“If ever it’s necessary to ride the bandwagon, it’s done with one leg swinging out and eyes scoping the fields.” ― Criss Jami (Killosophy)


TASK AT HAND: This week I’m thinking about what it means to jump on the bandwagon. The phrase is from the mid-nineteenth century and attributed to Phones T Barnum who, as a circus owner and showman, would urge audience to jump on the wagon that carried the circus band (a literal bandwagon). In the modern lexicon, “jumping on the bandwagon” usually refers to individuals supporting a person, team, idea or activity after it is popular or successful.

There is nothing wrong with supporting a movement or idea; in fact, you should curate movements that align with your mores, challenge your beliefs, and allow you to develop as a thoughtful creature. My issue with the pursuit of merely popular or successful people or ideas is that they limit your ability for independent thought. To join a collective for the mere sake of popularity, limits choice, and aggrandizes mass effect.

There is convenience in joining a bandwagon. There is instant common ground that, while at times merely superficial, allows connection and fabric to take hold. But, and you know how I fell about convenienceit breeds complacency – and this is where trouble begins. As you become complacent, history shows us with a multitude of examples that it becomes easier to succumb to groupthink and lose objectivity amidst the loud voices of a large group.

Be wary of bandwagons and, as the existential philosopher Criss Jami so nicely summarizes above, if you must ride a bandwagon, do so with one leg out the cart and be ready to move. Look for a landscape that challenges you as an individual. Realize that autonomous pursuit is lost on the backs of most bandwagons.


MEDICINE & MACULA: Check out one of our recent publications, Novel Technique for Submacular Hemorrhage Removal Using 27-Gauge Pars Plana Vitrectomy and Recombinant Tissue Plasminogen) Activator (Kunyong Xu MD MHSc, Eric K Chin MD, John B Davies MD & David RP Almeida MD MBA PhD).

Many thanks to the Journal of VitreoRetinal Diseases for publishing our work!

You can find the study here.


GRATIS: “If you see a bandwagon, it’s too late.” -James Goldsmith


My best to you,

David Almeida


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“Nothing’s beautiful from every point of view.” -Horace

TASK AT HAND: This week I’m thinking about points of view. Perspective is the context for processing information. Very little – if anything – is black and white. Actions and consequences rarely exist in a vacuum. Instead, there is nuanced context to words in a conversation, lines on a page, and in the decisions we act out.

We have previously talked about perspective here on the Sunday Surgical Scrub (March 2017) but, today, we are going to go beyond defining perspective and I will present 3 pearls to points of view that you need to consider for effective strategy.

1) Sensitivity Requires Perspective. Being aware of differing points of views provides sensitivity to the fact that we are all different people, from different cultures and with different mores. Sensitivity, and the ability to detect differences, aligns with one’s ability to be cognizant of diversity. Looking at a situation from the perspective of another, is empathetic and contributes to the fostering of collaborative relationships.

2) Do Not Substitute Perspective for Understanding. There is a strong desire, due to the bias of rationalization, to bend perspective to “fit” with your own thoughts and actions. Avoid this! Look to differing points of view as an empathetic tool but do not distort strategies to fit your unchanging perspective. “A point of view can be a dangerous luxury when substituted for insight and understanding” (Marshall McLuhan). The later quote is essential learning because we must remind ourselves that perspective can both help or hinder our understanding of actions. Cataloging the different points of view relevant to a certain situation are only one component of understanding.

3) Find the Vantage Point. It is possible to, when considering points of view, to ascribe to a perspective that is clear and concise. This is the Vantage Point. Vantage simply means a positon affording a good view. Think of the vantage point as a position of balanced and informative perspective; the point of view uncluttered by bias and most free of rationalization.

Try to find the vantage point of a conflict as a means to ascertain the key variables for all the parties involved. Find the vantage point for a decision you are pondering to offer you the needed perspective of consideration and avoid the collusion of bias that is so tricky whenever points of view come into play.


MEDICINE & MACULA: Many thanks to Judy Hoberman for having me on the Selling In A Skirt radio show! Judy has incredible insight into the gender differences that we should all understand and embrace instead of feeling unable to communicate about. We discussed entrepreneurship, my book Decision Diagnosis and, of course, gender differences.

