 individual videos. Individualized to this player.  And that's fine.  I don't get paid, and with that in mind, I'm actually going to start plugging a couple of ways that you guys can support me financially. But that starts in the next video. So I hope you've enjoyed the first 10 from number 100 to number 91. In the next one, we're getting into a pretty exciting player, Kyle Amari. I've seen some of his footwork. I've seen his pace. Now we're gonna find out exactly what the other players think of him. And I'm excited. So, I'll see you soon. Peace out.


So our next presenter is Kenneth Price. He's a fourth year medical student at NYU and he's going to present on the incidence and characterization of retinal detachments after macular hole repair. All right, thank you for the invitation. So today we'll talk a little bit about this incidence and characterization of the retinal detachments after macular hole repair. We have a case discussion to go over a little bit and we'll discuss a little bit more about the background information of macular holes, this diagnosis, treatment and further complications. And some characteristics of those complications as well. So for the case, this was the case I saw back in New York. The patient was Mrs. M.M. She was a 62-year-old Caucasian female presenting complaining of decreased vision in her left eye over the last six months. Her history was significant for a gradual onset. She didn't really know when she first started over the last six months, but she noticed a worsening within the last couple of weeks. She said that the blurring progressed until she was unable to read and that was really what prompted her presentation to the ophthalmologist. She denied any trauma flashes, floaters or any other ocular pain. Her further history included a medical history of significant for hypothyroidism and hyperlipidemia, well-controlled on levothyroxine. Her past ocular history is significant for mild and myelomia and gland dysfunction in both eyes. She was previously seen in this clinic two years prior and she was treated with artificial tears in both eyes, which she used, continued used about one or twice a day. Her familiar ocular history is only significant for primary open angle glaucoma in her father, which is well-controlled on drops. Her physical exam was significant for visual acuity of 2025 in her right eye and 2200 in her left with no improvement on pinhole. Important to note that two years prior, her visual acuity was 2020 in both eyes. Pupils had no efferent pupil or defect in either eye and her pressures were within normal limits. On slit-lamp exam, the anterior exam was within normal limits with some myelomia and gland dysfunction mildly in both eyes. She did have some slight cataracts in both eyes and there was no PVD in those cells. Her dilated fundus exam was essentially normal except for her left eye, which had a small red-colored defect. I was unable to proceed the pictures from New York, but here, this is one from the internet. And they similarly, they had a small red defect right there in the fovea of the left eye. I don't know, this is a little bit harder to see on the periphery there. But in the workup this lady had, she had an OZT, which definitely showed the full thickness macular hole with peri-ofovial thickening of the rims as well. It's a little bit about the definitions of macular hole. Macular hole is a full thickness depletion of the neural retinal tissue right in the center of the macula which can significantly affect vision. The most common causes of the macular holes include idiopathic, which would make up the majority of the percentages, about 90 to 95% of all macular holes. Other things include trauma and high myopia and less common causes include central macular edema, epiretinal membranes, crudal neovascularization and best disease. Some epidemiology on the disease as well, there's about 7.8 people affected per 100,000 population per year and that's about 8.7 nays. That's because there's bilateral holes occur in about 11.7% of the population. There is a significant predominance in females compared to males with 3.3 females affected for every one male. They're not really quite sure why as it, there's reasons aren't really clear. At that time there's, as there's no really change between premenopausal or hormonal differences as well. Epigates and incidences around the seventh decade of life as well. The prevalence ranges from 0.02 to 0.8% depending on population, though there has been no racial predilection been reported thus far. The presentation is like our patient that we had. They've very significantly dropped in visual acuity, some metamorphopsia, distortion in central vision and have left alone and progressed far enough and can present with a severe centric scatoma. Diagnosis is mainly due on a still-imp exam where you can see the foveal defect or wasky allen test or laser aiming beaming test. It's less popular but you can see these tests here. The main diagnosis in the gold standard is with OCT. So some things that can present as macular holes on physical exam but aren't quite macular holes include three main differential diagnosis. The first is vitro macular traction. It's an incomplete posterior vitreous separation with pre-retinal tissue proliferation with associated macular traction. Next would be a macular pseudo hole where it's mainly caused by an epiretinal membrane and this is where the epiretinal membrane and the internal limiting membrane both provide traction and this pulls the clivus towards the fovea and it deepens the foveal impression giving this pseudo hole. While it simulates a full thickness macular hole and the visual acuity is generally more spared and it