Right, view. There we go. All right. And I got to click that out of the way. Anyway, this is sort of a lot of stuff to go over. I understand most of you are probably trying to get this meeting in Park City, and I'll try to get you done well ahead of time so that we can roll on. The topics we've got today are ROP and retinal blastoma and abusive head trauma, kind of looking at it from a pediatric ophthalmology perspective of pediatric retina topics. Not to confuse what Dr. Hartnett, Dr. Wong may tell you, or what Eric Hanson, our wonderful new, you know, ocular oncologist may tell you about retinal blastoma. I'm in the process of kind of shifting patients over to him.  Now to review ROP, we want to kind of go through and I put on that cheat sheet that I set out the things that, you know, that are really pertinent terms of zone stages, and the issues that allow us to decide whether a given child is likely to do okay or need treatment. Can somebody to tell me about the zones? Just to volunteer, unmute yourself, chime in and share it with the group and we'll try to suffer through this on Zoom, although this is much better in person. Who wants to tell me about zones? Tell the group. I can do that, Dr. Hoffman. This is Tyler. So we have three zones. Zone one is two disc diameters from the optic nerve. Zone two extends from the border zone one out to the nasal aura, serata, and then zone three is the remaining temporal portion beyond zone two. Now zone one is really not just two disc diameters. It's twice, it's a circle whose radius is twice the distance from the center of the optic nerve to the fovea. Right. So if you want just from a practical standpoint, if you take a 28 or a 30 diopter indirect lens, and you put it so the optic nerve, you're looking at temporal retina from the optic nerve, the optic nerve is just at the edge of the field. With either of those lenses, you're pretty much looking at zone one. And it's a pretty good estimate. You know, if you just look at the optic nerve, look at the fovea and say, well, twice that distance, that's a pretty good way to gauge things. You know, the thing you can't do is look out temporarily and see anything that's going to tell you categorically I am in zone two or zone three. So that determination is made by looking nasally. And if vessels go out to the nasal aura, we assume that anything we see on the temporal side is in zone three. Now what about stages who wants to run through that quickly. I can run through that. And this is Lydia. So there are five stages recently a second, a six stage was added but the traditional five stages that I believe was still tested on is stage one is a demarcation line where there's just between vascular and a vascular retina there is a flat white line. Stage two would be a ridge that is elevated and a little bit pinkish. The third stage would be a ridge with extra retinal blood vessels, where there's some neovascularization and some tufts that are called popcorn. Stage four is a sub total retinal detachment, where there's some, it can be divided up an extra foveal and including the fovea, and then stage five is a total retinal detachment. That was the stage of the aggressive RP that was added recently but I don't believe were tested on that one. It's really been around for a long time. What they did in the most recent iteration of I crop was change what we call aggressive posterior RP to aggressive RP, but that determination was actually added in the 2005 iteration of the international classification. That was a good description.  So, this is Sean con plus disease describes vascular tortuosity specifically arterial or tortuosity and venous dilation of the vessels and there is a standardized sort of photograph that to know it's what plus disease and what plus disease, you know what what what is less than plus disease pre plus disease would be anything that is more tortuous and dilated than normal but not meeting criteria for plus disease. And in the more recent international classification RLP they talked about how they acknowledge that the this disease exists on a spectrum, while maintaining the classifications of pre plus plus disease. Yep, and probably just an important aside is that the original photographs that were published with the cryo rock study of plus disease were taken at the Moran eye center, then over in clinic eight University hospital by Paula Peterson.   And that's where those photos came from. So when you look at those understand that it was done here it was done with a great deal of effort and a kid that was intubated, bringing the ventilator and the baby and an isolate and everything over to photography. In the ophthalmology department now tell me about type one and type two where did they come from and what does that change. I mean what what's that mean. When you hear type one and type two in a short description. I can do that one. So these are the classifications of what what is and what isn't threshold disease. It's based on the ET rock study. And so type one, if you have any sort of disease, any plus disease in zone one that need treatment. It's stage three in zone one, but it's without plus disease you have treatment so anything in zone one stage three, or plus disease, you're treating, and then zone two has to be stage two or three with plus disease, right. And then type two that's doesn't need treatment is, you know, anything less than that but if it's stage one or two without plus disease in zone one, or stage three without plus in zone two but basically anything that's not type one. Right so in a nutshell if you type one, they need treatment type two, they're worrisome and we follow closely. And so the type two kids are the kids that we would see at less than a week. You might see the baby again in two or three days. Now, aggressive post area RLP or aggressive RLP as it's now turned the the the real kind of take home about that is that it looks different. You know when we first started looking at these kids in the cryo rock study, and we were one of the study centers here I was the local PI. There were a lot of babies that it was hard to tell if they actually had a great you know had RLP, and that vessels just ended very posteriorly, and they'd often have some hemorrhages, and over time, what we came to appreciate was that you don't see classic stage three. If you see dilated vessels looks like plus disease, and the vessels end abruptly, you need to get out your 20 day after lens and look closely, because you can have all this very flat knee vascularization that is at times hard to appreciate and those eyes go downhill quickly and they do need treatment. The other reason I want you to the way to think about aggressive posterior RLP is those are the kids that benefits the most from anti veg F treatment. That's the group that's been shown to have very clear benefit where that is almost always the preferred treatment and you see dramatic resolution of those changes, you have to watch them because it may come back later. Now, let's. And let's see here if I can yeah okay. So we're going to do a little game here and you know in the auditorium we divided everybody in half. And what I'm going to do here. If we look at our group here, do we still have just nine of us on here, or eight of you. So, let's. Okay, and we only have one senior resident right. I think that's me. Thank you Catherine. So, Catherine you're in charge of one team. Sean you're in charge of the other and will have four and four and Catherine you probably get more if there are more first years on your team and divide yourselves up. So Catherine, your, your team is the laser stars and Sean your team you're the anti veg F wizard so stars and wizards, and, and we don't have but but the idea with this what we're going to do is we're going to look at some patients on the these case based learning system and kind of work through those. And what I would suggest we do is we each keep track of our own scores on the team and you can add them up later, while we're doing something else and talk about it. The way I envisioned the scoring was for the third years, you get one point for everything you get right. And the end and minus three for everyone you get wrong. Second years, two and two, in the first years, you get three points for everyone you get right, and only one point off for everyone you get wrong to kind of even the playing field. And I need to stop the share of, let's see if I can do this will stop the share of this momentarily and we're going to digress. Let me do it there you go stop the share. And then we're going to come back to one second here. And am I going to get out of this. This is not letting me here we hit escape. Not let me do that I need to come up here let's do this. And documents. I think the PG Y twos you guys and I, sorry, you guys and I can all be on a team and then the yeah, I, all the PG Y threes I think are here so you guys can all be a team is that some good to everybody. That sounds good. Sounds really good and I'm trying to get this up here and it is not cooperating but we'll figure it out I suppose. And so, I need. How do I get out of screen share without. Hmm, I think you're out. Am I out. Okay. I think how do I get this to end show there we go and show. Good. Now, I can close or put that down here. And then, if I go to the, and I had this up on. Okay. And this was up before but we'll go to it. org. Sean. Sean just because there's two of you doesn't mean that we get more points. It was a slick trick but you caught me Cole. Sorry for the delay. I had this upgrade to go and somehow my computer decided to boot it so we're going to go. To this again here. And all right so launch this. And then we'll start that and then, then I've got to get out of somehow back to zoom. To share the screen again. Any ideas. If you just share your whole screen like the first screen in the top left corner when you click share screen, it'll show. Anywhere where I can see share screen that's the problem. Oh, I see. Right now, let's see show management exit stuff video start share. There we go. Start share. And let's go to this. And see if this works. Okay. Okay. Okay. Good. Good. Good. Good. Okay. So, And I kind of previewed these to look here and let's see what we got. So first up, what we do is the will alternate kind of patients here. Stars, you guys are up first, and I just need somebody on the team to give me an answer. We'll put it in here. We'll see how we do each keep track of your own answers and raise yourselves and we'll, we'll do it so with this, the idea is we're going to go through right and left eye and we have to decide what zone we're in, what stage we're in, plus is it, you know, what, how, how bad are things do they have a PR op. And when do we want to see him again, or do we want to treat him. And I can if you ask me to I can zoom in, and I'm going to move this up. And now, so this, this patient is a 671 gram at birth kids now 35 weeks, 24 weeks at at birth. So a little teeny peanut. And this is the view that we have. And when we look at this kid, we want to look at these posterior vessels this is where the distinction, you know, of, of. The vessels dilated Venus vessels are the arterial or vessels tortuous. And then we're going to look nasally. This is the nasal retina this right eye. Notice this stuff right here. This is kind of, you know, where the action is. And then we're going to look here again again more of the nasal retina and then temporarily, you see something going on out here as well. You want to notice the distance from optic nerve, the phobia, and where we are in terms of putting things in and is one of the are what are you calling me. No, I don't think so. Okay, then I'm going to ignore that because somebody's calling me and they can I just want to make sure that I suddenly hadn't gone offline or something and somebody's trying to reach me at which point. I'll, I'll talk to you and otherwise I'm not going to answer the bottom line here. So what do we think here as far as right eye what zone are we in. I would say zone two, since we at least didn't easily. I would say probably, I would probably