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Pacemaker induced #DVT Placed 2 years ago for HCM. Surprisingly sudden onset left arm swelling. 8️⃣F Brachial vein access ✅Glide advantage/IVUS cross ⚡️CAT 7 Lightning 🎈DCB 12 x 60 Impact Cause of DVT: poor collaterals and lead fibrosis. Anyone used DCB in this space?
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I have done several with DCBs! We have gotten reasonable results, better than PTA alone. I would be interested in pooling data as not much out there on this topic. Our group is very interested in lead -related venous occlusion. A few papers on the topic (@enricoferroMD @ZimetbaumP ): 1) 2)

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @SMPatelMD @JayMathewsMD Nice case with lovely results. No one knows if DCB in veins helps or not. Generally DVT has a large component of venous stasis w hypercoag state not necessarily endothelial injury as the initiating event, so mechanistically DCB is +-?

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @SMPatelMD @JayMathewsMD I don’t think DCBs have much of a role in treating venous disease since most cases aren’t caused by plaques or endothelial issues. Most are external compression or fibrotic. But if you have access to them, they’re probably a better option than PTA 🤷🏽. Excellent result 👏🏽

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @SMPatelMD @JayMathewsMD Just as an anecdotal example, I’ve used large DCBs for chronic venous obstruction within the thoracic outlet and have seen more durability compared to regular angioplasty; in one patient (who served as their own control) we got extra 2 months of patency

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @SMPatelMD @JayMathewsMD Fantastic result... Nice learning ...Thanks

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @JayMathewsMD Nice job the ones I have with this seem to come back even with oac —do we ever recommend extraction, leadless pacer? Or just life long oac or higher INR goals?

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @SMPatelMD @JayMathewsMD Great case. Post procedure anticoagulants……..!?!?

@t_intheleadcoat @AntoniousAttall @drochohan @IRKhalsa @RajWellnessMD @EricSecemskyMD @jcgeorgemd @HadyLichaaMD @SMPatelMD @JayMathewsMD Perfect spot for DCB trial, if fails within three months then stent

Great case and you did everything like I would EXCEPT I would use a larger catheter for thrombectomy - 16 flowtriever bareback or -penumbra cat12 Totally agree for DCB. Trials show that patients w AVF/AVG access and similar narrowing benefit significantly (thx @roblookstein )
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THE PENTAGON PEDOPHILES: U.S. Immigration and Customs Investigations identified over 5,000 Pentagon Department of Defense, U.S. Military, DARPA, NSA and NASA employees involved in Child Pornography, some had the highest Top Secret security clearances which may involve blackmail. Thousands of sexually exploited children were as young as 3 years old. (DCIS) The Department of Defense Investigation Service dropped the case after 8 months due to lack of resources. Over 1,700 employees were never investigated. This is a National Security risk to America that has been buried and ignored to this day. DEPARTMENT OF DEFENSE OFFICE OF INSPECTOR GENERAL DEFENSE CRIMINAL INVESTIGATIVE SERVICE REPORT OF INVESTIGATION: 200701199X-29-MAY-2007-60DC-Wl/F PROJECT: OPERATION FLICKER January 24, 2008 NARRATIVE: 1. On July 11, 2007, the reporting agent received a lead referral from Special Agent IDCIS Mid-Atlantic Field Office regarding the Immigration and Customs Enforcement (ICE) initiated Operation Flicker. Operation Flicker is a nationwide investigation that has identified over 5,000 individuals that have subscribed to predicated child pornography websites. A list of individuals in New York State that are employed by the Department of Defense/U.S. Military, that have subscribed to websites that contain child pornographic images or other material that exploit children via the internet. 2. In April 2006, the ICE/Cyber Crimes Center/Child Exploitation Section (ICE/C3/CES) initiated an investigation into a criminal organization operating a commercial child pornography website known as "Home Collection." The investigation has revealed that the same organization is operating numerous commercial child pornography websites. In addition, the organization utilizes various Pay Pal accounts to process the payments for access to the member restricted areas of these websites. The investigation is being worked jointly with ICE/C3/CES, ICE/RAC/Birmingham, the U.S. Postal Inspection Service, the U.S. Department of Justice/Child Exploitation and Obscenity Section, and the USAO for the Northern District of Alabama. ICE has designated this operation as PROJECT FLICKER. 