doesn't carry the same risk as progressive photoreceptor damage. Also a mellar hole is a partial thickness macular hole where the inner layer of the fovea is are involved and with traction detached from the underlying cellular layer of the fovea. It usually creates this anvil-like shape as well. Some pathogenesis has been proposed for the development of macular holes and it's not really quite clear although because it was first described back in the early 19th century but Coates et al described in 1907 that the Cystoid degeneration theory. So Cysts caused by hypertension, retinal vascular occlusion or trauma eventually degraded leading to the full thickness macular hole and the rupture of the overlying retina. Although this doesn't really occur in all patients as all patients don't really with macular holes don't have hypertension or these underlying diseases. So another proposed pathogenesis was given as a vascular theory and noting that the majority of these patients are about 70 years old that this is proposed that the age related changes in vascular led to Cystoid degeneration and then leading to a hole. Another theory proposed was the vitreous theory was first proposed when the may notice that the posterior vitreous detachment was describing and associated with peripheral retinal tears. They proposed that the same thing was happening at the macula that the vitreous fibrous traction band led to macular traction leading to Cystoid degeneration and then to a hole. But it was important to notice that some people even after vitrectomies develop macular holes and thus the hydration theory was proposed which caused stretching and causing umbo-dehiscence from the posterior vitreous detachment and then causing this allowed vitreous to absorb in the phovia and the para-phovial tissue and that proposed or that was associated with decrease or altered fluid flow by the retinal pigment epithelium pump led to swelling around the edges of the retina around the edges of the hole which then enabled the breaching of the retina and further progression. With the development of OCT was able to diagnose and stage these different types of holes or these various staging of holes as well. Dr. Gass and Dr. Johnson developed a classification based on the OCT staging. The first stage is the impending hole or foveolar detachment is defined as a loss of a foveal depression with posterior vitreous cortex still attached. The visual acuity at this stage is generally good ranging from 2020 to 2060 with the main complaints being blurriness and metamorphopsia. The important thing is it can go and notice especially if it occurs in the non-dominant eye. Described on exam there's two different stages stage Ia which is described as having an initial appearance of the slight yellow spot and stage Ib which is a slight yellowing ring around the foveum and that's mainly due to the lipofusion and due to the increased traction as well. The prognosis for this stage is generally pretty good about 50% progress and 50% regress on their own. Usually at this stage they propose to just watch and wait. As it progresses into stage II you can have the full hold of hiscence. It's usually less than 400 microns in diameter. It's associated with a cup of cusp of subretinal fluid and with the vitreous still attached to the foveum. The visual acuity at this stage is slightly worsened about 2040 to 2100 with an increase in metamorphopsia. Usually there's a centric and a pericentric progression of this disease. Centric is if it progresses equally in all areas of the tear and then also pericentric it can kind of open as it can open a little bit uneven on both sides. Prognosis in this stage is generally worse, 15% regress and 75% progress into stage III. Stage III is a full thickness macular hole with posterior vitreous attachment. It's usually greater than 400 microns and has vitreofovial attachment from the macula and you can see that due to the presence of the operculum which is usually suspended right above the hole. And it also has a rim of elevated macular around it as well. Visual acuity in this stage ranges from 2060 to 2200 and usually has a significant loss in central vision. The prognosis is generally poor, 5% regress at this stage and 50% enlarge to stage IV. The only difference between stage IV and stage III is that stage IV has posterior vitreous attachment all throughout as well. So macular hole repair is usually generally performed with vitrectomy and an internal limiting membrane peel along with gas and oil fluid exchange. Silicone oil is usually only used in altitude when there is concern for increase in pressure. The surgical goals are they want to prevent the progression of the macular hole and secure the closure of these full thickness macular holes.  Generally for many years, patients have been prescribed and told to lay down, keep their head down for many, many weeks as that proposed that the air fluid bubble, the air bubble would keep in contact with the macular hole and help healing. There was a recent study in Denmark that showed non-inferiority of the non-soupine positioning with about 70 patients. So it still remains a debate today among vitro retinal surgeons. Surgical outcomes, closure rates are pretty good. It ranges about 90 to 95%. And it usually is demonstrated on closure on OCT. Here you can see that there's the full thickness macular hole on pre-op, four days post-op. There's still a bit of sub-retinal fluid which completely disappears with, along with the closure of the hole about three months post-op. Some complications that can occur after surgery include cataract formations and faking patients about 80 to 90% after vitrectomy and ophthalmitis along with any