You can find our July 2017 episode here.


GRATIS: “Men are disturbed not by things, but by the view which they take of them.” -Epictetus


My best to you,

David Almeida


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“Beware the barrenness of a busy life.” -Socrates

TASK AT HAND: This week I’m thinking about “the busy life”. When I ask friends how they are doing, the most common answer I get – irrespective of whether they work in medicine, business, entertainment or sports – is: “busy!”.

How’s the day going? -Busy!

How was the weekend? -Busy!

How’s the week looking? -Busy!


I hear it so much, I am reminded of this Henry David Thoreau quote multiple times a day: “It is not enough to be busy. So are the ants. The question is: What are we busy about?”

Our language has a powerful effect on how we frame our relationships and strategy. Descriptors, like “busy”, create a disconnect from actions we perform. One is less able to extract meaning from an act that is defined in an impersonal manner such as “busy”. For the descriptor of “busy”, a strategy is simply to finish the event. Unfortunately, this is a rudimentary process because, in the end, what have you achieved? Completed a busy day? Almost always, the tasks have much more meaning that simply of being “busy”. You are living more than just a “busy life”.

For example, I see patients and perform surgery. There are days with more patients than others, some days with more complex cases, etc. I have three fantastic kids under 6 years old. Some days are marathons while others are sprints. Some days I enjoy the hectic pace while others I like the pauses for reflection. If I am left describing each of these different days as a homogenous “busy”, there is the deleterious effect of disconnecting me from what it is I am doing during those very different days. Instead, if you re-frame how you look at these “busy” actions, you can open the door to more engagement.

The call to action on today’s Sunday Surgical Scrub is to avoid using the word “busy” as a descriptor. Re-frame how you look at your tasks and actions.

How was your day? -It was a day with challenges that required me to…

How’s the week looking? -I’m looking forward to…

By simply changing the language you use to describe what you do or how you go about your days, has a demonstrative effect on your level of engagement. This approach allows you greater insight into managing challenges and resolving conflicts.


MEDICINE & MACULA: A few months ago, I had the privilege of being on a panel looking at best practices of the surgical technique of the dexamethasone intravitreal implant (Ozurdex). These events always remind me how much I learn from my wonderful colleagues. Many thanks to Seenu M. Hariprasad MD, Kimberly Drenser MD PhD, Sunir Garg MD and Bruce Saran MD!

For those interested, check out the publication here.


GRATIS: Happy Canada Day! Happy Independence Day!


My best to you,

David Almeida


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“Adulthood brings with it a pernicious illusion of control.” Juan Gabriel


TASK AT HAND: This week I’m thinking about control. The desire for control is commonplace and, overall, we hope to exert positive or beneficial control in the actions and events that take place in our lives. The hope is that we can “guide” strategies towards desired outcomes. Control becomes a surrogate for ends and outcomes.

You can see this is a reasonable and somewhat rationale thought process. However, let me introduce you to the cognitive bias of the illusion of control. This is a habit where we overestimate our ability to control events. The effect is named by psychologist Ellen Langer and has been demonstrated in numerous different experiments.

“The illusion of control is a type of cognitive bias where we overestimate our ability to control events.”

As we find ourselves in stressful and competitive situations, this type of bias increases significantly. Sports are common examples where a participant “believes” that he or she can make the basket or score the goal. In reality, once that ball leaves the shooter’s hands or launches from their foot, all control is foregone. There is no control that can be exerted beyond that action. Another example is financial markets where an investor is “sure” they can make a profit on a particular trade. For the latter, he or she has almost zero control over the outcome of that stock price or bond dividend.

So, what does this mean for our strategies and plans?

Do we just relinquish all control?

No, as with all types of biases, we need to learn to detect it and minimize it’s deleteriously effects. For the illusion of control, one can overcome this type of bias by focusing on processes rather than prediction of outcomes. I like reminding myself of the adage, “the ends do not justify the means”, to realize that I cannot control ultimate ends but I can influence the means and processes via a conscientious connection with acts. This liberates you from the stress of trying to control the outcome and allows you to deliver the best possible action or strategy. Try it!