say stage two, it looks more like a ridge than just a line. Okay, and let's go back here for a second look at this photo closely. Okay. It's hard to let me see. It's more hard to tell him to give you a magnified view. Oh, thank you. Maybe, what do you guys think PGA two twos, maybe stage one, then stage one. I would say stage three because there's. Oh yeah. What. Yes. Stage three. Okay, stage three very good so now I need to see if I can minimize this get back to where we were stage three. Now is there plus disease. I would say no. Okay. And so, if, and so, where would you put this if we're saying there's no plus disease and we're staying stage three. Where would that put us. It would put us in. It would be type two, type two. Okay. And then is it a PR OP. No, no. Okay. And when you want to see this kid again, based on these findings, you wanted to bring the right eye back and, and what interval of time. Probably one to two weeks. Okay, now let's look at the left eye. Okay. And what we can do is score this and how about if we go on this, this I, let's have the, the other, the opposition way in, let's try it right and left here so you're going to be our left eye folks here wizards. And we're looking here at nasal retina. There might be something going on out here. Give you the advantage of some magnification. And let's look at the nice picture of the kid right. And let's look up here with some magnification. And I got a page. Tyler you're not muted, by the way. So if you don't want us to hear your advice, you may want to do that. And so, and let's look with magnification here, looking Nate. I'm easily at this left eye. And I take a good careful look out here. What do you think we should put on here wizards the, what's owner we in to to what type of RLP do we have. We're thinking stage three. Okay, and is there plus disease pre plus debate. Pre press pre plus or plus, but we're having deciding. Let's go with plus. Okay. And it's not letting me click plus that interesting. Wrong. Oh here. No, it is now, it's just not responding. And so where would this put us, if we've got stage three with plus disease and zone to treatment, treatment requiring treatment requiring and then is this a PRP. I don't think so of its own to I and, and, and so now let's submit this stuff and see what we got. Okay. Here we go. Look here. And our answers are actually the wizards did well, which would make me think that the stars might be suffering. And come on. Let's go back over here and see what we've got and so right I incorrect but it's not letting me go back here. Let's go back to the case and then open it again. Yeah, maybe that'll let me do. Here we go. Yeah, you got it. Thank you. So, plus it's plus disease, which basically moves it to the category of treatment requiring and they dinged you for that so look at your answers grade yourselves accordingly stars. And let's go to let's see now here our next one we want to do is we want to do this guy. And this is a 570 grammar, who was born at 24 weeks, a little peanut you could hold in the palm of your hand, and is now 38 weeks, which if we're going to see bad things happen is a kind of classic time for bad things to happen. And so, again, the stars, you guys are up on this right eye. And let's look here and we've got. I can take this number of different views. And the one thing I want to draw your attention to photos at times it's hard to see things. We're not going to see much as own three in the photos, like you do clinically. So most of our actions going to be either zone one or zone two, but we're looking at something out here. And let's go through these pictures. And so that's the right eye what zone, are we in and what type of changes and how bad are they. I did see that rich so I would read it. It looks like when we're looking at the center of you it's not really visible to me. So I would call it zone two. Okay. And what type of changes are there. I saw if can we go back and magnify the view please to that more temple picture please. Sure. Let's look here. There you go. Thank you. So I don't believe that I see any blood vessels. I'm trying to decide whether or not I would call this popcorn. Don't worry about popcorn is an irrelevant side issue. Okay, what you're looking for is neovascularization popcorn is just something is there when you had neovascularization, and it's no longer connected so don't get hung up we don't want to get hung up on that I would kind of focus on do you see a line do you see a do you see extra retinal neovascularization on a ridge. Let's just focus our attention on that and that's where the money lies in terms of this. So, do you see normal retinal vascularization or a line. I see retinal vascularization up to up to a line but then there's a pink line and another line which makes me think that this could be a rich. Okay, make a decision what are you going to call it. I want to call it a rich and say to you. Okay, now is there plus disease. No, I don't see any tortures vessels. Okay. And so category, this would do we have some RLP. Yes, smile. Mild. Okay, is this APR OP. No, no. And when would you see the child again. Two weeks. Okay, two weeks. And now let's go to the other eye. Good job, Lydia. You went through that very well and I like the way you think about this stuff this is good. Now, for our the wizards here this is the left eye. And we're going to look here. And stop me if you see anything I want to sometimes these photographs it could be hard, but there is some hazy thing out here. And this is a nice posterior poll view to look at those vessels, keeping in mind that when we're talking about plus and pre plus, we're talking about things right in the posterior poll not out in the periphery. And that's what they're giving you to look at here. And so what do you think. I'm having hearing. Whoever's talking, I'm having trouble hearing you. Let me put you up here. Okay, Sean, you sound really distant. Like you're at the bottom of the ocean. Is it is it clear now. Much clear. Okay. Similar to the other I zone to stage two. Okay, no plus disease mild RLP. You went back to bottom of the ocean temporarily whatever just changed to change things from my end here. But I can still hear you. No APR OP and when would you see the kid and follow up. I think I want to say one to two weeks I don't disagree with two but I, but. Yeah, we go and let's let's submit this again and see where we wind up. And boy, the wizards nailed things here. Let's go back and see if it'll let me look here. And guess what? The stars nailed things too. So I think actually no we didn't go back so I'm still looking at the same thing. Let me close this. Oh, wait a minute. Yes, I want to resume where I left off. And wait a minute. I'll go to the second. Yeah, let's go back to here. And let's go to the right eye. And the right eye. This is, yeah, we're right I let's look at left eye now. And left I see you guys both did well. So great yourself. So any discussion on that. One thing I want to draw your attention to this is useful they're saying this is twice this distance. This is the outer extent of zone one. So if you're really in vessels, if you're worried about are we in zone one or zone two, let's go on. I have a question just just to clarify the bottom part of if you see this kid in the NICU. How long until you see them again. I would see them in one week. Okay. I'm on the conservative end of that. From my perspective, I see any kid that is in a situation where they could conceivably become a treatment needing patient in one weekly until they're, they're not in that situation. I think that once you've got if you've got incomplete vessels in zone to there are many people who would wait and see them in two weeks and that's probably what they want you to say if you're doing this and OKS. But personally, if they're incomplete in zone to they could change they could change a lot and I see him back weekly. If they're in the NICU. And without no though and those are judgment calls you know it's not a way to have a question if it's okay to ask that. Yeah. I think what I feel like I would struggle with the most on on these is to decide whether or not it's a PRP. And I know that it's kind of like, well, very posterior. But it looks a little different but I'm just trying to really understand what. The idea with this Lydia is that instead of the traditional line Ridge extra retinal knee vascularization, which is usually pretty easy to see in a lot of patients in zone to clinically. You wind up with flat diffuse knee vascularization in either zone one, or very posterior zone to. And it doesn't look like classic ROP. And that's when most people would apply the term aggressive posterior RP. And with a healthy respect for it if you look back at the cryo rock data. We put the cryo rock data us in the zone one disease folks. We took them from a 100% dismal outcome to a 90% dismal outcome. We salvaged maybe 10% of those eyes and the rest of them were all irretrievably blind.  But this is something that you'll get a handle on as you look at these patients. Okay, and look at pictures of it. And we can sit down and talk about it. Yep. Let's move on here and we're going to go to a third patient here and this patient. Now we're going to go through. And again, it's back to the stars and being the right eye specialist today. We've got this patient who is a 1200 grammar bigger kid now 38 weeks born at 31 weeks. And so still on the range where we'd screen the kid but we're probably not too worried. And you're seeing nasal temporal posterior pole and then temporal retina. And that's what they're going to show us stars what do you think as you look at this patient. You want to take this one Tony. I don't think Tony is here but I'm Brandon Brandon Brandon you're you jump in there buddy. There you go. All right so I'll probably say for this patient doesn't really look too severe to me I'd probably say zone to. Okay. Yeah, because you can't see zone three right just because of the way this is set up zone three is going to be a bad answer for any of these patients just to kind of head along. Now, do you see RLP. I do not if you want to go back to the nasal aspect I didn't really appreciate a demarcation line anywhere. But I can double check. Yeah, if you can make it. Yeah, I don't really see it. Okay, I don't either. Oh, zero. Okay, and is there a plus disease. Nope. Okay. Is there RLP category. No, none right. Is this and no, no. And now this kid where you've got. It's not letting me select that. And I'll try that again in a second what. And when do you want to see the kid and follow two weeks. Okay, and oh now it's selecting it for me how about that. And two weeks.   