3. ICE/C3/CES has conducted over 60 undercover transactions at the advertising websites associated with this investigation. The investigation has identified that a specific criminal organization is operating approximately 18 different commercial child pornography advertising websites which provide access to approximately 18 child pornography member restricted websites. 4. Among the 5,000 names ICE identified under Project Flicker, several individuals used their .mil e-mail address, Fleet Post Office (FPO), or Army Post Office (APO) military zip codes. Special Agent advised the U.S. Attorney's Office and ICE that the DCIS will assist in identifying any additional Department of Defense (DoD) affiliated individuals and provide any investigative assistance. 5. As a result of the database queries, 264 individuals affiliated with DoD were identified, including 39 individuals within the Eastern District of Virginia. Of those identified, 9 individuals possessed a Top Secret Sensitive Compartmented Information security clearance, 13 possessed a Top Secret security clearance, 8 possessed a NATO Secret security clearance, 42 possessed a Secret security clearance, and 4 possessed an interim Secret security clearance. 6. The subject information containing DoD query results were divided by location and forwarded to the appropriate ICE and DCIS office for action. 17. This investigation is closed based upon the lack of participation by the Immigration and Customs Enforcement to present the forensic evidence obtained during the course of the investigation to the U.S. Attorney's Office. This case may be re-opened if ICE presents this case for prosecution, and the U.S. Attorney's Office accepts this case for prosecution. YAHOO NEWS: News Report by John Cook September 3, 2010 Pentagon declined to investigate hundreds of purchases of child pornography. A 2006 Immigration and Customs Enforcement investigation into the purchase of child pornography online turned up more than 250 civilian and military employees of the Defense Department -- including some with the highest available security clearance -- who used credit cards or PayPal to purchase images of children in sexual situations. But the Pentagon investigated only a handful of the cases, Defense Department records show. The cases turned up during a 2006 ICE inquiry, called Project Flicker, which targeted overseas processing of child-porn payments. As part of the probe, ICE investigators gained access to the names and credit card information of more than 5,000 Americans who had subscribed to websites offering images of child pornography. Many of those individuals provided military email addresses or physical addresses with Army or fleet ZIP codes when they purchased the subscriptions. In a related inquiry, the Pentagon's Defense Criminal Investigative Service (DCIS) cross-checked the ICE list against military databases to come up with a list of Defense employees and contractors who appeared to be guilty of purchasing child pornography. The names included staffers for the secretary of defense, contractors for the ultra-secretive National Security Agency, and a program manager at the Defense Advanced Research Projects Agency. But the DCIS opened investigations into only 20 percent of the individuals identified, and succeeded in prosecuting just a handful. The Boston Globe first reported the Pentagon's role in Project Flicker in July, citing DCIS investigative reports showing that at least 30 Defense Department employees were investigated. But new Project Flicker investigative reports obtained by The Upshot through the Freedom of Information Act, which you can read here, show that DCIS investigators identified 264 Defense employees or contractors who had purchased child pornography online. Astonishingly, nine of those had "Top Secret Sensitive Compartmentalized Information" security clearances, meaning they had access to the nation's most sensitive secrets. All told, 76 of the individuals had Secret or higher clearances. But DCIS investigated only 52 of the suspects, and just 10 were ever charged with viewing or purchasing child pornography. Without greater public disclosure of how these cases wound down, it's impossible to know how or whether any of the names listed in the Project Flicker papers came in for additional scrutiny. It's conceivable that some of them were picked up by local law enforcement, but it seems likely that most of the people flagged by the investigation did not have their military careers disrupted in the context of the DCIS inquiry. Among those charged were Gary Douglass Grant, a captain in the Army Reserves and a judge advocate general, or military prosecutor. After investigators executing a search warrant found child pornography on his computer, he pleaded guilty last year to state charges of possession of obscene matter of a minor in a sexual act in California. Others included contractors for the NSA with Top Secret clearances; one of them a former contractor fled the country after being indicted and is believed to be in Libya. But the vast majority of those investigated, including an active-duty lieutenant colonel in the Army and an official in the office of