I'd like to thank the organizing committee for inviting me to talk on really second line and greater, so the refractory patient population. And as you all are aware, this is kind of the area in kidney cancer, which has seen the most rapid growth of new data over the past 16 months. So I've got now just nine minutes and 40 seconds to go through five trials. So let's move forward here. I wanted to remind us that overall survival is the key. We've heard that from earlier lectures here. Our patients want to live longer, and it seems like we accomplished that with sequential use of therapy. And I give you Tom Powell's slide from his talk at ASCO, which illustrates this quite nicely. We must remember that we must think beyond first line. We spent a lot of attention on first line, compares us out there, all these trials that we've done in first line, but we must remember that patients spend 30% or less of their time in the first line setting. And so really, sequential use of agents is what is driving the survival. And we really need to understand the contribution of the second, third, and fourth line as we're making treatment selection. And I want to make an appointment, a statement that I would beg you all to try to find how many patients in your practice has actually made it past fourth line. It's quite a minority of patients. Therefore, our choice of agents that we use in the second, third, and fourth line actually really matter. And I'm just like the rest of you. I used to tout to my patients, I want to give them all lines of therapy. I think that I could give them eight lines of therapy. And it didn't matter the order. While I'll tell you today, I really think it does matter the order. And what separates us out from other types of physicians is the ability for us to use evidence-based medicine. And for now, after these trials that have been presented over the past year, we now have evidence that supports the role of different agents. So we do pick winners now in the second, third, and fourth line setting. So let me share with you that data. And so our colleagues have tried to categorize different categories of progression and what would prompt us to want to switch therapies. And I think we agree with these. There are different categories of patients we see. Some patients will keep them on the front line therapy. Others will switch right away. And this is a publication from Bernard trying to put words to these different categories. So as we jump into second line therapy, I'd show you the ESMO 2012 guidelines, which, like NCCN, try to categorize based upon degrees of evidence. And if we focus to the second and third line, you can see in the second line we've got in the post-TKI setting, which is probably the most relevant globally right now. We have exidinib with a category 1A because it was a pure second line trial. And everolimus actually not given the same high degree of recommendation because as we'll explore, was really not a pure second line trial. And in the third line setting, we see everolimus, which would be appropriate. But what is not been updated is the gold results. And I would argue that seraphinib should now be listed as an equally option in the third line setting. So these are the trials that we're going to review that established this second line and beyond setting. We anxiously await for the switch results, which hopefully will come out at ASCO GU. So the two real areas are do we switch to another TKI, use this concept of VEGF suppression through multiple lines? This would be answered somewhat by the phase three access trial, or do we move and change mechanism of action to an mTOR through the phase three record one? So mTOR versus placebo was the topic of the phase three record one trial that was back, presented back in 2008, resulted in regulatory approval of everolimus affinity around the world and was published in the Lancet. And as you can see, stratification was based on prior VEGF receptor TKI one or two. What's not obvious in this slide is that patients could have had multiple lines of therapy. Patients were stratified also by MSKCC risk group. And you can see the randomization there, two to one to everolimus versus placebo. There were planned interim analyses. The second interim analysis was positive. So it became the final analysis. Patients were allowed to cross over from placebo to everolimus. Primary endpoint was progression free survival. We saw a clear separation of curves. And on the final update, a 4.9 month advantage to everolimus over placebo, no overall survival was deemed. But that may be from the crossover. And what, you know, before we would look at this data. And this data served as the means of marketing this agent as a second line agent around the world. And it actually, on market use, was the most commonly used second line agent. But until we had other agents to actually use with data, we didn't really scrutinize it. But as we've scrutinized the data, we've come to realize that actually there was only a minority of patients on this pivotal trial that were in the second line. In fact, the majority of the benefit, the majority of patients driving the benefit were actually in later lines of therapy, third, fourth, fifth, et cetera. And so that brings us to question then what really is the role of using everolimus second line. Should we be using it then, or should we use it later? And so this new data we're talking about is Exidnib. And Exidnib was received regulatory approval in the United States back a year and a half ago and in countries around the world based upon pivotal trial presented by Brian Rini and subsequently published in the Lancet. And you remember, Exidnib is one of these potent TKI's. So the hope of it was that it would provide us greater efficacy and less toxicity. And if we look at the progression free survival on this pure second line trial, it was in favor of Exidnib and the intent to treat overall patient population. 6.7 months versus seraphim of 4.7 months. Primary endpoint was met. It gets regulatory approval. If we look at the subsets, and really the two subsets we can actually draw conclusions are about are the cytokine pretreated subset and the synidinib pretreated subset. The other two, the TEM and the BEV, are two small numbers to really draw conclusions. And then we see that the bulk of data, the bulk of evidence driving Exidnib's benefit was really in the cytokine group. But there was still benefit of a more potent TKI in the second line setting over seraphim, but only a 1.4 month benefit in progression free survival. And when we looked at subsets across there, most of the subsets did benefit indeed from Exidnib, the more potent TKI, over seraphim. And if we look at partial response by resistance, stable disease, they all were in favor of Exidnib. Toxicity was what we would expect with seraphim. And what was key to us, I think, with Exidnib was what it wasn't necessarily overly easy to give. It was actually, it had its own side effects. And it was a differentiated side effect to profile versus seraphim, same with hematologic adverse events. So I need to move quicker because I'm running out of time. So based on this, Exidnib should be considered the reference standard as second line. Well, here comes Intersect. Intersect was a trial designed to hopefully get at the question of mTOR versus VEGF-TKI that we now scrutinize four or five years after its original design that it wasn't the ideal VEGF-TKI or mTOR, but at least it gives us some idea. And this was a randomized trial in the pure second line setting. Patients had prior synidinib. They could have had clear cell, non-clear cell. Prior nephrectomy was not required. And they got randomized one-to-one between TEM or seraphim. And what we saw was a progression free survival, although numerically in favor of TEM serolimus, no statistical difference, so the primary endpoint was not met. Shocking to us doing the trial was it actually a profound benefit and a secondary endpoint of overall survival, 4.5-month difference in favor of seraphimib and brings to point, you know, why is this? Now, we can scrutinize it saying we don't really have a full set of the post-progressive treatment. In fact, only 10% of the data, and it looked balanced in the 10%, but nonetheless that could have been an influence. But I would argue that the degree of difference between these two arms is beyond that. There's something potentially there we don't fully understand. And then record three trial presented by Bob Moser recently at ESMO was a trial looking at sequencing of synidinib everolimus, everolimus synidinib, and I think a point to mention here is going back to what I originally mentioned, we lose patients through attrition. Look at the number of patients in the front line that got therapy. Look at the number of patients in the second line that get therapy, 50% less. So your choice of therapy matters. Patients won't get all of the therapies. You want them to get. If we see this, we see a benefit in favor of synidinib in the front line setting. In the combined PFS, although crossover to synidinib and second line setting tries to salvage some, we see synidinib everolimus as being the better sequence. And in conclusion, and that is exactly what Bob said, that synidinib sequence followed by everolimus is supported by the preliminary overall survival results. And it's really questioned the role of everolimus. So in second line setting, Nick, and in sequencing questions are summarized right here. VEGFTKI, after VEGFTKI is becoming the new standard, I think the preponderance of the evidence based on access, inter-second record one, support that data. There's no direct