Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Sunday, July 22, 2018

10 Common Negative Thinking Patterns and How You Can Change Them

You are going to need to know this to stop your rumination about the disaster of your stroke. But you can't listen to me because I'm not medically trained. Are you getting something like this from your doctor since you are getting NO protocols to get you 100% recovered?
From the Best Brain Possible with Debbie Hampton

10 Common Negative Thinking Patterns and How You Can Change Them

Ultrasound Could Help Improve Dementia Symptoms

Mouse models, so you'll have to see if your doctor contacts these researchers doing human testing. You will need this;

Your chances of getting dementia.

1. A documented 33% dementia chance post-stroke from an Australian study?   May 2012.
2. Then this study came out and seems to have a range from 17-66%. December 2013.
3. A 20% chance in this research.   July 2013.


Ultrasound Could Help Improve Dementia Symptoms



 
 Summary: Researchers report applying ultrasound to the whole brain improves cognitive dysfunction in mouse models of dementia. A clinical trial is currently underway to test the effectiveness in humans with the neurodegenerative disease.
Source: Tohoku University.
Ultrasound waves applied to the whole brain improve cognitive dysfunction in mice with conditions simulating vascular dementia and Alzheimer’s disease. The research, conducted by scientists at Tohoku University in Japan, suggests that this type of therapy may also benefit humans.
The team, led by cardiologist Hiroaki Shimokawa, found that applying low-intensity pulsed ultrasound (LIPUS) to the whole brain of the mice improved blood vessel formation and nerve cell regeneration without having obvious side effects.
“The LIPUS therapy is a non-invasive physiotherapy that could apply to high-risk elderly patients without the need for surgery or anaesthesia, and could be used repeatedly,” says Shimokawa.
Dementia affects about 50 million people worldwide, with 10 million new cases occurring every year. But there are currently no curative treatments available for vascular dementia or Alzheimer’s disease, the most common causes of dementia. Also, the cells lining the brain’s blood vessels are tightly packed, forming a blood-brain barrier that prevents large molecules from crossing into the brain tissue. This limits the types of drugs and cell therapies that could be made available to treat dementia.

This is the LIPUS treatment system. NeuroscienceNews.com image is credited to Hiroaki Shimokawa.
Shimokawa and his team had conducted previous studies showing that LIPUS improved blood vessel formation in pigs with myocardial ischemia, a condition where there is reduced blood flow to the heart. Other studies have reported that LIPUS increases the production of proteins involved in nerve cell survival and growth, in addition to a role in promoting nerve regeneration. Focusing LIPUS treatment on a region in the brain called the hippocampus, which is involved in memory, has also been found to improve dementia in mice, but the details of how it does this need to be more fully investigated.
The Tohoku University team wanted to find out if whole-brain rather than focused LIPUS is effective in treating mouse models of dementia, and if it was, what was happening at the molecular levels to achieve this.
They found that cognitive impairment markedly improved in mice with conditions similar to vascular dementia and Alzheimer’s disease when LIPUS was applied to the whole brain three times a day for 20 minutes each time. The mice with vascular dementia received the treatment on the first, third and fifth days following a surgical procedure that limited the brain’s blood supply. The mice with a condition simulating Alzheimer’s disease in humans received 11 LIPUS treatments over a period of three months.
At the molecular level, genes related to the cells lining blood vessels were turned on. Also, there was increased expression of an enzyme involved in blood vessel formation and a protein involved in nerve cell survival and growth.
The researchers conclude that their study, recently published in the journal Brain Stimulation, provides the first experimental evidence that whole-brain LIPUS therapy markedly improves cognitive dysfunctions without serious side effects by enhancing specific cells related to dementia’s pathology.
The first clinical trials to evaluate the effectiveness and safety of the LIPUS treatment are already underway.
About this neuroscience research article
Funding: Funding provided by Japan Agency for Medical Research and Development.
Source: Hiroaki Shimokawa – Tohoku University
Publisher: Organized by NeuroscienceNews.com.
Image Source: NeuroscienceNews.com image is credited to Hiroaki Shimokawa.
Original Research: Open access research for “Whole-brain low-intensity pulsed ultrasound therapy markedly improves cognitive dysfunctions in mouse models of dementia – Crucial roles of endothelial nitric oxide synthase” by Kumiko Eguchi, Tomohiko Shindo, Kenta Ito, Tsuyoshi Ogata, Ryo Kurosawa, Yuta Kagaya, Yuto Monma, Sadamitsu Ichijo, Sachie Kasukabe, Satoshi Miyata, Takeo Yoshikawa, Kazuhiko Yanai, Hirofumi Taki, Hiroshi Kanai, Noriko Osumi, and Hiroaki Shimokawa in Brain Stimulation. Published May 21 2018.
doi:10.1016/j.brs.2018.05.012