the secretary of defense, were never charged. On top of that, 212 people on ICE's list were never investigated at all. According to the records, DCIS prioritized the investigations by focusing on people who had security clearances since those who have a taste for child pornography can be vulnerable to blackmail and espionage. The documents show that the probe then concentrated on people who had been previously suspected of or convicted of sex crimes, or had access to children as part of their Defense Department duties. But at least some of the people on the Project Flicker list with security clearances were never pursued and could possibly remain on the job: DCIS only investigated 52 people, and 76 of those on the Project Flicker list had clearances. A DCIS spokesman didn't return phone calls. But the agency's own documents obtained via The Upshot's FOIA request indicate that the decision to press investigations forward hinged largely on questions of the resources available to the investigators. "Due to DCIS headquarters' direction and other DCIS investigative priorities, this investigation is cancelled" is a common summation in the files. A source familiar with the Project Flicker investigations who requested anonymity because public disclosure could jeopardize this person's job confirmed that departmental resources, and priorities, were decisive factors in letting inquiries lapse. DCIS is primarily tasked with rooting out contractor fraud and investigating security breaches; its 400 staffers were already plenty busy before Project Flicker dropped 264 more names onto their caseloads. And child pornography investigations are difficult to prosecute. Many judges wouldn't issue search warrants based on years-old evidence saying the targets subscribed to a kiddie porn website once. "We were stuck in a situation where we had some great information, but didn't have the resources to run with it," the source told The Upshot. Many of the investigative reports obtained by The Upshot end with a similar citation of scarce resources: Of course, other federal agencies, including ICE and the FBI, may have prosecuted some of the Project Flicker names the DCIS ignored. But that's unlikely, given that some of the DCIS investigations were closed due to lack of cooperation from ICE. In one case, involving an Army Reserve corporal in the Pittsburgh area, a DCIS agent expressed exasperation after repeatedly trying to get ICE to collaborate with him on the investigation: "Based upon the complete non-responsiveness of ICE ... it is recommended that the matter be closed." As for the 212 Project Flicker names that DCIS didn't investigate, the source familiar with the investigation said there was no systematic effort to inform their superiors or commanding officers of their suspected purchases of child pornography. DAILY MAIL: By WILLS ROBINSON PUBLISHED: 13:01 EDT, 24 August 2015 EXCLUSIVE: NASA employees caught buying child porn from site which showed three year olds being abused, but they escape prosecution and now their names are being kept secret. 1. Staff were found to have purchased illegal images while at the agency. 2. Were bought from Belarus and Ukraine using credit cards and PayPal. 3. FBI uncovered the illicit transactions in 2010 as part of a government probe. 4. They were identified by authorities, but their names have been redacted. NASA employees were caught buying child pornography from a criminal ring in Eastern Europe that distributed images of minors as young as three, it can be revealed. An investigation by Daily Mail Online found staff members from the space agency paid for pictures and videos of children in sexual situations, but were never prosecuted. Their names have never been released because of government guidelines which protect their privacy. The probe found that in 2010, the employees paid for the pornography using personal credit cards or PayPal while working for the government. Their actions were uncovered during Project Flicker - an investigation by the FBI and Immigration and Customs Enforcement (ICE) into American citizens buying child pornography from Belarus and Ukraine. The investigation began in 2007 when more than 33,000 images of minors being abused flooded into the country. Investigators identified more than 5,200 citizens across the country who had paid for a subscription to illicit websites in order to access the content. In 2010 it was revealed that 264 of these worked for the Pentagon as either employees or contractors. Some of them worked for the NSA and had top security clearance. But the Daily Mail Online can reveal for the first time that NASA employees were also identified in the sickening scheme in the same year. However their names have been redacted in documents obtained by Daily Mail Online via a Freedom of Information Act request from NASA's Office of Inspector General. Some had highest available security clearance. After the probe was completed just 10 were ever charged with viewing or purchasing child