MEDICINE & MACULA: Many thanks to Jim Beach (@entrepreneurjim) for having me on the School for Startups Radio! Jim’s philosophy on entrepreneurship is refreshing and you can hear me on his June 22 episode here.


GRATIS: “If everything seems under control, you’re just not going fast enough.” -Mario Andretti


My best to you,

David Almeida


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“Nowadays I don’t want a perfect face and body – I want to wear the life I’ve lived.” Pat Benatar


TASK AT HAND: This week I’m thinking about scars. We normally think of scars as negative manifestations of past trauma. Sequels of serious harm. Instances where circumstances went beyond our ability to repair and restore our normal constitution. Whether they be physical, psychological or spiritual, scars are commonly unwanted tattoos of dramatic life events.

But this view is nearsighted.

As the insightful Pat Benatar quote echoes above – you, your body, your face and your smile – are reflections of the life you live. The scars you collect speak volumes of the miles you travel, the milestones you achieve, and the pain you reconcile. These are, whether negative or positive, the greatest hits of your life. The scars you collect are essential elements of your constitution; consequently, they should be celebrated for, so strong an effect they have, they change you forever.

“The scars you collect speak volumes of the miles you travel, the milestones you achieve, and the pain you reconcile.”

Don’t hide from your scars! There is no need for that “perfect face and body” Benatar alludes to above. Instead, embrace scars, imperfections, and stains. Actually, let me go one more: welcome the opportunity to develop new scars! Challenge your character and choices in ways that provide opportunities for personal growth and the ability to foster new relationships.

When life pushes you, push back.

When you are held down, the only next move is to get back up.

When you are questioned, answer in the affirmative. Answer without fear of scars.


MEDICINE & MACULA: Check out one of our recent publications, Dysfunctional Autonomic Regulation of the Choroid in Central Serous Chorioretinopathy by C Nathaniel Roybal, Elisabeth Sledz, Yasser Elshatory, Li Zhang, David RP Almeida, Eric K Chin, Brice Critser, Michael D Abramoff & Stephen R Russell.

It was published in the June 2017 issue of RETINA. You can find the study here.

We describe the effect of changing perfusion pressures on retinal and choroidal structure in central serous chorioretinopathy (CSC). In this study, we found that choroidal thickness increased in response to increased perfusion pressures in patients with CSC and not in normal controls. These findings likely represent an autonomic dysregulation of choroidal blood flow in patients with CSC.


GRATIS: Happy Father’s Day to the selfless individuals who, without fear, serve as mentors and role models!


My best to you,

David Almeida


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“Asynchrony – relationships occurring at unrelated times – offers the opportunity to thrive amidst change and turbulence.”


TASK AT HAND: This week I’m thinking about the concept of asynchrony. Asynchrony is a common term in computer science where it refers to events occurring at different times that are independent of the primary program. In biology, asynchrony pertains to the ability of a species to fluctuate in their evolution over time. As Bluthgen and colleagues have shown, asynchrony affords animal or plant communities the ability to fluctuate beyond biological diversity (Nico Bluthgen, Nadja K. Simons, Kirsten Jung, et al. (2016) Land use imperils plant and animal community stability through changes in asynchrony rather than diversity. Nature Communications 7, 1069. doi:10.1038/ncomms10697). The authors write: “The more the species in an ecosystem fluctuate in their evolution over time, the less they are likely to falter.” Think of these fluctuations as asynchronous behaviours.

So, what is the relevance of asynchrony for us here on the Sunday Surgical Scrub?

I define the term of asynchrony as relationships occuring at different times. These relationships may not be apparent because of their disparate temporal profiles; i.e., they do not occur at predictable times. Like a plant that can fluctuate its uptake of solar energy depending on its external conditions, your ability to act asynchronously with your environment can provide you with a strategic advantage when encountering complications or conflicts.

For example, take a situation where someone submits a work or community proposal and that proposal is met with resistance or outright denial. A synchronous response would entail countering with similar resistance amidst negotiation. This is a reasonable approach and appropriate in some circumstances. However, one could also try responding with an asynchronous strategy such as delayed deliberation. This will create a window of time that may, in turn, change the circumstances of how your proposal is met. Please note that this is not simply procrastination or delay for the sake of delay. Instead, you will alter your plan or proposal over a longer timeline so as to align with changing factors that may improve your chances of succeeding in your ultimate pitch.