Focused ultrasound combined with microbubble-mediated intranasal delivery of gold nanoclusters to the brain

For whenever we do have drugs that need to be delivered to the brain. Assuming our researchers read other research. 
https://www.ncbi.nlm.nih.gov/pubmed/30009893

Abstract

Focused ultrasound combined with microbubble-mediated intranasal delivery (FUSIN) is a new brain drug delivery technique. FUSIN utilizes the nasal route for direct nose-to-brain drug administration, thereby bypassing the blood-brain barrier (BBB) and minimizing systemic exposure. It also uses FUS-induced microbubble cavitation to enhance transport of intranasally (IN) administered agents to the FUS-targeted brain location. Previous studies have provided proof-of-concept data showing the feasibility of FUSIN to deliver dextran and the brain-derived neurotrophic factor to the caudate putamen of mouse brains. The objective of this study was to evaluate the biodistribution of IN administered gold nanoclusters (AuNCs) and assess the feasibility and short-term safety of FUSIN for the delivery of AuNCs to the brainstem. Three experiments were performed. First, the whole-body biodistribution of IN administered 64Cu-alloyed AuNCs (64Cu-AuNCs) was assessed using in vivo positron emission tomography/computed tomography (PET/CT) and verified with ex vivo gamma counting. Control mice were intravenously (IV) injected with the 64Cu-AuNCs. Second, 64Cu-AuNCs and Texas red-labeled AuNCs (TR-AuNCs) were used separately to evaluate FUSIN delivery outcome in the brain. 64Cu-AuNCs or TR-AuNCs were administered to mice through the nasal route, followed by FUS sonication at the brainstem in the presence of systemically injected microbubbles. The spatial distribution of 64Cu-AuNCs and TR-AuNCs were examined by autoradiography and fluorescence microscopy of ex vivo brain slices, respectively. Third, histological analysis was performed to evaluate any potential histological damage to the nose and brain after FUSIN treatment. The experimental results revealed that IN administration induced significantly lower 64Cu-AuNCs accumulation in the blood, lungs, liver, spleen, kidney, and heart compared with IV injection. FUSIN enhanced the delivery of 64Cu-AuNCs and TR-AuNCs at the FUS-targeted brain region compared with IN delivery alone. No histological-level tissue damage was detected in the nose, trigeminal nerve, and brain. These results suggest that FUSIN is a promising technique for noninvasive, spatially targeted, and safe delivery of nanoparticles to the brain with minimal systemic exposure.

KEYWORDS:

Blood-brain barrier; Brain drug delivery; Brainstem; Focused ultrasound; Intranasal delivery; Nanoparticle; Positron emission tomography
PMID:
30009893
DOI:
10.1016/j.jconrel.2018.07.020

Effectiveness of wearable upper limb assistive devices in hemiparesis for improvement of functional abilities: A systematic review

Fuck, research that says we need further research. My god, the complete stroke universe needs to be fired.  I would never support these researchers again.
https://www.sciencedirect.com/science/article/pii/S187706571831217X



Introduction/Background

Assess short-term benefits of wearable devices in activities of daily living (ADLs) and functional tasks, for people suffering from upper-limb impairment due to acquired brain injuries (ABI).

Material and method

Two independent reviewers conducted a systematic review across Cochrane Database of Clinical Trials, Medline, Web Of Science, PEDro, OT-Seeker and Open Grey databases until November 2017, identifying citations in included studies and systematic reviews. Inclusion criteria included: adults with hemiparesis due to all causes of ABI; wearable devices such as orthosis, prosthesis, exoskeleton, electrical stimulation devices, neuroprosthetics; use of functional outcome measures assessing ADLs and functional tasks with and without device. Methodological quality of articles was assessed according to the Joanna Brigs Institute (JBI) scale for case series.