pornography - prompting fears some of those caught could still be working for the military. It is not known whether any of the NASA employers were questioned, but it is clear they were not prosecuted - as their names have not been revealed. If they had been found guilty of a crime, their names would not have been redacted in the disclosed files. A spokesman for NASA told Daily Mail Online they would not be commenting beyond what was stated in the FOIA documents. The investigation, called Project Flicker, was conducted in collaboration with other U.S. and international law enforcement partners around the world, and identified 30,000 customers in 132 countries - resulting in hundreds of convictions in the U.S. and 16 arrests in Belarus and the Ukraine. 'The criminal rings involved used a variety of online and traditional payment methods, elaborate defense measures and a franchise business model that provided access to images and videos of sexually exploited boys and girls, some as young as 3 years old. HSI’s Cyber Crimes Center distributed more than 5,000 domestic leads to field offices around the country and shared more than 4,000 foreign leads with its law enforcement partners via HSI’s attaché offices. HSI is a leading federal law enforcement agency combating the sexual exploitation of children. HSI conducts investigations under Operation Predator, a nationwide initiative to protect children from sexual predators, including those who possess, trade and produce child pornography; who travel overseas for sex with minors; and who engage in the sex trafficking of children. The FBI said they would not be adding to the ICE's statement. The latest disclosure comes after Daily Mail Online investigations unearthed shocking breaches of computer guidelines inside the Department of Education the Department of Labor and the Department of Health and Human Services. FORMER CIA OPERATIONS OFFICER: There is a great cause for alarm. The Elite appear to be seeking to infect local and provincial law enforcement officers with a taste for Pedophilia. There appears to be a very deliberate attempt to push this interest in Pedophile movies including movies that include beastiality. We are seeing movies where military men are raping children including toddlers. Evidence shows these movies may have come from Afghanistan from U.S. soldiers. The center of gravity for taking down the Deep State is Pedophilia. Pedophilia is the induction glue of the Deep State. Pedophilia is how the Deep State recruits and controls its people, it is also the achilles heel of the Deep State. Once the public realizes that the government is not protecting their children, then everything else about the government will be called into question. For change to happen in our world the American public needs to get angry over the injustice. If the American public gets angry we will stop supporting dictators overseas and we will close all our military bases. There are one thousand U.S. military bases around the world and they are not there for national defense, they are there to smuggle guns, cash, gold, drugs and small children. UNITED NATIONS EXECUTIVE DIRECTOR: The Oligarch's, all of them are related to the System of Pedophilia. Millions of children every year disappear. These millions of innocent children need you to fight for them. They are being raped, tortured, murdered and sacrificed every year. Pedophilia has infiltrated every part of our society at the highest level by the Deep State and Oligarch's who use this for control and blackmail. Justice will not come through the current corrupt Pedophile System of things. Justice will only come through the people. The Committee of 300 is the Deep State and the Oligarch's that must be stopped.
Truth Justice ™
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![Apple’s iPad “Crush” Ad Is Bleak, Ominous and Threatening I don’t know if you’ve seen Apple’s just-released commercial for the “New” iPad Pro, but it’s pretty awful. It is dark, humorless, and feels like a not-so-thinly veiled threat to writers, musicians, game makers, developers, and artists of all kinds. …and children, even. I’ve watched it at least five times today alone, and I’m left with one big question. “Who on earth approved this?” It’s absolutely baffling that the world’s largest technology company, with the world’s biggest marketing budget, thought this would be a good idea. What kind of idiot—or idiots, since dozens or hundreds of people had to be involved in the writing, staging, producing, recording, and editing—felt this kind of ad would somehow create a positive emotional connection with consumers? Seriously, it’s terrifying. In a dank, cold warehouse, devoid of all life and humanity, an industrial crusher comes to life, and slowly starts destroying a collection of musical, philosophical, and artistic devices and instruments. For no apparent reason, everything starts getting smashed: first, a trumpet, then an arcade video game, then cans of paint, a piano, a globe, a