Let's look here this is and you can look with some magnification here if you want. Let's look at the nasal view here and look way out here and see if you can hallucinate a line or a ridge out there. And look at the poster pole vessels while we're here. And the other thing to pay attention to is do I see what looked like normal arcades or is everything dragged with the vessels straightened and those vessels to me look pretty good. We're out here temporarily and we can look with a little magnification and what do we see there. Anybody want who wants to take this that hasn't already spoken let's rotate this around with the wizards. I can do this one Dr. Hoffman. Sure. So, I think same kind of as the other team zone to. Could you go back to the nasal view. Yes. And there's some debate about whether there's a demarcation line. I say there's, it's hard to see, but I think there is a line. So I was Christ one. Okay. And it's not letting me it may let me check it in a second it's not letting me do it now. Maybe it'll show up. And is there a plus disease. No. Is it pre plus. Sorry, I meant, sorry, my answer to that was no. Okay. And yes, it is saying stage one and it is selecting it eventually. And then so we have mild type two or treatment requiring RLP being we've called it stage one. I would say mild no and two weeks. Okay, very good. Well, we will submit that and see where we wind up. And I think that they thought this was no RLP. I can hallucinate a line out there and it's you don't want to get burned on that either. But I think they're calling this basically incomplete vessels and zone to saying we can see the patient in two weeks. Let's see if it'll let us look at the right eye it does on this one. So it looks like our stars kind of get their points on this one grazers individually. And then wizards here are the answers here. And let's go to another one here. And now this patient is going to we're going to shift gears a bit here and Lydia this may help you a little bit here. And so you want to pay close attention to this patient stars. Who's up. We're going to look. I think it's me if Tyler is is busy and happy to take this one. I want to draw your attention to the location of the optic nerve the location of the fovea and some stuff that might be going on here. Okay. Yes. And let's just look at that with a little magnification. And I want you to look here. And this is a pretty good picture in this right eye of posterior pole vessels, keeping in mind we're looking for dilation and tortuosity. And this is our temporal retina here in this right eye. And there you go. So, what do you think's going on here and Yeah, so I would say zone one, it's very posterior. I would say at least stage three, I actually pulled it up on a laptop as to not embarrass myself again and for my junior team, but I I do see some fine muscles coming over I think that's probably stage three. And I would say that there is plus. Okay. And I think that this is well this is treatment requiring our OP. But you can see Lydia I've seen one patient with aggressive posterior when we were doing our rounds on my piece rotation and it looked just really angry that it's not just plus but the you can see how there's Venus and arterial just really I would probably I would call this call this aggressive posterior. Okay, and let's now patients with aggressive posterior p because it looks like this one is a little bit more hazy said something that you would see in clinical exam as well as such as this photograph. This could just be a bad photograph, but it turns out that smaller, more premature kids are often, you know, their vitreous is a bit more hazy. You could also have some blood in the vitreous. Now let's have the wizards. Let's look at this left eye. Okay, and the left eye we're going to look here and let's just magnify this a bit and take a look again, and you can see something going on right through here. Notice the distance from optic nerve to fovea, and where that is, and you see something going on here, and I agree Lydia the view is a bit hazy isn't it. Keep looking at this I, and, and there we are and and let's look up here, because I think that there's some other stuff going on here that is probably meaningful as well. Who wants to take this. I can do it. Sure. So this looks like it is zone one. I would probably call this stage three given the NV. Okay, this is definitely looks like plus disease to me. So be treatment requiring RLP but also a PRP. Let's see how we did. Wow. Wizards are good.  Yeah, this is now Lydia back to your question about this the thing that is most striking here when you look at this, even with magnification, you don't see that classic elevated neovascularization the need of magnification can be flat on the surface of the retina. And the way we were debating this when we first saw kids with this back in cryo rock we said, well gosh this kid doesn't look that bad, and they'd go down the tubes. These eyes can go south in a hurry. If you were in doubt about whether to treat this kid, you want to see this kid again in a day or two. But, but both of these eyes need to be treated, and they need to be treated soon, and the preferred treatment would be to do anti veget, because it is going to cause us to regress, and it's going to allow some persistent deterioration to occur. Whereas with laser, you're going to have to laser a whole lot of the eye these are eyes that can develop intersegment ischemia and bad things.  And unfortunately is what we learned from some of the patients we treated in cryo rock with very, very posterior ROP. Other questions comments about this patient because this is something I want you guys to remember, and it is that the dilation and tortuosity those vessels this is plus disease. And this is a patient when you see this that you need to push the panic buttons on, they need to be treated comments questions. And it makes a lot of sense now. Yeah, so you won't see classic knee vascularization, and it isn't going to be neat and tidy for you and let me go and we have now. Let's look here at this one and this one this is again an interesting patient and stars you guys are up whoever's up to bat, and we're going to look at this patient and this patient is a 630 gram kid who was born at 24 and a half weeks, now 37 weeks so in this case we're going to get ROP and need to do something territory.  This stuff right here. These here and let's I think if Tyler still busy it would be me again. Good. So we're going to look through these pictures. And this is your nasal retina in the right eye again, drawing your attention to this here. And this is just an answers in this we're going to loop around here so this is the. This is just your poll picture, looking at vessels. So we can come back here and look one more time nasally. And this is inferiorly superiorly. And we're looking out here temporarily. Here's optic nerve there's fovea. And so, what do you think what zone are we in. Zone to you got that I that would probably a reasonable thing based on what we've just seen, and what stage ROP do we have if any. We do have RP looking at it it looks like there is a rich just because I see these two lines with the line in between and you just got a little hazy but it looks like there are neovascularizations. So we're looking at so I would call it stage three. Okay, and less disease pre plus disease or, or no vessel dilation and tortuosity. That's a tough one when I'm looking at the vessels I think it's not as torturous as the previous one, but that one vessel that is kind of making the zigzag and the like close to the art and then inferiorly. Um, I'm going between yes and no so I wonder if I should call this pre plus. And is it none mild type two or treatment requiring. That would be I don't think it's treatment requiring. And if we call it pre plus we would go with type two. I think I agree with that just free with that and, and what about is this AP ROP. I guess I say no. Okay, and now, and it'll show up in a second. When do you want to see this kid again. I would see them closely just because of the, if I think it's pre plus disease and that would be a B or C. Yeah. Good job. Good job Lydia. No, it's not letting me do that. For whatever reason isn't that nice let's look at the other remember that and we'll see where it where it puts it and it'll probably make a select something before we can finish up now wizards left eye specialists here. This is a hazy picture. And we're looking at posterior vessels, but these are our posterior vessels and I mean his vessel look at this arterial our vessel. And we're going to keep going here and see if we see something down here. Let's look at this. Okay, and what are we. Is there something going on there, maybe and let's look here. There's nothing to be gained there and this is our again optic nerve. Our phobia is about here. And so we've got something going on out here let's magnify that take a look at it. And so let's go back there. And again left eye. And this is our fovea and we're noticing this stuff here. And who's going to tackle this for the wizards. I think it may have come back around to me. Okay. Zone two. Okay. Stage three. Yes, pre plus pre plus. So what does that make us type to. Okay. No, agree with the follow up. Okay, and let's go back to the right on see if it'll let us it did it, it did select things. It just didn't show them on my screen so let's submit this and see how we did. Well gosh darn those, those stars, they nailed it. Let's look here at the wizards and you guys did well with that too I think you guys are are have obviously paid attention to some of this RLP stuff. And I think it, you know this point I'm going to probably shift gears. What question now in terms of this, I think that you can go through this and I did wind up diverting accidentally to the hour there's an RLP tutorial on the AOA website as well and it that is definitely good and worth going through the cheat sheet that I put out has a list of pertinent issues that has to do with the stages type one type to plus disease definitions. And as opposed to conventional threshold and pre threshold which is a historical interest only type one type two or the way to go. The other issue, you know with this most recent iteration of I crop is, you know, they wanted to recognize that there are some kids particularly developing countries who are larger, who can have RLP that looks like aggressive RLP out in zone two, and be aware of that particularly if you're traveling and looking at infants and in foreign places. That's why they changed the name to aggressive RLP. I'm not sure it's going to make a big difference in what we're doing because most the kids here aggressive poster RLP is still going to be an appropriate term to use and considering things. Before we move on from RLP other questions issues concerns. Now, I'm going to stop the sharing for that. And we're going to go back to this, and I got to get back now to share screen, and we're going to want to do this share. And go back to this. There we are and now adventures and retinoblastoma. You guys still hear me okay. Yeah. Okay, good. Just and everybody's still awake. Anybody need less. Let's just stand up stretch wiggle. While I'm kind of getting started with this. As far as a review retinoblastoma I'm assuming that you've looked at the stuff in the talk that I provided and in both the Peds and the tumor book in the home study course. And I think that you're pretty much up to date as far as motor presentation realize the most common mode of presentation is Loco Korea, at least in the US. And to realize here, we usually see kids when our when RB is contained in the eye. When I am in Tanzania in two weeks. I will likely see at least one child with a fungating mass coming out of the head with very advanced RB, which is essentially in that environment and in ours, almost a death sentence for the child and that is what we're trying to prevent. And to save eyes and save lives. You've reviewed the genetics and hopefully know a bit about associated tumors, which unfortunately I have had considerable experience with. If you follow patients long enough either they are their affected parents get the associated tumors. So, my own thinking about this. First of all, do we have the right diagnosis secondly can we save life. First, can we save the eyes and what else to worry about and then future issues and future issues. A lot of things are really exciting on going. First of all is the development of this field of ocular oncology where we have people that specialize in this and offer all these high tech things such as intra arterial chemotherapy and intro vitrile chemotherapy, which don't take lightly because there's risk of spread of tumor outside the eye at a time when you have tumor in the vitreous and you're putting a needle there. So, those are really wonderful things this patient I saw on a trip to Ghana. And this child is no longer with us I mean this was a virtual death sentence in most environments and certainly in Ghana. In fact, they disappeared when the topic of doing an orbital exeneration and doing palliative care was brought up. I have a colleague in Surabaya Indonesia, who spends about three quarters of her time. She's an ocular oncologist, oculoplastic surgeon, a combo person, and she runs a palliative care unit for children with metastatic or extra ocular spread of retinoblastoma. And most of her patients don't live, but she makes their exit much more tolerable. Now, let's look at some patients to kind of put this in perspective in terms of issues going on here at