Results

From 1452 titles initially selected, eleven studies were finally selected (n = 95 participants), all focusing on post-stroke hemiparesis. Nine were self-controlled case-series and two were single-case reports. Six studies described functional electrical stimulation devices, three described use of exoskeletons and two passive devices. Command of the nine active devices included electromyography, kinematic data, push-button, inertial unit measurement and force sensors. Quality assessment using JBI Scale found low quality evidence of all studies with heterogeneity of outcomes. One of the two studies describing passive assistive devices demonstrated significant improvement in the size of block lifted during the box and block test (BBT). Only one of the three studies using exoskeleton found significant improvement in the BBT and various functional tasks. Four of the six neuroprosthetics studies found moderate to significant improvement across outcomes.

Conclusion

Considering high heterogeneity of studied assistive devices, small samples sizes and study designs implicating insufficient high quality evidence, it is not possible to either support or reject the use of assistive devices on the ABI population. Further research is needed to investigate the use of these devices on functional outcomes.

O 091 - A new method for computing gait deviation scores in hemiparesis

Absolutely worthless crap. NOTHING  here is a protocol to get you recovered.  Classification instead of intervention protocols.
https://www.gaitposture.com/article/S0966-6362(18)30883-X/abstract


The Gait Deviation Index (GDI) [1] and the Gait Profile Score [2] are two widely used scores for classification in clinical gait analysis. The principle of these scores is to compute the distance of time-normalized kinematic data to a standard, without considering phase and temporal information. Longer stance phases, greater on the unaffected limb, are common compensations in post-stroke hemiparetic gait [3], where paradoxically theses gait scores are often "better" for the affected limb. The objective of this work is to propose a method for computing these scores in order to make them invariant to temporal compensations, especially to stance phase extension.

To access this article, please choose from the options below

Saturday, July 21, 2018

Good news for heavy coffee drinkers

I brew and drink 9 cups of coffee a day, in my mug that is only 3 fillups, then there is the 20 oz. of cold coffee I drink getting in my 10,000 steps for the day for rehydration purposes. I think I'm covered in the heavy drinker category.  Of course if you can afford to drink this much coffee you can afford healthier foods. Also, if you have time to drink this much coffee you probably are working in a safe white collar job.
https://www.mdlinx.com/internal-medicine/top-medical-news/article/2018/07/02/7526818/?
Healthline/Medical News Today | July 02, 2018
Although coffee in moderation is widely considered to be good for our health, questions remain—such as what about people who are sensitive to caffeine or who drink large quantities? A new study investigates.
Coffee is among the most commonly consumed beverages on earth.
Because of its popularity, it has attracted a great deal of research over the years.
After all, something that permeates society so thoroughly must be studied for its pros and cons.
Scientists have now stacked up a fair amount of evidence proving that coffee, when consumed in moderation, can protect against certain diseases and may even extend life span.
Studies have now shown that moderate coffee consumption might protect against cardiovascular disease, diabetes, and Parkinson's disease, to name but three.

Gaps in our knowledge

But the findings to date leave some unanswered questions. For instance, "moderate consumption"—which usually means three to five cups per day—depending on the study, seems to be of benefit, but many people drink six or more cups each day.
So, do they still enjoy coffee's protective powers?
Also, certain people have genetic variations that alter the way in which they metabolize, or break down, caffeine. How are these individuals affected? Similarly, does the type of coffee—ground, instant, or decaffeinated—make a difference to health outcomes?
Other studies have attempted to answer the questions above, but, because fewer people fall into these categories, it has been difficult to make robust conclusions from the available data.
Recently, researchers at the National Cancer Institute (NCI) in Rockville and the National Institutes of Health (NIH) in Bethesda, both in Maryland, set out to get some answers.
Their work, which includes the data of more than half a million people in the United Kingdom, is published today in JAMA Internal Medicine.