Take another example; let us assume you have multiple investments and the market bears significant losses. A synchronous response would be to pull out and sell before you incur further losses. Instead, an asynchronous response would entail diversifying your portfolio to have a more robust defense against further market losses. By diversifying, you are responding with a relationship that will be most relevant to a later time frame when the market changes.

As you consider the varied applications of strategy, be on the lookout for the opportunity to utilize asynchrony. Look for diversity and relationships over courses of time that may appear to be unrelated. This will afford you greater stability towards success in your overall goals.


MEDICINE & MACULA: Many thanks to Don Hutcheson for having me on the fantastic podcast, Discover Your Talent–Do What You Love. I was featured on the episode, More Effective Decision Making, that went live Friday, June 2.

Check out Episode 512, Expert Interview: More Effective Decision Making with David Almeida here.

You can access the podcast, my episode 512, and show notes here.

The website page of Discover Your Talent can be found here.


iTunes (episode 512) is here.

Stitcher (compatible with Android phones and all computers) is here.


GRATIS: This past week, on Tuesday June 6th, I had the privilege of being part of a terrific panel of vitreoretinal surgeons in Dallas-Fort Worth looking at complicated surgical cases. There were terrific videos and discussion and I had a great time seeing outstanding colleagues. I contributed a video on proliferative vitreoretinopathy which, as many of you know, is a serious academic interest of mine.


My best to you,

David Almeida


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“Be aware.

Aware of who you are.

Aware of your surroundings.

Aware so that you may understand how to act.”

TASK AT HAND: This week I’m thinking about awareness. What does it mean to be aware?

Take the simple picture above of an animal and their surroundings. Is there awareness of self, of season, of a hunter in the distance? Or is awareness less complicated and a function of assuming the emotion of the moment?

From my vantage point, awareness is “situational knowledge”; i.e., insight into an instance in time.

“Awareness is situational knowledge.”


There are 3 types of awareness needed for self-realization, understanding and the application of successful strategy.


First and foremost, you must be aware of yourself. What are your core beliefs? What are you in pursuit of? What mores and values do you ascribe to?

This is a non-negotiable aspect of awareness. You absolutely need to know this because this will function as the compass of your life. It will guide your actions through conflict, it will instruct your decisions when pondering questions, it will be your strategic Virgil as you navigate the circles of life.



Second, you must be aware of your surroundings. Without knowledge of the space you occupy, you risk disconnection from your environment. Your environment includes everything from physical objects, to geography, to people. Proper awareness of your surroundings will allow you to be considerate and conscientious of how you move through space. Your impact on relationships are very much a part of your environment. Lacking awareness of this fragments our bonds and hinders our ability to mature our contact with the world around us.



Finally, aware of concept relates to how we apply knowledge. For example, understanding a concept or piece of information and successfully applying it are two very different items. Many times, you will see examples of individuals having correct conceptual understanding but failing in application. These examples occur in personal relationships, business strategies, and political undertakings.

In my opinion, to take a concept, and then successfully apply it requires awareness. You need to be aware of yourself, your environment, and how the knowledge in questions must be applied. This is analogous to working “in context”. If you are out-of-tune or lack situational knowledge – if you lack awareness – I doubt you will be able to successfully apply a concept through application.


So, the call to action on today’s Sunday Surgical Scrub is seek awareness. Constantly evaluate the multi-dimensional matrix of awareness in the spheres of self, environment, and concept to best guide your actions and strategy.


MEDICINE & MACULA: Many thanks to Michael Brun for showcasing me in the Woodbury Bulletin. You can check out the article entitled, A cure for procrastination: Surgeon combines diverse background in decision-making framework, here.


GRATIS: “That’s the biggest gift I can give anybody: Wake up, be aware of who you are, what you’re doing and what you can do to prevent yourself from becoming ill.” -Maya Angelou


My best to you,

David Almeida


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“The gastrointestinal system has over 100 million neurons. This “second brain” has more neurons than your spinal cord and is similar in number to the brain of a dog.”