metronome, a guitar… on and on it goes, obliterating everything in sight into a colorful, gooey, explosive mess. Books, camera lenses, lamps, a guitar, a sculpture, and a typewriter—all tools of the liberal arts—get mangled into a garbage heap as Sonny & Cher cheerfully sing, “All I ever need is you.” In the penultimate moment, a goofy yellow smiley emoji becomes a bug-eyed scary-clown freak as it, too, is crushed to death. Worse, if you enable closed captions like I do by default, the video says: “[POPPING] [SPLAT]” right as its eyeballs pop out of its head when Cher sings, “Give me a reason to build my world around you.” It’s enough to make a child cry. It has all the comforting vibes of the burnt pink teddy bear floating in the swimming pool on Breaking Bad after two planes crash in mid-air. I have so many questions (aside from simply wondering the names of the soon-to-be ex-employees who greenlit this abomination). First of all, as a trumpet player myself, I am personally offended that they made me watch a perfectly good trumpet get smashed to smithereens like it’s no big deal. Why would they torture me like this? Second of all, what is the message here? No, not that “the most powerful iPad ever is also the thinnest,” as the voiceover artist states in the last few seconds of the clip. I mean: what is the message? Ostensibly, pulverizing children’s toys, arcade games, architectural models, and ceramic Angry Birds into a paste implies something like “We’re taking all the best of humanity; all the collective works of Western Civilization, smashing it into pieces and putting it inside this remarkably thin device so you can have all of it in the palm of your hand.” But my oh my, is there an elephant in this room… he’s hiding behind the monstrous destroying machine. Did anyone inside Apple realize that everyone outside Apple will recognize this imagery in a metaphorical sense, but not the one Apple intended? We don’t see a crushing machine gently consolidating the greatest output of all our artistic endeavors, simply reformatted for a digital age and consumed by everyone with instant, fingertip access. We see what is painstakingly obvious to us, and the timing couldn’t possibly be worse. We see a giant, soulless machine consuming our work in a very different way. Right now, AI models are training themselves on our intellectual property and even our very own personally-identifying data. We aren’t the ones doing the consuming. We’re the ones being consumed. The tech industry has become one massive gaping maw, opening wide and swallowing everything in sight, chewing it up into little bits and pieces of comminuted waste, like a paper shredder or a garbage disposal. It’s destruction in its most literal form. And for what? For a newer version of the iPad that is only slightly thinner than its predecessor? For an only marginally improved version of Apple’s tablet device that has been around for 14 years? For increased profits? This is a terrible look for Apple. They may as well be saying: “All your work are belong to us.” Personally, I am a fan of artificial intelligence. I am eagerly embracing our robot overlords and I welcome our new CSV god (as the actual developers of AI models like to say). I look forward to the freedom and innovation that will come as a result of humanity augmenting our intelligence with AI like a force multiplier on a battlefield. But if Apple has the same perspective I do, they’re selling it in the worst possible way. When I see this video, I see that Apple is definitely crushing something… but I’m not sure what. -Crushing small companies that develop apps for the extremely heavy-handed App Store, which imposes byzantine restrictions on what they can and can’t do with their own apps? -Crushing competitors by limiting what they can do on the iOS and MacOS platforms with arbitrary and capricious rules about enabling functionalities that Apple doesn’t like, even if users do? -Crushing publishers and content creators with a punitive 30% fee on all subscriptions and in-app purchases? -Crushing choice and competition by not allowing app makers to make apps and programs that do the same thing that native apps already do, even if they do it better? -Crushing all human creativity and innovation by automating and systematizing everything? In the early days of the “Google vs. Apple” fight over the web and app stores, I was really concerned that Google was becoming way, way too powerful. Specifically, in 2015, when Google came up with “app streaming,” they announced a desire to form a “web of apps.” This was concerning. Especially when coupled with Google’s efforts to steal content from other websites and provide it to users via the “knowledge graph” results, ending up with the creation of “zero-click” search results pages, which absolutely punished website owners and content creators. By taking the most valuable content off a website and showing it to Google users without them needing to click through to the website itself, Google had