Reopening the coffee question

The scientists found that, as predicted, coffee drinkers had a lower risk of death over the course of the follow-up. They also found that this reduction in risk extended to people who drank eight or more cups each day.
It also affected people who metabolize caffeine slower or faster than normal, and it worked across all coffee types (although the benefits were slightly less pronounced for instant coffee).
The fact that individuals who process caffeine differently and those who drink decaffeinated coffee also saw benefits hints that caffeine is not the main player in this beneficial relationship. Coffee consists of hundreds of different chemicals, making this a tricky code to crack.
One group of chemicals that scientists have been interested in is polyphenols, which are found in reduced levels in instant coffee. Much more work will be needed to understand how they fit into the bigger picture, though.
The new study is based on observational data, but because of the large number of participants used, the authors conclude:
"[T]hese results provide further evidence that coffee drinking can be part of a healthy diet and may provide reassurance to those who drink coffee and enjoy it."
With its unwavering popularity, research into coffee is guaranteed to continue. The authors hope that future studies focus more on how the preparation of coffee influences health outcomes.
For now, it seems firmly established that coffee has a raft of health benefits.
To read more, click here.

Exercising in Polluted Air Still Protects the Heart

You'll have to ask your doctor to analyze and confirm the pros and cons of living and exercising near polluted air. You do expect her to know the answer? She does have medical training, doesn't she?

Study Shows Air Pollution Makes Genetic Changes in the Brain June 1018

 

Effect of Exhaust- and Nonexhaust-Related Components of Particulate Matter on Long-Term Survival After Stroke November 2016 

 

The Lancet Neurology: For the first time, air pollution emerges as a leading risk factor for stroke worldwide June 2016 

 

Loss of brain tissue in older women may be linked to air pollution July 2015


Exercising in Polluted Air Still Protects the Heart 

Friday, July 20, 2018

Omega-3 fats show minimal effect on CV health, mortality

Impossible to tell if this is true. Supplements have no guarantee of purity. What do you expect when the fucking stupidity of the US Congress passes the Dietary Supplement Health and Education Act of 1994 (DSHEA): (DSHEA) defined dietary supplements as a category of food, which put them under different regulations than drugs.
https://www.healio.com/cardiology/chd-prevention/news/online/%7Bd2cdda40-416c-48ce-9aee-86e978451ac9%7D/omega-3-fats-show-minimal-effect-on-cv-health-mortality?
An increased intake of eicosapentaenoic acid and docosahexaenoic acid from omega-3 fats had minimal or no effect on CV health or mortality, according to a review published in the Cochrane Library.
“We can be confident in the findings of this review, which go against the popular belief that long-chain omega-3 supplements protect the heart,” Lee Hooper, PhD, reader in research synthesis, nutrition and hydration at University of East Anglia Norwich Medical School in the United Kingdom, said in a press release. “This large systematic review included information from many thousands of people over long periods. Despite all this information, we don’t see protective effects.”
Asmaa S. Abdelhamid, MD, MSc, research fellow at University of East Anglia Norwich Medical School, and colleagues analyzed data of 112,059 participants from 79 randomized controlled trials that compared the effects of an increase in long-chain omega-3 and alpha-linolenic acid intake with usual or lower intake. Trials included in this review lasted for at least 12 months.
Increased intake of long-chain omega-3 had little to no effect on CV mortality (RR = 0.95; 95% CI, 0.87-1.03), all-cause mortality (RR = 0.98; 95% CI, 0.9-1.03), CHD mortality (RR = 0.93; 95% CI, 0.79-1.09) and CV events (RR = 0.99; 95% CI, 0.94-1.04). It also had minimal or no effect on the risk for arrhythmia (RR = 0.97; 95% CI, 0.9-1.05) and stroke (RR = 1.06; 95% CI, 0.96-1.16).
Long-chain omega-3 reduced the risk for CHD events (RR = 0.93; 95% CI, 0.88-0.97), although this effect was not seen in sensitivity analyses.
An increased intake in alpha-linolenic acid had a minimal effect on CV mortality (RR = 0.96; 95% CI, 0.74-1.25), all-cause mortality (RR = 1.01; 95% CI, 0.84-1.2) and CHD events (RR = 1; 95% CI, 0.8-1.22). A slight reduction in the risk for CV events was seen with increased intake of alpha-linolenic acid (RR = 0.95; 95% CI, 0.83-1.07), and it has the potential to reduce the risk for CHD mortality (RR = 0.95; 95% CI, 0.72-1.26) and arrhythmia (RR = 0.79; 95% CI, 0.57-1.1). The effect it had on stroke was unclear.
“There are several large ongoing trials of supplemental long-chain omega-3 fats,” Abdelhamid and colleagues wrote. “We suggest that given the lack of convincing effects suggested for omega-3 fats in the large number of trials to date, no further trials should be initiated until the ongoing trials have reports. Further large and high-quality trials of [alpha-linolenic acid] carried out in lower and higher income countries and that assess baseline [alpha-linolenic acid] intake and use biomarkers to assess compliance would be helpful to clarify the cardiovascular effects of [alpha-linolenic acid].” – by Darlene Dobkowski