comparison of exidinib and everolimus. We saw in subset analysis that the majority of patients on record one were actually in the third line or greater. So that brings us to third line or greater. What are the options? Well, up until gold trial, it was just everolimus. And again, based on this data that the majority of patients were third line or greater. The median progression free survival in the subset of patients who had prior synidinib and seraphim in the setting suggested a PFS of everolimus of approximately four months. So there's data in support of its role as a third line. If we look at recent GUASCO, the Italians attempted to look at a retrospective study looking at their patients. And if you look at the last two bottom two areas, you can see that in the patients they have identified that had sequential therapy. There was TKI, TKI-MTOR, which was suitent seraphim of everolimus. And TKI-MTOR, TKI, which was suitent everolimus seraphim. And if you look who did best was when you moved the TKI-MTOR inhibitor third in this retrospective study. And I think the prospective data somewhat supports this too. So here comes as I'm ending up running out of time, Nick. OK, as I end up going on the phase three trial of dividinib versus seraphim, which was recently presented at ESMO, this pure third line trial. And what was the hope with dividinib? Dividinib's hope was that it was a VEGF inhibitor, plus it inhibited FGF. And we know FGF is overexpressed or upregulated during the times of resistance. Maybe we could overcome resistance. So there was a lot of hope with this trial. Patients had to have one prior VEGF inhibitor. They could have had one prior MTOR. Patients were allowed to have cytokines, however true. So it was not a pure third line. But randomization was one to one to the dividinib on a 5-2 schedule versus seraphim. And what we see is superimposable progression free survivals, negative study for the primary endpoint overall survival superimposable. But what it does, folks, is it gives us an approved drug. And in some countries we have a broad label with this approved drug, with the PFS. The PFS is 3.6 months with seraphim. If you look at the subset of patients on the record one who had sous-tent seraphim of Everolimus, PFS was four months. So I give you two drugs with essentially equivalent progression free survival. So there are two options for us as we move into the third line setting. So my question for you is VEGF, VEGF, VEGF MTOR? Or not? OK. And so if we look at the waterfall graphs, again, the majority of benefit with both of these agents in stable disease. So in conclusion, it was a negative study. So finally, as I end, re-challenge with synidinib, the last group of data that we've had. Many of us, this data comes from studies. We pulled data from multiple institutions, retrospective data, on our experience of giving synidinib when we've run out of other therapies. And we found efficacy. And we've published this data. And you can see based on the patients enrolled in this trial, there were a variety of different therapies utilized. We found that the length of time off of synidinib front line predicted better benefit when you went back to synidinib later. And generally, greater than six months was better than less than six months. Boy, we've heard that six-month phrase before. So there's a variety of new anti-ingenesis. Bob Figglin's Schoenfeld Lecture is a good summary of where the field is going. I think we're looking for things beyond. And I just implore you, let's apply evidence-based medicine. Our community oncologists do not. We need to educate them. They will use whatever drug they want to in sequence. We actually have evidence that there are certain drugs that have proven benefit to be used in sequence. And since we never get our patients beyond fourth line, it seems, let's make sure we choose wisely in first, second, third, and fourth line. And with that, I'll thank you very much for your time.


Hello everybody welcome back to another Dolby Premiere Pro CC 2021 tutorial and this one I'm going to show you how to rotate an image and I'll do it while also having some video in the background. So here we go I've got a video on video track one of a bulldog and then on the top track as you can see here I've got a rotation here for my dog. So the image is rotating. Let me show you how to do that I'm going to go ahead and delete all of that stuff and We're going to start from scratch the first step You want to drag and drop your video into the project panel right over here? And then you want to drag it into the timeline Excellent, there he is. There's the bulldog doing his thing The second step is you're going to drag and drop the image onto v2 Which is a second video track and then you're just going to want to make it so that the video that the image is The same length as the video now I'm going to double-click on the image and you're going to see here that I get the bounding box and I get the handles on the end So I'm just going to make it a little smaller for this demonstration So I've decreased the size Proportionately and then I'm just going to move it to the bottom right corner so you can see it Okay, so we've got an image on top of a video now Let's rotate the image the step next step is you want to left click on the image here, which is In the v2 track and then you're going to want to go over to your effect controls panel If you don't see it go to window make sure there's a check mark beside effect controls Excellent making sure your playhead is at the beginning left click on rotation Now we're going to go ahead and move the playhead to the end So the end is right there Then I'm going to press back one key and then I'm going to go ahead and change this I'm going to slide through it so that eventually it's going to say basically one with zero degrees So it made a full Rotation and by clicking on that stopwatch we have animated the rotation. I'll move back to the beginning I'm going to hit play and there we go the rotation or the animation is happening Oh, it's a little slow because we're in RAM preview, but that's it guys. That's how you rotate an image in Premiere Pro Thanks for watching be back


Good afternoon, everyone, and welcome to Falco at Apple. I'm Melissa Kilby from the Apple Services Security Engineering team, no hybrid conference without a hybrid format. We're really good at this. So I'll be virtually joined by Eric Sage, a member of the Linux kernel team at Apple. Today, we're going to show how we deployed Falco as one of our security monitoring solutions. But first, we would like to address why the Linux kernel team at Apple loves EVPS. The Linux kernel team manages and improves the Linux kernel across the fleet of servers that power Apple services. EVPF provides us with an incredibly powerful and flexible tool for adding features into the kernel that provide many improvements over traditional methods of extending kernel functionality. Thanks, Melissa. To go into more detail, traditionally kernel modules have been used at third party code to the kernel, but they come at the high cost of giving full access to kernel data structures and access to the system's hardware. For example, the Falco kernel module may concern itself only with tracing, but is the ability to do anything at once and load it into the kernel. From a security perspective, it does not follow the principle of least privilege. EVPF programs, on the other hand, are limited to a set of curated function calls called EVPF helper functions, depending upon the EVPF program type. EVPF programs allow us to categorize the types of programs loaded into the kernel so that each program be given only the data and functionality it needs to complete its task. The new Falco EVPF probe, for example, is specifically a tracing program and only has access to tracing helper functions and data. In this way, the EVPF virtual machine provides a safe sandbox for the third party code to run in without giving full access to the kernel. Even though it runs in kernel space, it still follows the principle of least privilege. EVPF overall reduces the dependency complexity. There are many reasons why software needs access to kernel data or direct access to the hardware, which has led to frameworks and modules that bypass the kernel to process data in user space or load large amounts of code into the kernel to greatly extend kernel functionality. For example, there are many packet processing frameworks designed to circumvent the cost of the kernel network stack to process packets at line rate. EVPF programs alleviate the need for these drastic solutions by allowing user space to provide different types of EVPF programs to solve specific problems and gives the EVPF code access to very low level processing pipelines, such as tying directly into a network driver before the network stack is invoked in the case of XDP programs. When it comes time to debugging and profiling, EVPF also reduces the need for many complicated add-on solutions. Because EVPF unifies adverse set of frameworks and modules with a single solution, many tools can be created that specifically target the EVPF ecosystem. LibBPF is a user space library that provides functionality on top of the EVPF's call. LibBPF's common set of library abstractions make tool development quick and easy, greatly reducing the work one needs to do to build on top of the EVPF foundation. For example, BPF Tool is one such program that uses LibBPF to provide operators with information about loaded EVPF maps and programs. It can show map contents, jittered instructions, the amount of locked kernel memory, number of programs, invocations, and