TASK AT HAND: This week I’m thinking about “trusting your gut”. Although a cliché statement, there is real basis for its utility. Our gut is the home of our enteric nervous system; a collection of over 100 million neurons that function as an interface with the outside world by carefully interacting with that which enters our alimentary tract.

Humans are complex creatures. Of this, our gut is an incredibly complex component. It needs to be emphasized that such a nervous system goes beyond simply digesting food. The enteric nervous system, also known as the “second brain”, is constantly feeding you information about the outside world. If you are willing to listen, it can serve as a confidant for the interpretation of complex emotions and communications.

“The second brain is constantly feeding you information about the outside world. If you are willing to listen, it can serve as a confidant for the interpretation of complex emotions and communications.”

One can take a deep dive on the enteric nervous system in a myriad of ways. From the digestion of food, to neurotransmitter functions, to the gut bacterial environment that is crucial for homeostasis, to gastrointestinal immunity functions, there are countless books on topics that are beyond the scope of the Sunday Surgical Scrub. What I want to focus on today is your gastrointestinal tract and enteric nervous system as a strategic interpreter for decision making. This may initially seem haphazard, but allow me to explain.

Intuition, which I define as immediate comprehension without reasoning, is an integral part of decision analysis. There will be instances when, despite carefully organized analyses and sound reasoning, the correct decision may remain hidden. The preferred path, in these instances, requires you to remain connected to your second brain as a means of gaining further input. Learn to trust your gut and follow your intuition. We all know what this feels like. The “butterflies” of excitement, the shallow queasiness of apprehension, the disgust at the pit of our stomach from a wrong path taken. These are feelings we have known long before we could reason complex arguments.

How do you hone the ability to focus on what your intuition and gut are trying to tell you?

There are several techniques that one can use to centre on what our gut feelings are telling us such as meditation, sleep, journaling. However, one I really like to use is the act of distraction. At times, we can become entrenched in analyses such that we become susceptible to tunnel vision and bias. At these times, we can rationalize the wrong decision surprisingly easily. If you need to connect with your gut, distract yourself with some physical activity, music, or even a nap. This will serve to refresh the connection between your first and second brains with respect to the conflict in question. There is an essential, evolutionary-tuned survival need to trust our intuition. Trust and follow your gut!


MEDICINE & MACULA: Many thanks to Dr. Jay Sridhar, creator and host of the fantastic podcast, Straight From The Cutter’s Mouth.

I was a recent guest on his show and had a wonderful time discussing retina, work-life balance, social media and my recent book Decision Diagnosis. Check out Episode 44: More Social Media with Dr. David Almeida.

You can find the episode here.

You can also check out the Straight From The Cutter’s Mouth website, blog, other podcast episodes and more here.


GRATIS: “You’ve got a song you’re singing from your gut, you want that audience to feel it in their gut.” Johnny Cash

My best to you,

David Almeida


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“In the pursuit of happiness, the stairway is an illusion and the steps dreams, that convince us that more happiness in just steps away. In reality, it functions more like a treadmill, keeping you in place despite a lifetime of paces.”

TASK AT HAND: This week I’m thinking about the hedonic treadmill theory, which I usually refer to as the hedonic stairway. Simply surmised, the idea is that the pursuit of happiness is akin to a person walking on a treadmill. You keep walking, but stay in the same place. More steps does not equate to more happiness.

The “Hedonic Treadmill” was coined by Brickman and Campbell in their article “Hedonic Relativism and Planning the Good Society” (Brickman; Campbell, 1971, Hedonic relativism and planning the good society. New York: Academic Press. pp. 287–302. in M. H. Apley, ed., Adaptation Level Theory: A Symposium, New York: Academic Press).

In this seminal paper, the authors describe the tendency of people to keep a stable baseline level of happiness despite positive or negative external events. From the work of Brickman and Campbell, they interviewed 22 lottery winners and 29 paraplegics with the aim of assessing change in happiness levels after the life changing events of winning the lottery or becoming paralyzed. The authors found that the group of lottery winners reported being similarly happy before and after the event, and expected to have a similar level of happiness in a couple of years. They found that the paraplegics reported having a higher level of happiness in the past, a lower level of happiness at the time of the study but – surprisingly – they also expected to have similar levels of happiness in a couple of years.