Muscle fitness is strongly associated with improved rate of ageing in the brain

Research will have to be repeated for stroke survivors since these were healthy female twins.  I don't know what my leg power is right now since I'm not going to a gym, but when I was it was pretty substantial, even my left leg.
https://www.news-medical.net/news/20180720/Muscle-fitness-is-strongly-associated-with-improved-rate-of-ageing-in-the-brain.aspx
Researchers at King's College London have found that muscle fitness as measured by power in the legs is strongly associated with an improved rate of ageing in the brain.
The findings, published in Gerontology, suggest that simple interventions, such as increased levels of walking, targeted to improve leg power in the long term may have an impact on healthy cognitive ageing. The research was funded jointly by the NIHR and the Wellcome Trust.
Scientists studied a sample of 324 healthy female twins from the TwinsUK volunteer registry over a ten-year period from 1999, measuring various health and lifestyle predictors. Researchers were, therefore, able to control for genetic factors affecting changes in cognitive function.
Thinking, learning and memory were measured at both the beginning and end of the study and it was found that leg power was a better predictor of cognitive change than any other lifestyle factors tested. Generally, the twin who had more leg power at the start of the study sustained their cognition better and had fewer brain changes associated with ageing measured after ten years.
Previous studies have shown that physical activity can have a beneficial effect on the ageing of the brain with animal studies showing that exercising muscles releases hormones that can encourage nerve cells to grow.
The study is thought to be the first that shows a specific link between power (i.e. force and speed) in the lower limbs and cognitive change in a normal, healthy population. As the legs contain the largest muscles they are of particular relevance for muscular fitness and can be exercised easily through various habitual activities such as simply standing or walking.
Brain changes in identical twins discordant for Leg Explosive Power: stronger twin
Dr Claire Steves, lead author and Senior Lecturer in Twin Research at King's College London and King's College Hospital said: 'Everyone wants to know how best to keep their brain fit as they age. Identical twins are a useful comparison, as they share many factors, such as genetics and early life, which we can't change in adulthood.
'It's compelling to see such differences in cognition and brain structure in identical twins, who had different leg power ten years before. It suggests that simple lifestyle changes to boost our physical activity may help to keep us both mentally and physically healthy.'
Brain changes in identical twins discordant for Leg Explosive Power: weaker twin
However, more studies are needed to better understand the relationships between measures of fitness such as leg power or aerobic capacity and brain changes, and the specific cause-and-effect of physical activity on brain structure and cognition. The mechanisms behind this association are not yet clear and could involve other factors such as age-related changes in immune function, blood circulation or nerve signaling.
The study only assessed female participants with an average age at baseline of 55 (range 43–73), so further studies would also be needed to establish whether these findings can be generalized to older or male populations.

Ekso vest to help lift your arms overhead

When standing I can get my left arm maybe to shoulder height. If I'm laying flat on my back I can get it up over my head. This vest provides 5-15 lbs. of lift assistance. I could easily see this helping stroke survivors, but no one in charge will do one damn thing about it. Your stroke hospital doesn't have enough brainpower to identify anything that might help survivors recover. For all the airplane travel I did I always had to use my good arm to lift my bad arm overhead in the scanners.
https://eksobionics.com/eksoworks/

Effect of alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: The PRISMS randomized clinical trial

Regardless, both of these are failures. 100% recovery is the goal, not just a nebulous favorable outcome.
https://www.mdlinx.com/journal-summaries/alteplase-aspirin-acute-ischemic-stroke-minor/2018/07/18/7527902/ZZ3559DFF1FDFD43F3965FF05AF76C7B18?
JAMAKhatri P, et al. | July 18, 2018
In patients with National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 whose deficits are not clearly disabling, the efficacy and safety of alteplase were evaluated. Findings suggested that treatment with alteplase vs aspirin did not increase the odds of favorable functional outcome at 90 days in patients with minor nondisabling acute ischemic stroke. However, the very early study termination precludes any definitive conclusions.