much more. The Linux kernel team at Apple is always improving our testing and deployment strategy. EVPF has added compile once run anywhere, which allows us to write EVPF programs, which can be targeted to many different kernel versions. This is a drastic improvement of a kernel modules, which must be compiled and tested against specific kernel versions. Compile once run anywhere uses BTF type information to adjust the EVPF programs on the fly to work on a variety of kernel versions. EVPF is also kernel native. Which is a feature that cannot be oversold. Many of the solutions that EVPF replaces do not have direct support from the normal kernel development channels and must work to maintain compatibility with the direction of kernel development. Having EVPF be a part of the kernel means having the peace of mind that EVPF will always be supported by the primary kernel developers. For example, many tools are already being built with LibBPF, which is maintained in the kernel source and mirrored on GitHub. Users of LibBPF can get direct support from the kernels net dev and EVPF communities with libraries actively being developed. Last hybrid slide, let's hear about some of the ways EVPF could evolve in the future. We still believe there are many improvements that can be made to EVPF. We would love to see better tooling around analyzing the performance of EVPF programs to make it easier to identify bottlenecks and inefficiencies in EVPF program design. We would also love to see better tools and documentation for operators that may not be familiar with EVPF just yet, with the aim of simplifying EVPF so that it is easy to understand what each program is doing on a running system. Finally, there are many security features that could be added to EVPF, such as using the same kernel signing mechanisms used to sign kernel modules to sign and verify EVPF programs. That said, we can't wait to see what the amazing EVPF community comes up with next. Thanks, Eric. Now we dive into how an organization can leverage FALCO to supercharge its runtime security monitoring. We will cover a lot of content very fast, such as insights, detections, or data modeling implications. And we are in LA this year. Hollywood magic happens just around the corner, so there will be a magical offensive security demo with special effects, and then we show how you can use FALCO to detect such attacker behavior, which is pretty cool. At the center of the stage are running instances of a program in memory, and they make requests to the kernel via system calls to interact with a piece of hardware.  One could say that system calls hold the potential to capture entire classes of vulnerabilities and attacker behavior often chained together to a nice kill chain. If there was one takeaway message, then it would be, syscalls never lie. Consider this your open invitation to run off and make it a false statement. When a system call is made, it is the metadata around the system call, most notably the process execution path, command arcs, or file descriptor name. That is essential to determine if the observed behavior is unusual or even malicious for your environment. Here's a list of the most important system calls from a security monitoring perspective. They are important because they cover behavior observed in many explorations. FALCO rules are written in a basic expression language. How it works, the rules specifically built for Linux, Kubernetes, or Tognative are instantly evaluated on the host. FALCO ships with standard rules created by the community that you can easily build upon. FALCO can also lock container events or has a Kubernetes integration. Today, however, we continue to focus on system calls only. A subset of FALCO rules falls into the category of very specific security detections. For instance, SSH outbound connections could channel a shell over non-standard ports. Perhaps configurations are such that this should never happen. In this case, such a rule can also serve as assurance. If the alert fires, we can say with high confidence that this is unusual. A larger subset of FALCO rules falls into the category of less specific. They are derived from high-level constructs that are known to be security critical. For example, spawning a shell by a non-shell application or modifying files below a set of system standard binary directories. These type of FALCO rules generate a whole bunch of signals and it is hard to map them to attack our behavior. Such rules can also assist in developing new organization-specific detections. In any case, enormous work is required to analyze and triage them. This is why FALCO logs are usually sent to a centralized data lake where the environment is profiled over time in order to fine-tune the rules. It's now time for a story worth sharing. Once upon a time, there was a web application. What can possibly go wrong? Over the next couple of slides, we will show some of the ways you can exploit the top three consistently exploited vulnerabilities and misconfigurations. That is arbitrary file read bugs, remote product execution, and misconfigurations leading to privilege escalation. I am a hacker now. My terminal is ready to go. Suppose we found a third-party PHP application and then discovered that the app contains a local file include vulnerability. This means the app takes a parameter from the user in the PHP request and then goes to that file to evaluate it as PHP code. Interesting here is that we can use such an LFI to trigger an arbitrary file read. We just successfully read the world readable Etsy password file. More interesting is how do we get remote code execution out of this? The way we can achieve this is to upload a file we create over the LFI and then invoke that file using the local file include vulnerability again. The file we create would typically contain a payload that gives us a shell on the victim machine. In this example application, there was an authenticated endpoint that processes uploader files. So we simply include this admin upload functionality PHP file with the LFI in order to upload our script to the web app. Let's sneak you. And we also know where that file ends up. After setting up the listener on the attacker machine, we make another request to include the just uploaded file with the LFI and that way invoke the payloads. Now we have remote code execution on the box. I now switch roles and am a defense magician. One by one, we will build up the sub-process tree that will contain all the events collected by Falco for the suspect processes. Falco can log the open reach of the file containing the payload. Then Falco detects that the non-shell application spawned a shell. Subsequently, the payload unwraps. And finally through the doop system call, best standard in, send it out, is hooked to the TCP socket effectively providing the attacker with a reverse shell. Over the reverse shell, remote commands can be run on the victim machine. Besides vulnerabilities, misconfigurations are a common concern. In this scenario, the RPM manager is terribly misconfigured. The current user account can run the RPM binary, literally anything as root. I get it, it's not actually that glamorous, but I hope it gets the point across. The pseudo process executed without password enforcement, the attacker now has full control on the system. Falco also has a generic rule that detects if a package management process is run inside a container. This demo made it look very easy to accurately detect all malicious artifacts. In reality, systems are very noisy. And Falco logs, yes, they can drive you crazy. This is why we're now going to dive deeper into some of the challenges in my face once you're ready to get even more value out of Falco. The application is to start a file named Etsy password with a technique called directory traversal. Etsy password is quite literally read all the time on Linux systems, so generically modifying or monitoring this file would be very helpful. But this particular artifact is pretty suspicious and indeed could indicate that the app is vulnerable to an arbitrary file read bug. But what happened to the Falco logs here? The directory traversal signal is not in the file descriptor name. This will make a good and bad Etsy password read look exactly the same. Some source and make file modifications are necessary to unlock the entire debugging engine. So we start our debugging journey in kernel space. BPF printk will show that the file descriptor name is captured as expected. Following the control flow in user space will show that the FD path is being sanitized. Modifying the sanitization function can fix this. Ironically, user input sanitization function, or let's say better like they're off, are often the root cause for such arbitrary file read bugs we're trying to detect here. Next, making sense out of command arcs or file descriptor names is the tricky part that can drive you crazy. This is because one, you rely too much on prior assumptions to match for two specific strings and are at risk of missing potentially malicious behavior. Or two, you have a hard time tuning your rule and constantly play catch up with filtering out benign activities specific to your environment. The hard part really is that shell input is touring complete. Combined with the inherent variability in exploits, there is an unknown amount of semantically related process behavior that will look very different in all of these system call metadata. To make matters worse, many benign commands contain exotic elements. Think of hashes, IPs, timestamps, that can make normalization and profiling a daunting task in and of itself. Furthermore, similarity or rarity alone is of little