essentially stolen everybody’s intellectual property with only the most minimal attribution possible (to fend off lawsuits no doubt, but with no intention of users actually visiting the website in question anymore). “Google is eating the internet,” I thought, and said out loud, (although I probably wasn’t the first person to use that phrase) But what I meant was purely an analogy. It was vague and ambiguous, almost silly. Maybe I was wrong, though: maybe it’s Apple that’s doing the eating. Maybe Apple is not only gobbling up everyone else’s work, but also homogenizing it—and us—and forcing us to use their platform, pay their fees, abide by their rules, and constantly keep upgrading, upgrading, upgrading, to an ever-thinner iPad in order to use it. Watch the video again. This is the stuff of nightmares. To be perfectly fair, even if I were to take the commercial at face value and ignore it’s off-the-charts creepiness and just stick to its one stated claim—that the new iPad Pro is thinner—it still fails as a commercial. Why? Because nobody cares how thin an iPad is. Seriously. I’ve owned an iPad since 2010: that means I’ve carried around a version of Apple’s already-thin tablet every day for over a dozen years. Never once have I said to myself: “You know what improvement I’d really like to see in this thing? I wish it were thinner.” Never. That thought has never crossed my mind, even once. You know what has? -Better battery life. -I’d like my iPad to not get hot to the touch when I use the Apple Pencil to take notes. -I wish it wasn’t so fragile: I dropped my brand-new iPad 2 back in the day when it slipped out of the arm-hold I was carrying it in, it bounced on the pavement, and the screen shattered into a thousand pieces, making it unusable. -I wish it had more storage. -I wish Apple would stop changing the type of cable connector it uses: I’ve gone from the original 30-pin connector to the Lightning connector, and now to the current USB-C/Thunderbolt connector. -I wish I could view the screen in direct sunlight. -I wish it wouldn’t overheat and turn off automatically when I use it outdoors in the summertime. Those are announcements I would welcome in a new iPad Pro commercial. None of this “now even thinner” nonsense nobody needs or cares about. So, back to the commercial. In my opinion, whoever made this ad should be fired. I almost never say that about other companies, especially for good-faith marketing efforts gone wrong… those of us who work in marketing make mistakes sometimes, and we learn from them. But cases like this warrant a special exception. Marketing and advertising are designed to make people want to buy your products. This commercial doesn’t just not make me want to buy Apple’s products. It makes me not want to buy Apple’s products, which is something altogether different. It turns me from someone who likes iPads into someone who is almost rethinking iPads entirely. That’s not just a bad advertisement; it’s a harmful advertisement. Apple’s usually known for great commercials. The legendary 1984 Super Bowl commercial was, of course, their best. I thought “Hello, I’m a Mac” was absolutely brilliant. They have made some missteps along the way, but this one is really bad. Not even their nauseatingly preachy and woke “Mother Nature” ad from a few years ago was this bad. Steve Jobs once said, “Technology alone is not enough—it’s technology married with liberal arts, married with the humanities, that yields us the results that make our heart sing.” My goodness, that last line alone is poetry itself! This ad seems to be Apple signaling that they don’t believe in that anymore. And I don’t think all this handwringing is an overreaction to where you could say “Oh, c’mon, it’s just a commercial! What’s the big deal?” It is a big deal. It tells you about the values of the company, and what they intend to communicate. Really, how is this the same company that used to sell iPhones by showing grandmas using FaceTime to connect with their baby grandchildren from afar during the holidays? Everything about it is wrong: even the thumbnail they chose for it (the bulging-eyed smiley face) and the fact that they gave it the title “Crush!” It was fun to see the reactions to the video online today. I find it fascinating that Apple shared it on YouTube but turned off the comments. On X, Tim Cook shared it Tuesday, and the video, which so richly deserves to be mocked, is getting it in spades. Some people are calling it “anti-art.” One user called it “soul-crushing,” which was about as literal and logical a response as you’d expect. It turns out Apple actually made an announcement about the commercial. In response to the (apparently unexpected) poor welcome it got, Apple wrote: “We missed the mark with this video, and we’re sorry.” Lame response from a tone-deaf tech behemoth, but still, they hopefully got the message. C’mon, Apple. I have seen the future, and this ain’t it.](https://image.24vids.com/tw-1788740167194579387/media/GNLjSOOaEAAZ6VT.jpg)