some of these patients are from a long time ago, some are more recent. And this three year old girl had this right eye that showed up with a, you know, a problem and in looking at her in clinic she'd actually been seen by another ophthalmologist who told the family that the child had a retinal detachment in this eye and center to me saying I would be able to arrange to have it fixed because they didn't want to discuss the topic at hand and broach the fact that the child had a tumor in the eye. And so this was the right eye. I want you to notice this. Can you all see this. Yes. Okay, good. This large mass with blood vessels in it. This lighter stuff right here is calcium in the tumor that you can see clinically. What are these things right here. Seeds, seeds, those are vitreous seeds this is a large vitreous seed, and another view of that. And so that if we were to say let's go back to this patient and we're looking at this patient and the other is absolutely perfectly normal. When you see this patient. One of the first things that you want to do is do an exam on her anesthesia. It's never appropriate to give patients advice about treatment for retinal blastoma without doing an exam or anesthesia. When I took oral boards, one of the questions asked was just to sort out whether or not I would feel that I could make the diagnosis and offer treatment based on a clinical exam or we'd go to the or go to the or you need to look. And I prefer to have two examiners look at the entire surface of the retina. Looking at this, this eye with large tumor, overlying the optic nerve and massive seeding of the retina. What, what group, as far as the ABCDE classification, would you put this eye in. I would call it group D, because it has extensive vitreous seeding but it's not yet 50% of the globe that it's occupying, at least from the pictures from the picture that you're showing. And the other eye looks great and this actually was close to 50% of the globe, but I call that a D to E, you know, category and this was patient was seen before the days of intra arterial or intra vitriol chemotherapy. So this eye, what what other treatment modalities would you have that would be able to treat large tumors and vitreous seeds. Did you see into arterial. There's no this is before before anybody get done into arterial didn't exist yet. Your options would be a nucleation, external beam radiation, systemic chemotherapy, laser treatment. And, you know, to go through those is laser treatment going to help treat these seeds, or the size of tumor that we have here that's very elevated. No, no, not a chance. Would external beam of radiation, possibly treat the patient, possibly, but you'd have significant collateral damage, and, and almost no one would offer that as prime treatment now, because of the collateral damage to surrounding structures, and the risk of inducing, you know, radiation field tumors. And so what we offered this child and the family was, you know, I mean, the appropriate thing with this was through the eye was removed. And when you look at that. And this was strictly this was unilateral retinal blastoma with seeds, not bilateral not hereditary the genetic testing was negative. And this child went on to do perfectly well never had another issue with this. This was not a good seeing I to begin with. And for this family, it was the right decision, and they did well. If you have questions concerns comments on any of these. And we'll talk about it. This again is a child who's presenting finding was six months of strabismus, sent in by the pediatrician no family history. And this is the one being here in this I and this is the other I and this I left I was normal out to the aura Serata 360 degrees two different examiners. So we have this large posterior tumor in this I what are our treatment options here. I mean his story. Yeah. So you guys ever do chemotherapy for tumor reduction, and then followed by external beam radiation therapy, not usually external beam unless it doesn't respond to other modalities, but the idea of doing, let's say systemic treatment before, you know, inter arterial was done. I've done it and you'll see more of it here, where we've done chemo reduction, and then additional to get tumors to consolidate shrink, and then treat what's left, and we have this I am RT radiation treatment that our colleagues at Huntsman can do to try to avoid damage to other tissues, if we have something that isn't responding, as we would like, but that's very rare to use external beam radiation as a primary treatment for anything. But after chemo reduction is very common to use laser, sometimes even a plaque, radio therapy, and you know Eric Hansen is our kind of treatment specialist now and he's geared up to do intravitrile, intravitrile plaque, radio therapy. And so you'll see him in the course of your training probably doing all of those things and let's look. And I think that this just to spill the beans is how things looked after the rounds of increased in carboplatin etoposite. This is a seeing eye it doesn't have its vision, you know, in the 2200 range. No radiation and this child required virtually no laser, this tumor is completely regressed this is calcification. This is all flat dead tumor. This is an area where we had sub retinal fluid. This eye continues to look just like this many years later. The other I remain normal genetic testing showed this, you know, to not be a germline mutation. But again you always want to suspect it if you don't have tumor to look at. So you're looking specifically for specific deletion. I found that genetic testing is not as useful. Another patient. This patient's referred for bilateral retinoblastoma somebody actually told the parents what they thought they had which I appreciated very much. And this patient was sent up from St. George. I saw her on a Wednesday afternoon in clinic, did an exam center for an MRI scan which is something I always get before the EUA in part to try to get another way of looking at this and to look at the optic nerves and the wall of the eye for possible spread through the wall of the eye. And I got a panic call from the radiologist. And I want you to look at these photos and when you look at this, this patient was seen by a colleague of mine whose thoughts I always trust. And she saw this kind of fluffy gray mass here in the posterior pole in the right eye. And in you'll notice that there is another one here. There's a tiny one here. And when you look in the left eye, we see this kind of fluffy stringy stuff that looks like some early local seeds possibly.  And so panic call from the radiologist and what do you think the radiologist had had to say what what did the radiologist find a pineal gland tumor. That would be a very good guess and I was going down that same road. When I picked up the phone that's what I thought I was going to hear, but I also was a little suspicious about something else, based on the appearance of this lesion. It turns out when I saw the kid in clinic and heard about seizures and developmental delay. There is another disorder that can look like retinoblastoma that this child turned out to have. What's that T s. Yes, that is absolutely what she has she's got tuberous sclerosis. And these remember astrocytic hematomas and T s in infancy are often and you know as a toddler not calcified. And so we've got lesions all over here of T s and I can tell you that these lesions in this child look exactly the same. I followed her through childhood not that we had to do repetitive exams on her anesthesia and look at these. The reason we did exams on her anesthesia is she's on sabral by gabatron, which is the magic bullet for seizure control it's a known retinal toxin, and we were doing surveillance, looking for that toxicity, but keep in mind there's a long differential diagnosis, I would recommend that if you do your oral boards, you have a list of at least probably 15 things that could be on the list for RB, because somebody's going to ask you that.   Now, moving on. This is a little boy who showed up with a white reflex. And this kid caused me lots of stress and aggravation over the years and I still follow him now and he'll be followed by Eric Hansen. And that was the right I at presentation. Now these cysts are important, and that this, looking at this is very obviously from my perspective, retinoblastoma. It doesn't look like anything else. When you see these cystic changes, these changes are the changes of well differentiated retinoblastoma that often doesn't change much with treatment, but should have a pretty good prognosis, as long as it looks okay. But when we looked at his left eye. We saw this tumor and all of this debris and what are these white things here that are obstructing our view of the retina and these tiny little things. Anybody. There's seeds. So this left eye, the left eye. Lots of seeds active, you know, tumor in both eyes and I had a long phone conversation. The day evening I saw the kid with Carol Shields in Philadelphia. And Carol recommended that we go for six cycles have been Kristen Carboplatni toposide. And we did that. And the seeds looked a bit better, but still remained. And so I sent them off to Philly for intravitrile mouth land, which she gave him, and then sent him back to me for follow up. And about a week after he got back, I got a panic call from mom one night, very late, saying that this child was just an agony, could I see him the next day. This is another picture that I, and this is the picture when he came in for an urgent examiner anesthesia with this left eye that had been treated. And you notice he's got diffuse blood in the anterior chamber. We have no view posteriorly. And this was a blind painful eye that it had active tumor and seeds. I had a discussion with Carol and we decided to recommend take the eye out. When Nick looked at the eye in a path lab, everything in the eye, the retina, the tumors, the lens, the iris were in various states of decomposition, everything was necrotic. And they were not able to explain that Philly the nearest thing I could come to is that there probably been some sort of decimal point error in the mouth land dosing. And I suspect that he got probably 10 times the dose he was supposed to get, although no one was able to confirm that on the other end. They shook their heads and were not able to explain it. The plot thickens this child now has the right eye that didn't change much with the chemotherapy we did, but six months later has sheets of vitreous seeds. And these tumors that remained unchanged otherwise. And the question is what do we do now. Do you primarily a nucleotide design make the child bilaterally blind. Or do we do really the only treatment option we have it's good for vitreous seeds is intro vitro chemotherapy. And I sent him off to see a partner, rum super money and who was with us and then went to Louisville, and she did intro vitreal mouth land in this child's only seeing I, and the seeds left. And this is the appearance. These are changes left where he had all those seeds and some of the changes from the mouth land is somewhat toxic to the retina, even an inappropriate dose, but he remains tumor free, having very useful vision in this eye to this day. But that was a very, very difficult decision for me to work through to send him off for the treatment to be done in his only eye that destroyed his other eye. The decisions at times are difficult. Now, moving on, we've got another patient 16 month old boy leftisotropia comes in for examination. pediatrician saw something funny in the red reflex and wanted me to take a look urgently so instead of seeing him a month or two down the road we saw him about a day after the pediatrician saw him in Jackson. And this is the left eye with a large intraocular tumor and multitudes of sheets of vitreous seeds. And this is the retina detached. And this is the right eye. This is his better eye with these big dilated vessels, and a large intraocular tumor in the posterior pole, and multiple other tumors. The retina is what to do. And this poor little guy did have six cycles of chemotherapy subsequently