help to know if the intent of the process is malicious. Therefore, knowledge bases that encode domain knowledge are super critical as well. Finally, depending on your threat model and the type of activity you seek to detect, you also have to be aware of ways that obfuscate behavior. For example, when reading a file over shell built-ins, no external exactly ease system call is made that would allow you to see those intermediary steps. However, when touching a monitored file, FALCO has the power to accurately log such activity regardless of the level of obfuscation or exploit variability. This file descriptor or monitoring capabilities are beautiful and one of my personal favorite features of FALCO. In summary, the community as a whole still has a lot of work to do to solve both the semantic similarity challenge and the intent attribution challenge. Moving on to another important aspect. There is a growing body of research on correlating signals according to the MITRE attack framework in order to derive a higher fidelity alert. Correlations can also help tremendously in the alert triage process. Popular tools are big data technologies such as Presto, Spark or Elasticsearch. As far as methodologies are concerned, there are endless ways. One simple approach could be to simply group and aggregate the signals. Grouping could be done on a per container basis or for a particular sub-process tree. When performing sub-process tree analysis, there are a few tricks that can help reduce computational burden. For example, you can check for the same virtual process group ID to correlate all FALCO rules in a connected sub-trees. Or you can check for the same TTY or login shell ID if the use case is to track down activity in the same terminal or interactive shell. One point of caution here, again, making too many prior assumptions regarding how correlated signals are expected to look like can be tricky. In reality, we just don't know. Things always look very logical in retrospect and puzzling in prospect. And this is especially true in security. Personally, a big fan of first focusing on high value single events one at a time in line with what we have shown up to this point before performing correlations. One big question remains in the room is FALCO rights for my organization? We demonstrated that these type of tools hold the potential to capture exploitation artifacts for entire classes of vulnerabilities. Within one day of deployment, you can get a lot of value out of the tool as the standard rules that were created by the community are very well-tuned. FALCO is production-ready and battle-proven, featuring a sophisticated, yet easily extendable kernel instrumentation. Finally, the tax you pay in terms of CPU and memory usage is appropriate considering FALCO's capabilities. Earlier, we touched on some of the possibilities EVPF in general could evolve, but also for security monitoring focused extension, there are a lot of possibilities that have yet to be explored. One projection could be that more high-value kernel signals could be discovered. This is also in line with what we heard earlier this morning that perhaps the way we do tracing at the moment with FALCO is not what we should be doing in the future. And this also includes new ways of deriving high-value kernel signals, also enhanced encoding of the enriched metadata around process collection, which would address all the challenges we touched on earlier when making sense out of command arcs or file descriptor names. Finally, advanced pre-filters in the kernel could be in enticing proposition. Advanced here could mean that the semantics or intent of a process is encoded as a state vector for more dynamic AI ML-like reasoning right in the kernel. And I am aware we're very, very far away from this, but remember a lot can happen between now and never. Wait, what if I didn't pay any attention at all? It happens. Start with a very simple rules created by the community, customize FALCO and FALCO rules to suit your environment and threat model better, then slowly venture out eventually into deep space to start getting even more value out of the tool. And for which sophisticated data modeling approaches can be of help. Perhaps in the future we'll be given the opportunity to dive even deeper into modeling implications for now. Thank you for having us here and big shout out to the FALCO developers and the FALCO community.


From 6th of April 2024, it will become law for all businesses, charities and public sector organisations to sort their waste for recycling. From small businesses like Keras's Cake Cafe to big businesses like DAV's Distributors or organisations like Olly's Office and charities like Shan's Second Hand Store. Let's get workplace recycling sorted together for a greener Wales. For information on how your workplace will be affected, search Workplace Recycling Law Wales. Workplaces of Wales, let's get it sorted.


Sonography of Urinary Tract Infections The role of ultrasound is in the diagnosis of UTI, follow up and looking for complications of infection and also diagnosing the conditions which predispose for urinary tract infection and intervention in case of predisposition condition or complication. Now predisposition conditions are an anatomical abnormality which causes stasis of the urine which predisposes for the infection. It may be congenital like pelvic erotric junction obstruction, primary obstructive megauretor, horseshoe kidney or vesicoerotric reflex or it may be occurred where it is a cystocene, vesicle diverticulum or a fistula and it may be iotrogenic like an indwelling catheter and also comial infection or following surgery and it can also be the predisposing condition may be avoiding dysfunction which happens in neurological disease pelvic floor dysfunction or a high post void residual urine in enlarged prostate and incontinence. The urinary tract obstruction is also a predisposing condition like any obstruction like bladder outlet obstruction, uretric stricture or calculate and rarely there may be other causes like pregnancy, urolithiasis, diabetes and other immunosuppression. Acute diffuse bacterial infection of the kidney otherwise called the acute pylonephritis is a combination of parenchymal, teletial and pelvic inflammation. It may be a hematogenous seeding not that common causing the infection but usually it is an ascending infection facilitated by an anomaly obstruction, vesicoerotric reflex and the causative organism is usually E. coli and more common in diabetics, pregnancy and after instrumentation or after debilitating disease and in cases of altered host resistance and drug abuse. Acute pylonephritis diagnosis is typically the condition is typically diagnosed on the basis of the clinical symptoms and laboratory findings. Routine radiological imaging is not required for diagnosis and treatment of uncomplicated cases of urinary tract infection. It is a clinical diagnosis made out of abrupt onset of chills, fever of about 100 degrees or more and unilateral or bilateral flank pain with tenderness. Often accompanied by dysuria, urinary frequency and urgency. There may be nonspecific gastrointestinal symptoms like abdominal pain, nausea, vomiting and diarrhea. Add up to this a positive urine culture of infection results in the clinical diagnosis of acute pylonephritis. So ultrasound is required when the patient feels to respond to appropriate therapy within the first 72 hours occurs approximately only in 5% of cases of acute pylonephritis. So its role is also to assess those patients at significant risk for more severe life-threatening complications like diabetes, elderly or immunocompromised patients. And it is also useful to characterize the severity of infection to direct future therapy or interventions, evaluate the extent of organ damage, subsequent to resolved acute infection. So ultrasound is positive in 20 to 25% of acute pylonephritis. Tissue harmonic imaging has improved the sensitivity and specificity. Now this is a coronal scan in the case of right flank pain and fever and the left kidney is normal whereas the right kidney is enlarged. So the characteristic feature of acute pylonephritis is renal enlargement as seen in the right kidney here. And swollen parenchyma which is appreciated well in the transverse scan and changes in the ecogeneity of the renal parenchyma may be hypochoric due to edema of the parenchyma or hyperechoic due to associated hemorrhage. And there is loss of cortical medullary differentiation due to edema. And the loss of renal sinus fat due to edema of the parenchyma compressing the central ecogenic area. So these are the characteristic features of acute pylonephritis along with the clinical symptoms of fever and pain. The differential diagnosis is renal vein thrombosis. So a color Doppler will rule out renal vein thrombosis as seen here the renal vein flow is normal. The swelling of the parenchyma is better appreciated and transverse scan as seen here the coronal scan the kidneys almost look normal whereas the transverse scan shows the normal right kidney whereas the left kidney the parenchyma is swollen. So this swelling of the parenchyma is better appreciated in a transverse scan. So coming to the ecogeneity of parenchyma we saw previously it was ecopore but here on the right side you see the parenchyma is ecogenic and you see the swollen parenchyma which is appears ecogenic along with the clinical features the diagnosed acute pylonephritis. So again the swelling of the parenchyma is well marked here with compression of the central ecogenic area which is not well seen and there is also loss of cortical medullary differentiation. We don't see