instrumentation of the eye. Late reopening of macular holes have been described in about 5% of cases. Retinal pigment epithelium alterations have also been described. Mainly in those holes who do not close, there's been descriptions of degradation of retinal pigment epithelium which is the most common. There's also been a few case reports of retinal pigment epithelium proliferation mimicking a retinal tumor with a histopathological shows that RPE hyperplasia without neoplasia. Also retinal detachments is what we're gonna discuss a little bit further, occurring in about 5% to 10% of these cases. Back to our case for Mrs. M. M. She went to surgery with a paris planivitrectomy, internal limiting membrane peel and C3F8 gas fluid exchange. She did well post-op. She had no complications in surgery as well. However, on post-up day 59, she went to clinic complaining of new onset flashes and floaters in her left eye for one day. She was found to have an infrotemporal subretinal fluid with an associated small inferior temporal oblique in her left eye. So the retinal detachments associated with macular hole repair is a serious condition. It usually is the regmatogenous retinal detachment. Regmatogenous meaning regma coming from the Greek word break. And it's a full thickness break of the retina and it's most commonly effected about 0.01% of the population annually. So three days after she was diagnosed with this, Mrs. M. M. was treated with a further retrectomy, endolaser, SF6 infusion and scleral buckling. So the rates of retinal detachment with macular hole repair ranges from one to 13%. There's been various studies looking at the incidence of that. Now our question is, why does this happen? Does it occur during or after surgery? There's been various studies looking at the retinal breaks during and after par splen of atrectomy.  However, despite correction of the breaks, he still had a post-op retinal detachment percentage of about two to 3% within the expected incidence. Rezo et al looked also looked at the incidence in the standard 20 gauge versus suturalist par splen of atrectomy and concluded that retinal detachments in most cases are not caused by surgical technique, but by new retinal breaks after the surgery. So another question proposed was that due to the vitrectomy ports, Wimpsinger et al showed that the entry site, they had some associated the retinal detachments were located around the 20 gauge entry sites and they hypothesized that it was caused by vitreous incarcerations at the sclerotomy sites, possibly due to the induction of the posterior vitreous detachment. So when they do vitrectomies on these novice eyes, they have to, sometimes they have to induce a peripheral posterior vitreous detachment. And so Remicus et al showed that the iatrogenic, that they both of these, all these requires, all these eyes that required induction of the PVD increased the risk for retinal detachment about two fold. Another possible complication could be by fellowship trained or fellow being trained in fellowship. However, Wilkins et al showed that the complication rates among fellows is the same as vitro retinal fellowship trained physicians in practice. So with our purpose, we did a small post retrospective case studies on about 293 patients in macular whole repairs from one surgeon out in New York City and Dr. Kenneth Wajay Wald. And he had nine patients that had post-op retinal detachment. So these characterizations that we were able to find in these nine patients, the average age was about 64 years old and the majority of these patients, five out of the nine had pre-existent retinal pathology. Two of them had peripheral lattice and two had peripheral retinal tufts. One had a previous retinal tear and one patient also had a strong family history for retinal detachment in both eyes. So both his mother and his sister had bilateral retinal detachments. The time to retinal detachment after surgery was about 52 days, which was within the literature range as well. And the majority of these occurring within 60 days. The location of the retinal detachment was the majority inferiorly. They had seven out of nine cases occurring inferiorly. For patients that completed post-op, seven out of eight had good macular whole closure and five out of six that had pre-up and post-op visual acuity, showed good visual acuity improvements. So with this, we were able to conclude some important things and some important characterizations of the retinal detachments after macular whole repair. It's a known complication and the percentage that we saw within this short study fell within the accepted range of 3%. Now these results suggested that the majority of these eyes that suffer rheumatageous retinal detachments after macular whole repair have pre-existing retinal pathology that predisposes them to these retinal detachments. Other findings include early post-operate onset of a retinal detachments, both within the tourist two months and a tendency to form inferior attachments. Complications are not associated with failure of macular whole closure as most cases result and most cases result in a favorable visual outcomes. So our suggestions would be and many have been saying this, but that careful preoperative and interrupted peripheral retinal examinations and possibly prophylactic treatment of precursors appear to be warranted but cannot be fully presented, prevented. And our patients, four out of the five patients who were treated with intraoperative laser also went on to have a retinal detachment even after laser surgery. So this is our presentation. I appreciate all of my help that I have on these collecting data as well and I welcome any questions. Actually, yeah. Thank you.