had intra arterial chemotherapy in both eyes, intra vitriol treatment in the left eye, left eye that I with all the seeds was ultimately removed. The right eye is stable is seeing. And he is tumor free at present. So it often requires a juggling act of different modalities in terms of chemo reduction and additional treatment to get these kids taken care of. Another view of him. This is the most recent picture that I have that we took with our reticam here of his right eye with flat regressed tumor notice the yellow pigment in the macula. And these are just flat dead tumors. And so that's a safe view nasally that same eye. And one more here. This is this is a patient who has, again, large tumor in the right eye, vitreous seeds, and in this I he wound up with intra arterial chemotherapy in both eyes, lost the eye with that larger tumor. And this is post treatment of all of the seeds and everything and he's got a recurrent tumor that's just been treated with laser, but this I has a normal optic nerve macula and perfectly normal vision and is one remaining I. Those tumor. Other I completely regressed. And this other illustrate a little different topic you look at this I this guy was noted to have nystagmus and referred for evaluation. And we saw him in our clinic. And I looked in the right I said, Oh, this is bad. And then I looked at the left eye and said, Oh, this is worse. This child. The question is what to do, you know, in a nuclear both eyes the tumor looks very similar in the two eyes. And this is the appearance after six cycles have been christened carboplatin etoposide in both eyes. And this is completely regressed tumor. He's got vision in the 2200 range it's allowed him to function as a sighted child in school on he's done well. Now, let's go back up a couple of the things to touch on. When you see anyone with retinoblastoma in this day and age, you need to think about genetic testing, and you need to think about keeping them involved with oncology for future treatment, or a future follow up, because what is the risk. What is the risk of developing additional tumors. If you're talking let's say we're talking in clinic to a patient who's got bilateral retinoblastoma. Is there a quick way to think about it in terms of their risk of developing osteogenic sarcoma and other sarcoma is just based on their genetic makeup. Anybody are you still there. I think, I think if anybody who has retinoblastoma they have the tumors pressure gene mutation, and especially if they get x radiation therapy that increases the risk, the most common would be sarcomas. And based on Dave Abramson's paper which is probably the best on this out of the, you know, New York. Kids irradiated under a year of age, particularly under six months of age are particularly at risk for radiation field tumors. But the risk of distant tumors, not related to radiation, not directly related to treatment is about 1% per year. So by the time if I had bilateral germline, you know, mutation retinoblastoma, my risk of developing additional tumors goes by at my age, I would have a almost 70% risk per year of developing tumors. That's why you don't see a lot of very old patients. And I have personally had kids, parents die of secondary malignancies while I'm taking care of them. I have had older teenagers and young adults die of the consequences of either their sarcoma or treatment of it. And so I make a huge point of having the germline mutation kids followed up at least yearly in the oncology clinic, and they have a clinic for these are be survivors that they roll them into at Huntsman. The other issue to consider is the this issue and somebody mentioned earlier trilateral RV and trilateral the risk of that is mainly in early childhood trilateral RV is basically a peanut, you know, this primary neuroctodermal or primitive neuroctodermal tumor in the pineal that is share common tissues and development with retina. And it is a bad thing to develop most of the kids who develop it do not survive. And we look for it to try to treat it and identify it early and to, you know, shunt their hydrocephalus and try to deal with other issues are going to make the miserable, but it is a bad bad thing to develop. And so there was an overlap genetically between RB and neuroblastoma. I've had one patient who showed up while his sister was being treated after she had a bone marrow transplant, following treatment for neuroblastoma, and he had bilateral, you know, germline mutation, a retinal no one could find the exact I mean both of them are the abnormalities are due to suppressor gene abnormalities, but retinal blastoma remains fascinating, I would urge you to maintain an interest in it in one way shape or the other you'll probably encounter patients with it. And if you haven't it real interest in this talk to Dr. Hansen about being an ocular oncologist, maybe he'll start a fellowship. Now, going to shift gears that has been that I've encountered on tests is the malignant melanoma as well and I think the question I had is was what is the second most common tumor outside of the field of radiation. And I think it's important to know for us that the osteosarcoma is the most common one but then inside the field of radiation it's fibro sarcoma and outside it's mid lignin melanoma would you agree with that clinically. Yeah, no that's that's that's true. And the other question they might ask you that I might ask you if we're doing oral boards is what is the most common secondary malignancy during systemic chemotherapy for retinal blastoma. I don't know if I know that. It's AML, acute myelogenous leukemia. And that is a discussion that the oncologist have when they talk about treating, you know, parents, and I've had parents opt for a nucleation in a unilateral RB that would probably respond. This isn't the days prior to inter arterial chemotherapy, which you clearly do now, instead of systemic if you had the option in a unilateral case. And it looked like the eye was salvageable. But prior to that, we did a fair amount of systemic chemotherapy for unilateral RB if the eye looks salvageable with very good results, and I have not personally had a child develop. But it is a risk that is real that is identified in the oncologist talk about it now. This is something that all of you have had some role in in your, your training and hopefully you've had a chance to look through again, the talk and the material that I put out in those two books are sitting on Laura's bookshelf if you haven't looked at them, the photos in there. I took most of them. Some of them are okay, some of them are not so good. And years ago they were terrible because it was a handheld 35 millimeter film camera and a 20 doctor indirect lens that I use to take pictures. Now we talked about location distribution of hemorrhages associated findings sequelae and then long term things. This patient is the very first patient I saw as a resident with abusive head trauma and was taken just prior to this child becoming a multiple organ donor. He had been shaken and beaten by his father, who then came into the ICU at the University of Michigan, looking for me with a gun, because I was the one who had said that he'd abused his child. I'd actually said that the child was abused I didn't have any way of saying dad did it but I think his behavior caused him some trouble in the future court proceedings unfortunately a nurse ushered me out the back of the ICU. And I am here to tell you the story today and didn't get shot. This was taken through a four mirror lens again with a film camera at bedside. We didn't have to dilate the pupils they were fixed and dilated for us. This picture looks a lot different. And this picture is taken with a reticam the very first generation reticam and significant series you see hemorrhages of multiple layers. Superficial pre retinal, you know nerve fiber layer dot blot hemorrhages. There is a sub retinal hemorrhage under this part of the retina and the optic nerve is not particularly swollen. So if someone, the question always gets raised is this simply due to the increased intracranial pressure. And when we see hemorrhages that extend from the optic nerve of the aura Serata and multiple levels, barring extreme accidental head trauma. And there are case reports of things that look just like this with accidental head trauma, but those reports have involved a child that fell two stories on the concrete, a child that was involved in a crash on our two vehicles going 60 miles an hour head on car crash with a child was an unrestrained missile. And the third one is a child who climbed onto a large console television stand and pulled a very heavy television set over on his head and findings like this were present at autopsy, barring those cases which every defense attorney in the country that defends cases like this know intimately. This is highly suggestive of abusive head trauma. Another view. Again, this is a left eye, same patient very large pre retinal hemorrhage. One of the things I want you to remember about this is that these very superficial hemorrhages, the small pre retinal hemorrhages, those can leave very quickly in 24 hours, they can disappear. You'll been a bomb at shot published information about this. That is the reason for urgent consultation and for urgent photography to document things. Unless there are issues such as neurosurgical, you know instability, and they don't want us to dilate pupils. Another view the same patient. What is this. This is the optic nerve, the fovea is here. The pictures tilted a bit, mainly because I took it and I wasn't holding the darn camera straight. What is this white thing here is that stage two RLP. It is absolutely a circum-macular fold. And that is important because circum-macular folds again, apart from severe severe accidental head trauma have only been reported in abusive head trauma. So this is one of the things that would allow me to say even more strongly that this is most likely the changes are the result of abusive head trauma. Having said that, can we say that this is panthenomonic. This is absolutely child abuse. You cannot, you have to interpret things in the view of the clinical findings. Another view of a circum-macular fold. And again, for me, the fact that the optic nerves not particularly swollen is useful because it means that you can say fairly likely that the changes are not just because intracranial changes are reported. A close up similar view. And one of the questions that comes up is causation of the hemorrhages causation of the circum-macular folds. And this is a child who's got a circum-macular fold that has vitreous traction documented vitreous strands on OCT. The most plausible explanation for the etiology of this and a lot of it is supposition. There's not a lot of hard data is that there is, there are strong vitreous attachments between the internal limiting membrane of the retina and the vitreous. Where in a particular young child, the vitreous is more dense and more firm and less liquid over the posterior pole, over the vessels, causing traction on those areas. And this is evidence and I have used this paper in court educating attorneys and judges about abusive head trauma. And again, showing this patient to again give you an idea that we see these things, these are not, this is not a sinus septicemia. This is just the reflection off of this dome shaped pre-retinal hemorrhage in this patient. But these findings barring some other explanation are very suggestive, abusive head trauma. Other pictures that we have here and I'm going to flip through these. You can see patients like this where they have confluent retinal edema. The optic nerve is right here. This is part of a circum-macular fold and this is just eyes of mess. And one of the things I want you to take in looking here, this is optic nerve, this is a circum-macular fold here, large pre-retinal hemorrhage. And Lydia, the reason this picture is hazy, like back to the ROP things, when you're wondering about that is that there's blood in the vitreous. All you need is one of these pre-retinal hemorrhages to break through into the vitreous. You wind up