the renal medulla. Another feature of acute pylonephritis with other features is subcapsula parenifric fluid and ecogenic parenifric fat as seen here that is ecogenic parenifric fat. There may be in some patients ipsilateral floral fluid as a sign of infection. Now real time scan we can see fixation of the kidney as seen here now this spleen moves over the kidney the left kidney is fixed because of the inflammatory adherence. After treatment you see the difference the left kidney and the spleen move together whereas here the left kidney is fixed so that is another feature of acute pylonephritis on real time. There may be adherence of the adjacent organ either liver or spleen to kidney which is showing acute pylonephritis as seen here you see the parking movement of the liver over the kidney because the liver is adherent to the right kidney here the rest of the liver moves around. So that is another feature of acute pylonephritis may be present not always present. Now pylitis component of acute pylonephritis can be seen as ureothelial thickening in the calisthenics and pelvis as seen here that is the ureothelial thickening in the renal pelvis. Another form of acute bacterial infection of the kidney is focal that is acute focal bacterial infection otherwise also called acute focal lobar nephronium. It is an inflammatory mass without drainable pus it is the causative organism is E. coli. Some patients presents with fever chills, flank pain more common in females diabetes. On ultrasound we see it as a poorly defined ecopolar mass absent corticometallary differentiation associated with the clinical features of fever and flank pain. So here you see the left kidney you see a poorly defined ecopolar mass in the lower pole and in the transverse scan in the posterior parenchyma and the absent corticometallary differentiation you see the renal medulla here but here you are not able to appreciate the medulla. So that is acute focal lobar nephronium another case where you see a poorly defined ecopolar mass and absent corticometallary differentiation you see the medulla here but you don't see the medulla. Another case of acute focal lobar nephronium better appreciated on high frequency scan this is the conventional you see the ill-defined mass on high frequency transverse scan you see compared with the normal you will see the echogenicity of the parenchyma and the loss of corticometallary differentiation these are the medulla pyramids in normal which are not appreciated in the acute focal lobar nephronium. Another feature of acute focal lobar nephronium is seen on color Doppler because of the edema compression of the vessels in so you see sparse vessels or no vessels in the ill-defined mass. Now here that is the ill-defined mass loss of corticometallary differentiation and if you put on color so the vessels are not seen in the in the particular area confirming that they are compressed. Now acute parenchyma and focal lobar nephronium what is the course so most of them result with treatment and some because of destruction of parenchyma it results in a scar or it can progress to an abscess a complication of an abscess anal abscess which can rupture either into the perinephric space collecting system or both. So this is a case of renal abscess which is seen as a hypercoic mass in the renal parenchyma with acoustic enhancement indicating fluid pus in the mass and debris may be seen as internal echoes and on color Doppler there will not be any flow within the mass so these are features of renal abscess with of course the clinical features. Now there are multiple renal abscesses seen in the kidney in the parenchyma you see one abscess another abscess another abscess here here so multiple abscesses. Our complication of the abscess is a subcapsular abscess as seen here and coronals can on the periphery and it may be large as seen here the rest of the parenchyma is compressed by the subcapsular abscess which is due to rupture of the renal abscess. Renal abscess can rupture into the perinephric space you see a renal abscess which is ruptured into the perinephric space with a perinephric abscess and here in a child of six months use a high frequency scan which shows clearly the kidney the small renal abscess which has ruptured and produced by concave perinephric abscess which is brought on very well with the high frequency scan. Now there are the renal abscess can rupture into the collecting system as seen here that is the renal abscess which is ruptured with the the collecting system you can see the communication between the renal abscess and the callix brought on with the color Doppler by press release movement red and blue alternatively which is seen on the real time you can see grayscale there is a communication with the abscess and the callix which is shown by color Doppler by alternating red and blue with the compression it can rupture both into the collecting system and the perinephric space and which is also seen on real time as the movement of debris from the perinephric space into the collecting system and the abscess so this is rupture of renal abscess both into the collecting system as well as perinephric abscess or it can extend further outside the kidney as a perinephric abscess here you see the kidney the abscess is extended into the sova's muscle as a perinephric abscess. Then we come to condition of acute emphysematis pylonephritis which is a life-threatening condition of necrotizing infection of the kidney characterized by gas formation within or surrounding the kidneys most common in diabetes in 90 percent case seen in diabetes rarely in obstruction and the causative organisms are E. coli, Klebsiella and Proteus and anaerobic gas production within the parenchyma results in the gas it's most often unilateral it is rapidly progressive to fulminant sepsis and septicemia carries a high mortality rate because of septicemia now this is a ultrasound of a case of acute emphysematis pylonephritis where you see gas within the renal parenchyma or collecting system or both and with or without gas in the perinephric space so here you see dirty shadowing deep to the gas in the kidney and in the severe case we see gas in the renal area and the kidney is not seen separate from the gas when there is the amount of gas is very high so that is one of the classical appearances or you may see an enlarged kidney as seen here with the gas within the renal parenchyma and collecting system and perinephric space with the dirty shadowing typical of acute emphysematis pylonephritis a little milder form you see the swollen ecopower kidney with the pockets of gas both in the parenchyma collecting system and the perinephric space very rarely acute emphysematis pylonephritis may be bilateral as seen in the gas in the right kidney and the left kidney and when it is bilateral patient will be sick and patient may be in renal failure the variation of emphysematis pylonephritis is emphysematis pylite is where the gas is localized to the renal collecting system more common in women associated with diabetes and urinary tract obstruction mortality rate is significantly less than that of all the emphysematis pylonephritis when the presence of gas in the collecting system it has to be differentiated from calculus because both appear as a cogenic spots in the collecting system with shadowing whereas in gas it will be dirty shadowing at times it may not be so marked and so in that case when you can change the position of the patient here you see the axial scan of the kidney when supine position you see gas in the chelises whereas when you turn the patient to left lateral decubitus the gas from the chelises moves into the pelvis so the gas is seen in the pelvis confirming that it is gas and not calculus then we move on to the chronic pylonephritis as a result of multiple recurrent infections or a remote single severe infection the which has resulted in scarring of the parenchyma which is often associated with vesicoeriatric reflex or chronic obstruction or calculate now vesicoeriatric reflex is cause of chronic pylonephritis reflex when papilla reductors are incompetent more common in compound papillae so in the poles begins in childhood because of the reflex and more common in females chronic pylonephritis is often unilateral if it is bilateral it is asymmetrical in involvement and feature of chronic pylonephritis is scarring due to fibrosis which results in loss of parenchyma, cortical thinning, depression on the surface, retraction of the papilla resulting in a dilatation or clubbing of the calyx and the scars may be multiple if there are multiple it results in decrease in renal size and irregularity of the contour this is chronic pylonephritis you see cortical thinning and because of thinning there is depression on the surface and retraction of the papilla results in clubbed calyx or dilatation of the calyx deep to the cortical thinning now the scar and here a typical case of chronic pylonephritis with multiple scars of thinning parenchyma and dilated kinesis which with hypertrophied intervening normal tissue normal parenchyma which mimics a mass and as a result overall asymmetry of the contour of the kidney and because of multiple scars or trophy it results in decrease in the renal size so visecarytric reflex as a cause of chronic pylonephritis has to be evaluated ultrasound of the urethral vesicle junction will show the jet in red and reflex in blue which is seen in the real time you see the jet followed by reflex visecarytric reflex that is the jet followed by visecarytric reflex in blue so ultrasound can pick up visecarytric reflex next condition of infection is xanthogranometer pylonephritis a