Methods

  • The PRISMS trial was designed as a 948-patient, phase 3b, double-blind, double-placebo, multicenter randomized clinical trial comparing alteplase with aspirin for emergent stroke at 75 stroke hospital networks in the US.
  • Subjects with acute ischemic stroke whose deficits were scored as 0 to 5 on the NIHSS and judged not clearly disabling and in whom study treatment could be started within 3 hours of onset were qualified and enlisted from May 30, 2014 to December 20, 2016, with final follow-up on March 22, 2017.
  • After that, patients were randomly allocated to receive intravenous alteplase at the standard dose (0.9 mg/kg) with oral placebo (n=156) or oral aspirin, 325 mg, with intravenous placebo (n=157).
  • The primary outcome was the difference in favorable functional outcome, characterized as a modified Rankin Scale score of 0 or 1 at 90 days through Cochran-Mantel-Haenszel test stratified by pretreatment NIHSS score, age, and time from onset to treatment.
  • Due to early termination of the trial, before unblinding or interim analyses, the revised plan was to investigate the risk difference of the primary outcome by a linear model adjusted for the same factors.
  • Symptomatic intracranial hemorrhage (sICH) within 36 hours of intravenous study treatment was the primary safety end point.

Results

  • The study results showed that among 313 patients enlisted at 53 stroke networks (mean age, 62 [SD, 13] years; 144 [46%] women; median NIHSS score, 2 [interquartile range {IQR}, 1-3]; median time to treatment, 2.7 hours [IQR, 2.1-2.9]), 281 (89.8%) finished the trial.
  • It was observed that 122 patients (78.2%) in the alteplase group vs 128 (81.5%) in the aspirin group achieved a favorable outcome (adjusted risk difference, -1.1%; 95% CI, -9.4% to 7.3%) at 90 days.
  • Findings revealed that 5 alteplase-treated patients (3.2%) vs 0 aspirin-treated patients had sICH (risk difference, 3.3%; 95% CI, 0.8%-7.4%).
 Read the full article on JAMA

Thursday, July 19, 2018

“Garbage in, garbage out.” Stroke has garbage goals

Another great Seth Godin writeup. Applying this to stroke, We have garbage goals that our researchers are shooting for. THE ONLY GOAL IS 100% RECOVERY.  Our stroke associations have garbage goals of prevention and F.A.S.T. press releases.

THE ONLY GOAL IS 100% RECOVERY.

Avoiding the GIGO trap

“Garbage in, garbage out.”
It has a nice ring to it. And engineers have long embraced it as a mantra. If you don’t put the right stuff in, don’t expect to get good results.
And so, when we banned leaded gasoline, the car industry complained that they’d never be able to make cars run well again.
And when HP started making printers for consumers, they were eager to point out that you needed to use special paper, and definitely not labels.
And if you’re using the command line on a computer, well, don’t spell anything wrong or whatever happens is your fault.
And if you’re a patient, be sure to take the precise amount of medicine, on time, and follow all the doctor’s instructions.
The thing is, “garbage in, garbage out” is lazy.
It’s lazy because it puts all the onus on the user or the environment. It lets the device off the hook, and puts the focus on the system, which, the device creator points out, is out of his control.
It’s one thing to make a sports car that runs beautifully on smooth roads, perfect tires and premium gas, but it’s a triumph of engineering to make one that runs beautifully all the time.
It’s one thing to organize the DMV so it works well when every person reads all the instructions, fills out the forms perfectly and patiently waits their turn, but it’s a generous act of customer service and organization when the system is resilient enough to work with actual human beings.
The extraordinary teacher adds value to every student, no matter what their home is like. She sees possibility and refuses to settle or blame the inputs. Isn’t that the way we’d like every professional to see the world?
You don’t need to measure the flatness of your bread to use a toaster. And the persistence of the car and printer industries means that the type of gas or the paper we use matters a whole lot less than it used to.
The better mantra is, “garbage in, gorgeous out.”
That’s what we hired you for.