with diffuse blood in the vitreous and the vitreous hemorrhage alone can limit vision, as well as the damage. So imagine the fine structural detail of the retina and it being essentially trashed with all of this swelling and traction on it. It's no wonder that we have sequelae. And this is a patient who this eye looks like this, this eye looks like this, and you say, well, gosh, the changes are only in one eye. How could that be? It turns out about 30 cases. The changes are unilateral, often on the side where you have a larger subdural. You can see changes where it's hard to identify retinal structures. This is a circum-macular fold and there's a very large amount of blood under the retina. This pre-macular retinose schesis or splitting, which is present in this patient, here's the edge of the schesis right here. Here's the fold. There's the optic nerve. And this patient probably, you know, 24 hours ago had a lot more hemorrhages. But if you see this, you don't see optic nerve swelling. If the child's ICP is probably not elevated, this can be all we see in an eye with abuse of head trauma. Now this patient, another example of the unilateral findings, right eye, this eye looked perfectly normal and I got a good look out to the aura serata, and this eye has these diffuse hemorrhages. This child, this was one where there was a confession. This child was, we know that this was abusive head trauma by shaking. You can see very large sub-retinal hemorrhages. You can see optic nerve swelling. Now what do we see at pathology? What do you think? What have you guys seen with Nick looking at these eyes? Have all of you seen eyes that have been removed and sent by the medical examiner? To the path lab and your path rotation? I'm not sure. I guess they ever have. Okay. Nick gets them, but they're probably few and far between. It turns out that he can corroborate the presence of hemorrhages in the retina when they look at the eye.  They don't have an autopsy at the children's hospital. They go to the medical examiner's office. And we, I usually ask the folks taking care of them last in the hospital here and our pathologist to request that the Emmys send the eyes to our eye path lab. It turns out that there are at least two things. These pair, you know, the intruscleral hemorrhages around the optic nerve and optic nerve sheath hemorrhages that you can't see clinically that Nick can find that have been found to be suggestive of abusive head trauma. There is a lot of debate when in discussion in court, when Nick has removed eyes and he's trying to talk about retinal hemorrhages, whether changes seen particularly the circu-macular folds are an artifact of fixation. And there are unfortunately a lot of our ophthalmology colleagues and a parcel of folks in the pathology arena that make their living off of providing expert testimony in these cases. There's an ophthalmologist in Colorado, whose letterhead on his office stationary. The first thing he lists is he is an expert witness in shaken baby cases. I find that a little hard to take personally and I would urge you not to follow that career trajectory. And now it's about sequelae of abusive head trauma. And this is something where the pediatric ophthalmologist, you know, I follow kids and I have seen, and I know some of you gotten calls where the person on the phone in the pick you says, each child isn't going to survive they need an eye exam now we drop everything we run we see the kid we take pictures and lo and behold they take them off life support and they survive. And some of those kids go on to live pretty miserable uncomfortable lives and we try to make it as good as possible. The things that are common threads for me are central or cortical visual impairment due to the brain injury, optic atrophy, both associated with axonal injury and increased ICP. And sub retinal neovascular membrane formation. Now this guy, who is alive is well is a married productive member society was shaken by his father, when he was six months old. And I was told that he wasn't going to live, we should come see him and we took pictures with the film camera, he had confluent retinal hemorrhages and edema everywhere and optic nerve swelling. And when all the dust settled, he developed these large raised lesions in the retina optic nerve power best corrected vision of 2200 in each eye. This is the other eye. I had Mike Teske see him at the time we did fluorescein angioscopy with him asleep in the operating room these are sub retinal neovascular membranes because of the location. This is before the days of VEGF treatment anti VEGF treatment for neovascularization and we watched it, and things have remained stable. This is an FA left eye and it's not progress things have been stable this and you know what a normal OCT looks like. This is his OCT right eye and left eye. And it isn't ever going to change or get better at this point. And I think that for me, you know this guy is is one of the kids that makes me think of all, I don't trust it when someone says they're going to pass away we drop everything and run and see them, but don't assume that the kids have gone on pass away because some of them will come back and you get to fall for a long time watch them grow up and, and he is about a plus eight hyper hope if we hadn't found that and put him in his glasses. He might not be seeing as well as he is, and he, you know, as a productive member of society, and as a happy guy with a number of kids, none of whom I have seen for abusive head trauma. What burning questions or issues do you have with with abuse of head trauma. Any questions that have come up problems that you've run into or concerns that you have. Hoffman I feel like you should write a book of all the encounters you've had, especially with that dad, I came into the human after you. Yeah, well, that was. I mean I had nurse grab me and she said there's a guy at the front desk with a gun. He's looking for you. You need to leave now. So, there was a back stairway at my children's hospital out of the, the ICU, and I went down it pretty quickly, and they had the security dudes come get them.  They all looked like ex members of the offensive line on the football team. And so they, they very effectively took care of it nobody got hurt in the process. But it's those are tough issues you know I think that these kids need thoughtful ongoing care, and in it and they need it at a time when they're usually in limbo socially you know they're often in the social services work, they may be in foster care, or with a relative. And it's so easy to lose track of them so we really try hard to keep track of these kids and, and keep them going I have one young lady who I still see she is probably Catherine I think she's older than you are, and she is at this point in a wheelchair. She's been cared for by her paternal grandparents, who have raised her from the time she was an infant, and she is very low functioning but they make her life as happy as possible. The real question is what's going to happen to that poor young lady when her grandparents pass away, because they are the only relatives she has that care, anything about her existence or happiness. That's that. On that cherry note. Unless I'm open any questions or issues in her I'm going to stop the sharing so we can kind of look at each other maybe questions concerns and I do apologize for doing this on zoom is you're already where I'm not the most facile with zoom. On the other hand, I didn't disconnect y'all. We did stay on for most of the time, and I haven't had anything bad playing in the background. But next time we'll do something similar to this, we do this again next year in, you know, in person, I am hopeful. Guys, are you guys all going to the meeting at Park City today. And I think some of us are going to clinic and then heading up after but thanks so much for having we really appreciate it. Now this is this is my pleasure and look if any of you have concerns about this.  I'm happy to talk through that with you and I think that, you know, our goal when you're on our service is to have you do exams once a week with one of us. So part of that learning process is getting a sense for how we sort these things out. And I think it'll be a lot, lot clearer to you, then, but you're you're worrying about the right things already, for which I'm very grateful. Have a wonderful day, good weekend, happy Valentine's Day to everybody. And stay healthy. See you guys. Happy birthday Catherine. Okay, is this your birthday. Yes, it is. Happy birthday to you. Well, I'll leave it at that because you don't want me saying anything. You guys have a have a great weekend and enjoy the meeting and I think Susan McDonald was up there. Somebody give her a hug for me. Okay. Perfect. See you guys.


What's up everyone? It's your girl Kenzie here from Layton Sports Cards and I'm ripping 2021 Top's Chrome Formula 1 Racing Sapphire edition 5 box break number 14 random teams. Again, here's a look at the random results. You can always find these at LaytonSportsCards.com underneath the results tab. Link is also in chat for you. Alright, here we go. Good luck again. Thank you so much for filling up the breaks tonight. We are all full. I will check personals after this. I think we should still be good to go.  We've got Future Stars, Misani, George Russell, George Russell, and a Disconnected of course. Latifi, we've got Orange of Zendeli for MP Motorsport. I'm at zero ping. That's out of 25. Rookie of Schumacher and Grand Prix Lewis Hamilton. Let's check if Caleb is out too. We're stopping. Corner. A Mazepin. Oh, it's back. Yeah, it's green again. That's weird. It's a second time I've found that. Well, it went to zero earlier, didn't it? Deleta, Future Stars, Grand Prix, Sergio Perez, Stroll. We've got a Daniel Ricciardo. Love the look of these ones. Out of 100. Thanks for subscribing, MN. Nice one there. A Lawson Future Stars and Grand Prix of Ricciardo. Draws Leclerc, Leclerc, Mazepin Rookie and Grand Prix of Lewis Hamilton. We've got Lewis Hamilton, Yellow to 199. Nice one there, Mercedes. Breeden Kaye on that. Beautiful Hamilton. Love the background with the forest wheel, forest wheel, and fireworks. Nice. Sants and Lewis Hamilton, Grand Prix. Packed box warm. Gasly, Latifi, Perez and Sato. Box two here. Gasly, Pia Stree, Sants and a Lewis Hamilton. Throwing his trophy up in the air. We've got, so tell me that's gold. Gold to 50. Lewis Hamilton. 338. Very nice. Wow. Gasly and Vassior. We'll bag that Hamilton for you for sure. Eddington, we've got Lewis Hamilton. Wow, we're on a roll here for you, Breeden. Again, this is going to be to 100. From Mercedes, 45 out of 100. All the platinum, I believe that is. Stroll and Betel. Formula One, Mercedes and G. We've got Stroll, George Russell and Leclerc. Conan, Future Stars of Poushari. Poushari. Poushari. George Russell and Ricciardo. We've got another Lewis Hamilton on the Platinum to 100 Grand Prix. On a roll with the Hamilton's here. We've got Rookie of Mick Schumacher and Grand Prix Lewis Hamilton. Lewis Hamilton. Beckman Wolf and a Nikita Mazepin Rookie. Mazepin. Pack box two. Poushari. We've got Leclerc on the yellow to 199. Nice Ferrari. Della Della Della and Grand Prix Sergio Perez. We're here. We're stopping. We've got Aqua George Russell. Williams Racing. Nice one there. Thomas Jay on that one. That is to 99. Nice George Russell. Noto and Betel. Gio Nazi. We've got Gold Rookie Yuki. Nice hit. Wow. That is William L. on the Gold Yuki 12 of 50. This is 358. Does that mean it's a variation? It could be. 338. That's a big one. Nice Gold Rookie. I believe that is. I remember someone saying they had their helmet on and it was like a close up. They thought it was a. Variation. Yeah. Vassur and a Votas. Wow. Future Stars. Vashor. Gross Gene. Betel. Gasly. Sony. Lewis Hamilton. Leclerc. Stroll. Petticoff. We've got a. The Ruvalla on the yellow for Red F2 Carlin. That is 156 of 199. Russell and Recchiardo. Latifi. Yellow Latifi. Nice one there. Williams Racing. To 199. 