rare form of chronic destructive granulometous process from an atypical incomplete immune response to subacute bacterial infection renal parenchyma is ultimately replaced with lipid laden or foamy macrophages most cases occur in association with the renal pelvic calculus which is usually a staghorn calculus and the height of the process is thought to be a contributing factor the accostative organisms are rotis mirabilis and e coli symptoms are often nonspecific no-grade fever and malice flank pain and hematuria. Anthogranometer pylonephritis is rare more common in female diabetes in four to five decades now this is a ultrasound of typical xanthogranometer pylonephritis it shows an enlarged kidney of normal shape but heterogeneous parenchyma normal renal architecture of the parenchyma is lost you may see multiple cavities with debris but the classical feature is a large calculus in the renal pelvis is a very characteristic picture of xanthogranometer pylonephritis so xanthogranometer pylonephritis with fatty replacement appears as a fatty mass in the renal fossa as shown by the arrows I have replaced in the kidney and a large calculus in the center that is the renal pelvic calculus and the entire renal parenchyma has been replaced with fat then we pass on to fungal infection usually due to candida albicans usually occurs in premature infants females and advanced age diabetics and immunocompromised patients with obstruction and indwelling catheter and patients are usually asymptomatic now this is a premature infant term shows hydronephrosis and fungal balls in the dilated chelises and pelvis and with parenefric abscess also containing fungal balls that is a fungal infection of premature infant and this is a diabetic with obstruction and hydronephrosis and the dilated chelises and pelvis are filled with multiple large fungal balls that is very characteristic of fungal infection and our case of hydronephrosis with fungal balls in the dilated chelises and pelvis and also in the upper ureter now fungal infection can result in abscess rupture into the collecting system which will show as fungal balls in the dilated chelises pelvis and ureter then we pass on to pionephrosis pionephrosis is simply an infected and obstructed collecting system untreated a rapid off and permanent decline in renal function will result her patient may develop septic shock two cases of pionephrosis the dilatation of the pelvic lacyl system ecogenic collecting system you see debris fluid fluid levels within the collecting system these features give rise to a sensitivity of 90% and accuracy of 96% in diagnosis of pionephrosis and then both the cases you see calculate causing the obstruction so features are dilatation of the pelvic lacyl system debris as indicated by a course within the collecting system and the fluid fluid level shown in the calyx by the arrow another case of pionephrosis dilatation of the collecting system ecogenic walls of the collecting system debris in the pelvis and fluid fluid level a large pionephrosis serviced by dilated chelises and pelvis with third debris and also multiple fluid levels in the collecting system the pionephrosis may be due to obstruction by ureterocene as seen here you see that the hydronephrosis of the left kidney and in the dilated ureter you see the debris in the ureter and because of the infection there is total obstruction so no efflux from the ureterocene when we move on to parasitic infestation of the urinary tract the rear renal hydrated disease is rare two to three percent your patient is usually asymptomatic or they may present as flank mass pain and dysuria and the way complicated with assist rupturing into the collecting system are causing acute renal colic and hydrated urea urinal hydrated disease with two types type one is unilocular or it may be with multiple dot assist type three is completely calcified and represent the depth of the parasite now here you see the type one unilocular assist the thick bilated wall and hydrate its hand seen within the cyst or it may be type two with the spoke wheel appearance with because of multiple dot assist separated by fluid matrix so that is a typical appearance of spoke wheel in renal hydrate now here there is a assist in the parenchyma with internal debris which is ruptured into the collecting system with the dilatation of the achillesis and pelvis with the debris in the collecting system that is the hydrate sand filling the collecting system in which can result in acute renal colic and under urine examination there will be hydrate urea then we come to condition of papillary necrosis which may be due to analgesic abuse common in diabetics it may be due to urinary tract infection obstruction dehydration or sickle cell disease or hemophilia now in diabetics papillary necrosis occurs with poor control it may be due to over super added fungal infection now features of papillary necrosis the swelling of the papilla it sloughs and gets passed away which may obstruct cause some hydranoproses or it may get calcified now here this is the high frequency scan of a normal papilla that is the cortex and that is the medulla with the papilla this is the calyx so here you see the swollen papilla of papillary necrosis and papilla gets sloughed off and produces a papillary cavity which is seen as a clubbed calyx and filled with sloughed papilla or it can be passed out and it may get calcified in the place of the papilla itself or when it passed out it can cause obstruction so this is the papillary necrosis this is normal calyx normal papilla in tuberculosis you see the calyx and that is the medulla there is a papillary cavity communicating with the pelvis that is the typical appearance of tuberculosis whereas here in papillary necrosis you see the entire papilla necrosis sloughed off and lying within the clubbed cavity that is in the cavity so there is sloughed papilla remaining in the papillary cavity and see that is the sloughed off necrosis papilla in the cavity and when this gets passed out you see only the cavity communicating with the calyx and you do not see the sloughed papilla inside so that is the different appearance of papillary necrosis now here this is a coronal scan coronal scan of the kidney showing multiple papillary necrotic cavities all the papilla have been passed out sloughed papilla have been passed out here you see cavities filled with sloughed papilla and another in the lower calyx which is communicating and part of the sloughed papilla passed out and filling the pelvis and the ureter passed out sloughed papilla can cause obstruction to the ureter with high frequency you see the dilated ureter proximal and the sloughed soft tissue papilla causing the obstruction in the upper ureter and in the lower ureter and that is the ureterscopy showing the sloughed papilla in the ureter in the calyx you see the sloughed papilla after removal of the sloughed papilla you see the papillary necrotic cavity and that is the removed sloughed papilla now here you see the papillary necrotic cavity communicating with the dilated calyx because there is hydronephrosis there is also some soft tissue there and you see distally in the lower ureter you see the soft tissue filling the ureter indicating that it is sloughed papilla which is causing the obstruction that is the real time you can see the hydronephrosis you see the cavity in the upper pole parenchyma that is the papillary necrotic cavities another case you see hydronephrosis and you see upper ureter there is a calculus but it is the case of poorly controlled diabetes and if you watch carefully you see the hydronephrosis and you see actually they are communicating with the cavities in the parenchyma so that is papillary necrotic cavities multiple cavities you can see in real time you see the multiple papillary cavities in the parenchyma how to differentiate so here papillary necrotic cavities with the echogenic mass causing obstruction it is actually calcified sloughed papilla which got passed out and causing the obstruction and not a calculus so how to differentiate papillary necrotic cavity versus hydronephrosis so here these are dilated calisthenes and the parenchyma this is dilated calisthenes and the cavities so in the dilated calisthenes are confined to the central echogenic area and there is symmetric dilatation whereas in papillary necrosis the cavities are seen in the parenchyma outside the central echogenic area in the parenchyma and they are asymmetric they are not of the same I hear the calisthenes are of same size symmetric whereas here it will be asymmetric you can see the cavities in the parenchyma whereas dilated calisthenes is confined to the central echogenic area so hydronephrosis progression if you see this is mild this is moderate so the calisthenes are confined dilated calisthenes are confined to the central echogenic area however much the dilatation is these are the renal pyramids in the parenchyma that is the parenchyma confined to the central echogenic area gross again symmetric there is parenchyma thinning again very gross with high frequency you see the parenchyma made out and very gross very thin parenchyma and finally no parenchyma they slay it's just a bag of fluid so however much is the dilatation the cavities are not seen in the parenchyma whereas in papillary necrosis you see them in the parenchyma necrosis papilla you see as ring like calisfications in the region of the renal medulla and two cystitis that is the infection of the bladder more in women coronation of the urethra by rectal flora because in women the urethra is short it is common in men usually in case of bladder obstruction or prostratitis positive organism