What can we take away from these results?

For the most part, individuals can expect to have the same baseline level of happiness irrespective of quite drastic, dramatic and different life events. The effect of a large monetary gain had no effect on baseline level of happiness for both the present and the future. In the paraplegic group, although there was an initial decrease in happiness, they too expected to maintain or return to the same baseline level of happiness for the future.

How can we use this for our development and strategies?

Awareness that, at least with respect to the pursuit of happiness, more steps you take on the hedonic stairway, will not grant you any additional happiness. Striving for that next promotion, a new car, or even great personal gain or loss, does not seem to alter your baseline level of happiness. Does this mean we should avoid these or strive for less? No, but it does call for awareness for why we pursue certain stations in life. More steps does not equal more happiness so be cognizant of your pace, journey and destination.


MEDICINE & MACULA: For those who know me, you are aware of my squash enthusiasm (although obsession might be a better descriptor…). This week, the WHOOP Performance Optimization System featured me in their The Locker feature.

Thanks very much to WHOOP and Mark Van Deusen for their interest! I don’t have any financial ties to the WHOOP system but believe, wholeheartedly, it is the best fitness tracker available for the serious sports enthusiast.

You can read the story here.

Stay active!


GRATIS: “Yes, there are two paths you can go by. But in the long run, there’s still time to change the road you’re on.” Jimmy Page & Robert Plant


My best to you,

David Almeida


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Think about the last thing you did that made you feel really good?

What was special about it?

Most people I ask this question answer with the resultant accomplishment or achievement related to whatever event they are thinking about. Let’s take a fictitious example; someone might say, “I enjoyed my last run. It was special because I completed 10 miles.”

There is nothing wrong with this answer and I believe it’s important to celebrate accomplishment. However, now, go back to that event or action, and describe it without using some sort of productivity or accomplishment associated with it. You cannot use an outcome as a means of ascribing value to it.

Get’s difficult right?

What am I getting at? We tend to value productivity over presence. We want to extract takeaways from actions and events like: “I had…”, “I did…”, “I got…”. Instead of the desire to immerse in moments and experiences, we are all too ready to define our life in basic terms.

To continue with our example from above, maybe the significance of that last run was it allowed connection with nature or moments of mental clarity. Only if you are present, can you catch these wonderful experiences.

TASK AT HAND: This week I’m thinking about presence. One of my favorite quotes is from Walt Whitman: “We convince by our presence.” The ability to be present and engaged with the turbulent twists of life – rather than a mere passenger of happenstance – is not trivial!

The title of this blog, the Sunday Surgical Scrub, is dedicated to a ceremonious time of clarity. From the blog introduction above, “Before each and every case, a surgeon scrubs and disinfects his hands. At the same time, he or she becomes solely focused on the task at hand – preparing to navigate a complex surgical path – and ready to confront any difficulties that lie ahead.” The scrub is a moment of reflection to remind the surgeon to be present in the moments that lie ahead.

Unfortunately, too many times, we lose the connection to presence. A common example I see is simple conversations. You will notice that people will speak and, as soon as they stop speaking, they focus on what they will say next rather than listening. The other person does it as well. Is the point of the conversation to conduct some sort of business (productivity) or an opportunity for engagement (presence)?

Look out for all too easy trap of productivity. Efficiency and productivity are cornerstones of success but make sure you are producing relevant outcomes. Pause and ask yourself what it is that you want out of an action or interaction. More often than not, you will find that presence in a simple conversation, a parenting action, a commitment to a cause has great worth and impact than a trivial takeaway.


MEDICINE & MACULA: Thank you Tina and The Morning Blend for having me as a guest this past week! I had a wonderful time on the show and continue to be humbled and excited about all the interest in Decision Diagnosis.

You can watch the interview here.


GRATIS: Happy Mother’s Day! Resiliency I learned from my grandmother. Kindness and unyielding support I absorbed from my mother. Every day, I am lucky to witness the virtues of patience and grace in the mother of my children


My best to you,

David Almeida


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