79 of 199. Lewis Hamilton and George Russell. Horner. We've got green of Remy Raconin. Nice one there. Alpha Romero. Anthony P. Haven't seen green yet today. It's 75 on that one. Beautiful green sapphire. Massapen Rookie and Schumacher Rookie. Packed Box 3. Stoppin. Perez and Wolf. Awesome. So the Hamilton negative. Lewis Hamilton. Lewis Helmet Negative. Let's get that one in a minute too. Awesome. Thank you. Thank you. I thought it was something to do with the Helmets. We have Lawson. Alonso. Lewis Hamilton and Massapen Rookie. Lewis Hamilton. Ocon. Sato and Sance. Sato Future Stars. You've got yellow Lance Stroll for Ashton Martin. Nice. To 199. 174. Shea and a Sergio Perez. That's 338. That's amazing. I thought that was a short print for a second too. Yeah. Braden is killing it with the Hamilton. Vips Future Stars. Gasly. Capito and Perez. It's crazy the market for these F1 cars. We're stopping. We've got a Future Stars of Viscale for F2 Tritids. Where's one there? Two Tritids. That is 66 out of 100. Beautiful hit there. Vettel and Alonso. I wish they made the variations easier to know. Yeah. Gasly. Drogovitch Future Stars. Alonso and Vettel. Lewis Hamilton. Ranconen. Gasly. And Leclerc. Last Packed Box 4. Staphen. Armstrong. Zendeli and Ricciardo. Last Box everybody. Sance. We've got a Beckman Future Stars Negative out of 100. 96 out of 100. Belvedaga and Perez. Vettel, Norris, Lawson Future Stars and Ricciardo. Mazepin. We've got Aqua of Ottmar for Ashton Martin. That's 2.99. Mazepin Rookie. Grand Prix Louis Hamilton. Nonini. Max Verstappen. Alonso and Capito. Roucher. Leclerc. Sands and Lewis Hamilton. Lewis Hamilton. Schumacher Rookie. Sergio Perez. We've got a Sergio Perez on the yellow to 1.99. Red Bull Racing. Sergio Perez and Wache. Last Packed Box and we will do a recap. Vettel. Votas. Vettel and Vettel. There's a Vettel pack there. 3 out of 4 cards. Peace. Alright, let's do a recap here. Again, Sergio Perez. Red Bull. The Brent Viscale on the F2 Trident Future Stars. Lance Stroll. Ashton Martin. Reconin for the Alpha Romero Green. George Russell for Williams Racing. Aqua. Charles Leclerc for Ferrari. Lewis Hamilton. Mercedes. Lewis Hamilton. Mercedes Yellow. Daniel Ricciardo of Rendalt DP World F1 Team. We had the Yuki Gold Rookie Short Print there. Beautiful hits for Alpha Tari. Yeah, that was a big hit there. Beautiful Yuki. We had the Short Print Lewis Hamilton negative to 100. Another hit there for Mercedes. And a Gold Lewis Hamilton again for Mercedes. Beautiful hit there out of 50. That'll do for everyone. Thanks again and we'll get these cards right out to you.


Hello everyone and welcome. This is Melissa Armo with a Stock Swoosh and I'd like to invite you to a free webinar that I'm doing this week. And I'm going to be talking about how you can make money trading momentum. That's really how you can profit in the market. You're looking for the momentum, you're spotting the momentum and then you're playing it. If you'd like more information, you can email me at Melissa at thestockswoosh.com or call me at 929-3200 Gap, follow me on Twitter, Facebook, YouTube or Skype. It's hard to believe but 2019 is halfway over. It really is and there's still plenty of time left in the year for you to achieve your financial goals. We're going to talk about how you can do that if you've been actively trading and haven't seen success so far this year for 2019, you still have time. But half the year is over. I wouldn't wait too long. You should know your goal. Which is what? Do you want to do this for a living or is this just a sign thing or is your goal to make $1,000 a week or $1,000 a day? I do think it's important to know what your ultimate objective is for doing this and also what your financial goals are as well. So I teach a class once a month. It's called the Golden Gap course and in that course I teach my method and my system. So you can learn that system and you can trade it on your own or you would be eligible then after you do the class as a Golden Gap course student then to sign up for the live trading room. In the live trading room I'm calling the trades, the entries, the stops and the exits live and there's also an options letter which I determine those trades based on the Golden Gap system as well or you can just sign up for the options letter. But everything I do is based on the system. Here was a trade back from earlier in June and let's even just go back to late May where this is Amazon. Amazon was falling, falling, falling, had this massive move down in here and it's based on the gap. So what is a gap? A gap is the difference between the close and the open. So Amazon closed here, open here. Amazon closed here, open here. So these were gap downs in Amazon. So again stocks can gap up and gap down. In this case here there was two gap downs in Amazon. So you would have bought puts or you could have day traded it short if you wanted to. It was very expensive. This was better as a put because of the cost. So anyways this is what I'm looking for each day and I'm looking for gaps. So the webinar which I'm going to talk about all the momentum and the trades we've been doing and some really good ones we've done lately. Adobe BYMD, it's going to be Wednesday, June 26th, 4.30pm Eastern Time. It's a free webinar in stock trading. You go here and you just sign up and register and you can have access. Again it begins at 4.30pm. Then I'm doing an open house on Friday and Friday, June 27th and 28th. Everyone that comes to the live webinar will be given access to the open house. No password. It's Thursday and Friday, 8.30pm to 10.30pm. The room opens. It's a free open house. You can come. You can sit in the room. I tell people if you're there just observe and then you'll get a feel for it to see if it's something that you think you want to learn more about and do and if you want to do the class. So again I teach a class once a month. It's called the Golden Gap Course. Class for July is July 13th and 14th from 9 to 5 Eastern Time. Cost of the class is 59.99 US Dollars. Class is online. You can be anywhere in the world and take it. Email me at Melissa at thestockswish.com if you would like to sign up. It has been a really good year and I'm looking to take this momentum myself after the break, after the July 4th break into the remainder of 2019 and close the year very, very strong. Have a great day everyone. Email me if you're interested in coming to the webinar. Go to the link and sign up. And if you'd like to come to the open house you're invited as well. Thanks.


Pow, what's up everybody once again it's Brandon and Shawn and today we're going over three reasons to release a single. At the end I'm going to compare singles to a high volume single strategy and even make a few recommendations which first let's get right into number one. The number one reason to release a single is basically just to create hype. Increase exposure. If you want to think about this as an artist because you don't have a fan base and you want to increase exposure and get more people to know about you, get some hype around you so people could start becoming fans or if you want to look at it from a standpoint of pre-game in a project where somebody releases a single and then they're creating hype for a project that's coming up all of it is just to create hype and awareness hype and awareness that simple nothing complicated and then you have number two which is extend the life of a single project so extending the life of a single with another single is typically a remix yeah people might do videos and other things to add on to extension but it's pretty much a remix and extending the life of a project looks like single after single after single on a project as a matter of fact Michael Jackson back in the days used to do like a year plus on one album sometimes just releasing single after single after single doing the single and video for the entire project and number three focus one of the primary differences between the high volume strategy and just a single by itself is when you just have one single you get to put a lot of focus and a lot of resources and energy behind that one single since you're focusing on it you're going to get the most out of it you'll probably create all this additional aesthetic around it so basically what number two and three on this list are about is really milking every single thing you can out of a project before you move on to something else perfect example of all three of these is how Fitty Wop did with Trap Queen I did entire video on that so I'm not gonna talk too much about it right here check it out and as he did many artists use this strategy when they want to get signed not necessarily in a penny but they just want to push you get the most results and most exposure out of it so then they can build enough fan base to leverage and get signed and as promised a few recommendations one thing I like for a lot of artists particularly if they haven't released anything at all or even if they're just new is a single a project and then another single to extend the life of the project and this is all so many people actually you know like what you're doing so what that might look as is drop a single just to start letting a few people who are immediately around you know that hey you're doing this but then going really serious on the project but I like to keep it super simple especially for new people or independent and doing it on their own so let's create say you create a five to seven song project you kind of put the project out you don't say anything about it but you push one song as a single you push one song as a single and that leads people back to everything else and you get exposure off of that but then at the same time you're watching behavior and seeing which other song people like the best and then you end up pushing that song as the second single and going hard on that and if you want to do three you know that's all up to you but that's just some general advice nothing sticks for everybody I would obviously have to know more particulars about people situations but that's just a nice framework to start off other than that you know what to do hit that subscribe button


It is truly my pleasure to join you for this 107th session of the Council of the International Organization for Migration. I would like to be in my contribution by celebrating the 65th year of successful leadership, which IOM has brought and continues to deliver to the field of migration. Furthermore, under the sure guidance of Director General William Lacy Swing, it is exciting and challenging to consider the new opportunities opening to IOM as an allied organization within the United Nations. My remarks today shall center on the importance of peace and well-being with the hope of stimulating further thought and reflection. Our aspirations to secure these values can only become a reality when they are built on a shared commitment among nations, to safeguard our fundamental human rights, the upholding of human dignity, and the promotion of a global social solidarity approach. This global social solidarity approach is portrayed in the full implementation of the United Nations' sustainable development goals, which were adopted by all countries within the United Nations last year. The international community must endeavor to implement these goals in all areas of social, economic, environmental, and cultural betterment, to create meaningful well-being and sustainable peace in our world for the benefit of all humanity. We must continue to compel our governments and all stakeholders to walk the talk. All our strategies must recognize the important link that exists between inclusive democratic societies and the culture of sustainable peace that must be built in our diverse communities and nations. However, as we all know, the expanding diversity of our global societies is being portrayed with growing hostility. This is truly alarming. Citizens in many countries are anxious about precarious economies and their experiences of growing inequality. In response, unscrupulous fear-mongers and populists are capitalizing on such unease, pointing the finger of blame at the migrant who is considered the newcomer, the stranger, the outsider. The