is E. coli the symptoms will be bladder irritability in the form of dysuria frequency or hematuria on ultrasound you see diffuse mucosal thickening or it may be focal mucosal thickening here you see diffuse mucosal thickening of bladder and then color you see hyperemia typical of cystitis and another case you see diffuse mucosal thickening and there is peri vesicle fat inflammation in a severe case of cystitis with treatment all of this will disappear there may be focal mucosal thickening as seen here in a case of cystitis now emphysemitic cystitis is acute urinary infection which threatens patients life characterized by gas in bladder wall or in the lumen of course in diabetes or in urinary tract obstruction causative organism is E. coli and clebsiella pneumonia so here you see a case of emphysemitic spiline apparatus where you see thick gold bladder with gas in the wall as soon as in the lumen and when it is in the wall you will see alderone in the wall that is typical appearance of emphysemitic cystitis a rare form of cystitis is cystitis glandularis or cystitis cystica it is a proliferative disorder of urinary bladder glandular metoplasia of the transitional cells lining the urinary bladder it occurs due to chronic irritation from infection or calcule here this case you see focal polypoidal wall thickening of the urinary bladder in the region of the trigone and there may be mild obstruction with hydronephrosis or may not be there and here another case you see the polypoidal thickening of the base in the region of the trigone with tiny cystic areas so that is the typical of cystitis glandularis the cystitis or the infection of bladder may be extension of adjacent infection like appendicular abscess here you see an appendicular abscess which is extending into the wall of the urinary bladder it can even rupture so you can see with high frequency the abscess extending into the wall of the urinary bladder or it may be a diverticular abscess you see an abscess near the dome of the bladder mimicking a uraical mass but in the sigmoid colon you see diverticular we have to think of an abscess due to diverticular so because of the uninflamed diverticular so it is confirmed after three months the abscess is ruptured into the bladder resulting in a colo vesicle fistula which is with evidence of gas in the urinary bladder let me pass on to the last component recurrent urinary tract infection the uti follows the complete resolution of a previous uti then you call it recurrent urinary tract infection a threshold of three uti's in 12 months is used to signify a recurrent uti the role of ultrasound in recurrent uti is to pick up predisposing conditions like anatomical abnormality which may be congenital, acute or voiding dysfunction or obstruction so those can be picked up or just one example of a role of ultrasound in recurrent uti in this patient you see the bladder you see a gas in the urinary bladder and careful scan you see a gas filled attract from the urinary bladder to the colon with a suspicion of colo vesicle fistula which is confirmed by water enema you see gush of fluid from the colon by enema into the bladder confirming colo vesicle fistula as the cause of recurrent urinary tract infection due to diverticular so you see an influent diverticular in the colon confirming that it is due to diverticulosis. Now ultrasound is also useful in guided interventions in correction of predisposing anatomical abnormality like Pugab's Fiction or vesicle retric reflex and also in intervening complications like renal abscess or perinephric abscess. Thank you for your patient listen.


Hey survivors, welcome to the video. I am going to be discussing self-preservation within the narcissist fake world or alternate reality. Please like, comment and share. Subscribe if you haven't subscribed yet. My donation link and email if you are interested in coaching are in the video description. What is self-preservation? I am going to begin with a definition of what this is. Self-preservation is the protection of oneself from harm or death, especially regarded as a basic instinct in human beings and animals. It is the instinct to act in your own best interest to protect yourself and ensure your survival. An example of self-preservation is running away when you see a giant bear. What does this have to do with narcissism? I believe that when we are around narcissists, the act or natural instinct of self-preservation is limited. The narcissist conditions us to not trust our instincts. The narcissist changes our core beliefs, values and principles. What you once believed or valued before meeting them can be completely different during or after the relationship. This includes what you believe about yourself or the world and other people or things. The narcissist teaches us to not trust ourselves, to not trust our own instincts, our own beliefs, values and principles. This is done through a form of mind control or gaslighting. They will tell you that something you believe or something that you have said or done is wrong and then they will display what they believe is correct to you. Over time this can result in a significant change of your beliefs, values and principles. It will also change your natural instinct of self-preservation as you will no longer trust your own thoughts or feelings. So instead of trusting your own instincts, your own thoughts and feelings, your own beliefs, values and principles, naturally we are going to turn to the narcissist for what is right and what is wrong. We turn to them for an understanding, for validation and this is where the problem begins. As narcissists are very good liars, they will intentionally deceive you. They also like to use manipulative tactics such as denial, projection and blame shifting. So the very person who we should not trust becomes the person we are turning to for answers.  The narcissist can change everything about you and the environment you live in. You may look back throughout your life and realize that you do not possess the qualities you once had. You may no longer believe in yourself as much as you did. You may no longer view yourself as an attractive, loving or caring person. The narcissist may have changed your beliefs to view yourself in a negative way. They may have changed the way you once valued love, intimacy and relationships. They may have changed the way you once valued honesty and trust. Now I'm going to go into the narcissist's fake world or alternate reality and how this affects your self-preservation. At some point the narcissist created this fake world or alternate reality. They created their own rules, their own beliefs and interpretations, most of which go against social norms. You are expected to comply with these rules, beliefs and interpretations. Over time this form of conditioning can change you at a core level. In this alternate reality they will rewrite the past. They will make you believe that you haven't achieved anything. They will also prevent you from achieving or obtaining anything. They will make you believe that what you have isn't that great. They will make you believe that you are not as attractive as you may think you are. They will completely reconstruct your character and personality to be whatever they wanted to be, which is never going to be anything good, of course. For this to take place, for them to be able to reconstruct your original character and personality, they are going to have to take away whatever it is that makes you who you think you are. They will abuse and manipulate you to the point where you don't know who you are anymore. Then they are able to re-engineer your mental composition. They are able to reconstruct your beliefs, values and principles about yourself, other people and the world you live in. This is an essential process if they are going to bring you into this alternate reality or world. In this alternate reality or world you have to be isolated and taken away from the real world. Anyone who is in your proximity must be programmed or conditioned in a way so that they develop false attitudes and beliefs.  To be a healthy functioning individual, there are certain needs that you may require. The narcissist knows this and they are very good at targeting whatever it is that preserves who you truly are. As a healthy functioning individual, you may desire human connection, hobbies and interests, finding your purpose in life. The narcissist will target these areas of your life to ensure that you are unable to practice self-preservation. If you have everything you need to practice self-preservation, this becomes a threat to the narcissist's narrative of you. In order for them to maintain their narrative and make it believable to those around you, they must target whatever it is that helps to preserve your true self and I've noticed in my personal experience, certain areas they would target that they believed made me who I am. Women and relationships were definitely something they knew they had to target. I have always been naturally attractive to women. They became aware that I would always have a woman in my life who I was intimate with. Be aware that the narcissist studies all of this very deeply. They know the science and the psychology behind it. They understand the neurotransmitters that are released within the brain when you have an intimate partner. Chemicals such as oxytocin and adult neurotransmitters, these neurotransmitters have a similar effect to drugs. When a person is removed from experiencing the intimacy that they have been used to for many years, it is going to cause a significant change within the person. Over a long period of time, it could even affect them at a core level. You may feel as though you are no longer the person you used to be. The narcissist understands all of this and this is actually what their alternate reality or will is designed to do. It is designed to deprive you of whatever it is you naturally need to function as a human being. It is also designed to deprive you of any form of human interaction or connection. Once again, the narcissist understands that this will affect the release of dopamine within the brain and it will also affect your overall mood. They may not know the specific names of the transmitters or the actual process behind all of this, but they do know the exact effects that this is having on your brain. It also makes it far easier for the narcissist to point the finger at you and call you crazy. A trick the narcissist likes to use is to have sex with you maybe for several days in a row and then not contact you for a few days. This is intentional and they do this because they know the effects it is going to have on you. Once you have been excessively intimate with them your brain becomes conditioned to expect this level of intimacy again.  