threat of extremism and intolerance, even in what we believe to be the most secure democracies, is breathing a dangerous atmosphere of hatred and suspicion. In light of these troubling trends, the phenomenon of migration is an increasingly polarized topic in many of our countries and across our world. Unfortunately, words of reason are being displaced by anger even at the highest levels of governance. Complacency at this critical juncture in human history is dangerous. We cannot allow the substance of our human rights and the mandate of our covenants and conventions to be diluted. Governments must ensure that human rights are effectively and equitably accessible to each and every member of our societies, so as not to risk even more discontentment among the peoples of the world. Such an approach would be of long-term benefit to address discord, exclusion and the risk of radicalization. As I see it, two parts are opening up for us. One leads deeper into alienation and despair, back to a past we thought we had outgrown. The other leads us forward with a message of hope. The violence that is becoming more frequent and bolder in our societies is only held back by the hard work of passionate people like yourselves, individuals and groups who uphold respect and peace. The international community has had a number of opportunities to come together and develop strategies to move from words to action. However, it seems to me that still very little is being done. The New York Declaration for Refugees and Migrants acknowledges that the multidimensional reality of migration must include collaboration across countries of origin, transit and destination. Furthermore, the Declaration explicitly links these concerns with the remit of the 2030 agenda and its sustainable development goals. Other important proposals were agreed upon during the Valletta summit on migration held in Malta last year. The summit brought together stakeholders from Africa and European countries of origin, transit and destination. Present around one table to create a unified roadmap for the future. Key outcomes included the need to prioritize more investment in highly affected countries, linking the global north and south, while also creating a holistic, collaborative approach to internal and external migration. The most recent joint statement from 78 organizations, including IOM, entitled Children Cannot Wait, Seven Priority Actions to Protect our Refugees and Migrant Children, urges European Union leadership to act immediately in cooperation with civil society in seven priority areas to safeguard refugee and migrant children in their comprehensive needs. World organizations, like IOM, have the duty to remind and assert that governments live up to their responsibilities. We must work together to advocate for an approach that values the well-being of each and every member of our societies and communities. All the work that IOM has done must serve as an encouragement to move further, to do more, to change the unfolding situation for the better. I come from Malta, a nation in the center of the Mediterranean Sea. I am living proof of the strength that comes from the diversity of cultures and the movement of peoples connected across regions. This diversity is a source of my identity and the driving force of resilience and well-being in my life. Human migration is a global phenomenon that no organization or nation is equipped to deal with alone. In particularly, the Mediterranean remains the primary access spot for migrants coming from very serious of the African continent. According to recent data presented by Federico Soda, I think he's somewhere here, director of IOM Coordination Office for the Mediterranean. Some 90 percent of migrants attempting to traverse the sea leave from Libya. Moreover, at the Valletta Summit, former president of the European Parliament, Martin Schultz, said, and I quote, the Mediterranean is the most dangerous route. It is heartbreaking to recognize that this route is also responsible for the largest number of reported fatalities. UNHCR reports that over 347,000 have already crossed the Mediterranean this year. Of these arrivals, 58 percent come from the world's top 10 refugee countries of origin. According to data from IOM, for 2016, over 4,600 people have been reported dead or missing in the region. In light of these facts, we must respond even more passionately to the arguments of those individuals who profess that walls and fences are the only way to deal with growing numbers of vulnerable people. It is with the goal of finding sustainable responses that my foundation for the well-being of society in Malta has facilitated a refugee-led NGO platform. It has created a space of empowerment for asylum-seeking groups and communities across Malta. Through this platform, we are better able to address issues of well-being within these communities and bring their concerns to the attention of the relevant authorities and the public at large. My foundation also assisted in the launch last year of a publication produced by the Jesuit Refugee Services of Malta. The book recounts the experiences of six Somali women who are seeking asylum in Malta. One Somali refugee said, and I quote, In my country, my rights were violated. My life was not mine, but dictated by someone else. If I am to be respected, first, I need to be free, free from the bars surrounding me, free from being controlled by someone else, free to run my life, unquote. Earlier this year, I was also invited to launch the autobiography of a young Somali transgender woman. This unaccompanied child had fled in fear for her life due to the discrimination and threats of violence she faced as a result of her gender identity. I quote, Little did I know that the gates of hell were now wide open. We parted ways with the smugglers from the desert, who handed us over to Libyan smugglers, who now would help us to get to the Libyan capital of Tripoli. They were more ruthless than their counterparts. This became evident when they showed us a torture chamber where people who refused to pay them would be served their punishment, unquote. Her story is both a harrowing reminder of the struggles faced by minority groups around the world and the testament to the courage of the human spirit. I am pleased that in Malta, she was able to publicly celebrate the fullness of her identity and recognition of her fundamental right to self-determination. The resilience of such individuals is an encouragement for us to keep pushing against the agendas of rabble-rousers who are riding waves of hostile populism. Furthermore, the suffering of refugee women is inevitably connected to the suffering of children who are often at greatest risk of social exclusion. During my time as Minister for the Family and Social Solidarity, I worked to ensure that the detention of unaccompanied asylum-seeking children was ended and that families were kept together. IOM, working hand-in-hand with UNHCR, were essential collaborators in making these changes possible. A technical report facilitated by my foundation made it clear that united in purpose, your organizations have the power to create meaningful improvements in policies, protocols and services which directly affect people's lives. Earlier this year, I was confronted by the massive need for essential services on a recent visit to Al-Zatari refugee camp in Jordan. As you all probably know, Al-Zatari camp has a population of over 80,000 refugees which is predominantly made up of children and young people. Indeed, some 57% of the camp's population is under 18 years of age. Families in the camp are struggling to achieve some semblance of normality. While these families are living under the burden of uncertainty, even though Jordan, as the host country goes out of its way to support, the international community can do much more to make real progress to better the lives of all the innocent victims of war. I saw with my own eyes the lack of even the most basic resources. If food, water and the appropriate sanitation are lacking, what does that say about access to education and processes of justice? The international community must not allow a generation of people to be abundant, lost in an environment of unrest and open to the threat of radicalization. The sense of exclusion being created in Europe and the suffering being created in these camps will result in a lost generation of children and young people. I fear that their disillusionment will leave them particularly vulnerable with potentially devastating repercussions. I would like to reiterate the need for governments and authorities and international organizations to assert the importance of human rights at every opportunity. It is by witnessing the struggles of such families, risking all to cross the Mediterranean in search of a better life for themselves, that I was, myself changed. Allow me to share another of my experiences with you. When I was minister, I met a seven-year-old Syrian boy named Muhammad, who was a survivor who had seen his entire family drown in the Mediterranean in October 2013. The child was saved by a 30-year-old Syrian man who might have drowned himself, but did all he could to save Muhammad's life. Due to the severity of his trauma, the little boy was unable to speak. After an intensive social media campaign, the boy was identified by his paternal uncle, thanks to the assistance of Red Cross Moulta and IOM Moulta.  Much of IOM's work focuses on reunification, and I am glad to know that representatives from IOM shall be present at the upcoming international conference entitled Lost in Migration, working together to protect children from disappearance to be held in Moulta next month. According to UNHCR data, more than a third of migrants have arrived in Europe since January 2016 have been children. These include unaccompanied children whose first-hand experiences shall be shared by young people during the conference. Missing children in Europe, alongside my foundation for the well-being of society, will bring together key stakeholders with the hope to develop a forward-looking action plan which shall protect children in migration and improve coordination among stakeholders. In Moulta, we have experienced the fruits of IOM's hard work. Let us now work together to be stronger than ever in response to an increasingly aggressive and hostile politics of populist division. The fundamental well-being of our peoples must be a top priority for policymakers around the world. If all of our communities feel secure, are listened to, and are respected, then we shall reduce the unhappiness, anxiety and tension which are being manipulated by the amagogues. This is the way to address the roots of political extremism. This is the way we prevent extremism from spreading throughout communities and nations. If we do not prevent political extremism from spreading, I fear there shall be terrible and far-reaching effects with refugees and migrants bearing the brunt of this growing anger and disillusionment. Moulta recognises that we must act to implement effective and efficient measures which acknowledge the concerns of individuals and communities in Europe and uphold the human dignity of migrants and refugees. Moulta's upcoming presidency of the Council also presents an opportunity to practically implement the outcomes of the Valletta Summit which include tackling public perceptions, effective investment in countries of origins and attitudes in transit and destination countries. In conclusion, let us recognise the empowerment at community level that sows the seeds for a transformation that shall embrace into our nations. Let us strive together to build a democratic culture of solidarity which we shall be proud to hand down to our future generations. I refuse to accept that this period of anxious uncertainty will define our future. I have too much faith in humanity. However, the international community needs to move from words to action. It is up to each and every one of us to walk this journey together, united in pursuit of peace and led by our ethical commitment to the well-being of all humanity. Thank you.