It gives them a huge amount of narcissistic supply and makes them feel desired and wanted by you. They like to have control over you. They don't want you to choose when you are intimate with them. One of the narcissist's favorite tactics is to withhold sex after they have already got you hooked on being intimate with them. You become used to it, you become conditioned and the narcissist understands that this is one of the most natural cravings that you are going to have whether you like it or not. They have also likely asked about your past and your childhood experiences. They have studied your past.  They know that you are going to be craving some form of attachment. They understand the effects of what they are trying to achieve. They specifically targeted you for this reason. They are very predatory. They probably studied your family, social circle and any potential support you may have. Then they gradually removed these people so that you could experience the full effects of their programming. The narcissist wants to have complete control of your body, mind and soul. There is nothing more satisfying for them. Towards the end of the relationship they will prepare a smear campaign and enforce flying monkeys. This is designed to condition anyone who is in your proximity and anyone who you could potentially meet after they are gone. The narcissist wants you to be in a condition where you are constantly deteriorating. They know that if you have the ability to go on and develop new friendships or relationships hobbies and interests finding your true purpose in life they are going to lose control over the situation. They are going to lose control over you. The smear campaign is designed to prevent any of this from naturally occurring. Even in the real world the majority of people feel as though they are not being heard or seen. When people interact it is not to listen to the other person rather it is used as an opportunity for them to be heard. We live in a narcissistic world where people are becoming more and more self-absorbed. This is why we are starting to see so many people acting out these days. We have lost the ability to connect as human beings. We have forgotten the value of listening to the other person. When people are having a conversation they are not really listening to each other. They are in their own minds thinking about what they want to say. They are just waiting for the other person to finish what they are saying so that they can express themselves and get something off their chest. So everyone wants to be heard but no one wants to listen and if you look at the world today you can see the effects that this is having. It is a problem and there have been many things that were supposed to be a solution such as social media. It was supposed to help us to connect but it seems that it has only divided us even more. Real intimacy or genuine human connection is extremely rare in today's world. Another potential solution is ASMR. It has become very popular over the last few years probably hundreds of millions of views on YouTube. The problem we have is that there is no real intimacy or human connection. ASMR was designed to treat this issue but when you think about it it is just masking the problem. Some of these videos are so intimate like when you have them looking deep into your eyes and whispering in your ear. How can someone in real life ever compete with that? If someone did that to you in real life it would feel very uncomfortable but then when you are watching it on YouTube with your earphones in it has given the same effect without feeling as invasive. Just my thoughts on that. Anyway back to the alternate reality or world which the narcissist creates. As I said in the real world people do not feel like they are being seen or heard so they are constantly doing whatever they can to be noticed. You will see people splashing out on fancy cars, design a clothes, dress and half naked doing whatever it takes to be seen. If they are not being heard it creates a conflict. To resolve this conflict everyone must be heard. But of course as I said before everyone wants to be heard but no one wants to listen so how could this ever be resolved until people realize the value of listening and this is in the real world. In the narcissist alternate world it's even worse. Once you have been smeared no one will value anything you say. It doesn't matter if it's completely true. If it doesn't go along with their false narrative it is irrelevant. It has to validate them or gratify them in some way to hold any value.  This will be very challenging in the beginning but over time you will feel strong and remember it is better to have no intimacy or human contact rather than to be connecting with toxic or narcissistic people.   It's designed to prevent you from experiencing peace, joy, love, reason, acceptance, willingness or even neutrality so you are going to have to learn how to experience these higher emotional vibrations on your own and I'm going to be honest with you it is a very difficult thing to do as human beings we are designed to crave intimacy and human connection there really is nothing you can do about that and the narcissist knows the power of their smear campaign or alternate reality it is specifically designed to break you down it is designed to change your beliefs values and principles about yourself the world other people and things you need to start focusing on yourself rather than the narcissist while you are in this alternate reality or world it may be tempting to turn to addictions addictions such as drugs alcohol prostitutes gambling or pornography but this is exactly what the narcissist wants you to do this is how their world is designed to affect you they want to see you begin doing drugs and drink an alcohol anything to relieve the pain right they want to see you lower your standards and settle for prostitutes they want you to substitute any real feeling of excitement for gambling they don't really want you to watch pornography because that's very difficult for them to compete with it makes them feel inferior but in general they want to see you develop addictions because of the alternate reality they have created they want to see you substitute in whatever it is you are used to they want to change you at a core level anytime that they even see you trying to go back to the person you used to be it triggers their inferiority complex all over again they are thinking in their minds you're not supposed to be doing that that's not who you are that's who you used to be before we changed you anything that resonates with your original character or personality will trigger them to feel this way remember the real you made them experience emotions they don't want to experience again intense hatred anger envy and jealousy they don't want to feel that way again that's why they felt compelled to create this alternate reality but enough about what they are trying to do to you i want to talk about how you can practice self-preservation you need to remember the person you once were before they created this world start doing this the the exact same things you you were doing back then start listening to the same songs songs that will make you feel the same way you once felt if the narcissist is stopping you or making it difficult for you to be yourself in your current environment go somewhere else don't tell them you are going somewhere just leave and start being you instead of being their version of you because that's not who you really are that's just who they who they want you to be they want you to be that person because it makes them feel more comfortable they don't want you they don't want to see you progressing or succeeding achieving or obtaining because it makes them reflect on themselves and how miserable they are so you just leave and start living the life that you want to live if you don't have the money right now take a short trip so you can get your mind in the right place you can start remembering who you really are before they stuck their noses into into your life and started changing everything being around these people you are constantly reacting to them you are constantly being what they expect you to be because any time that you aren't following their false narrative they feel uncomfortable they try to change you to suit how they want you to be so you need to get away from that environment as long as you are around these people you will never be able to be your true self how can you be your true self when your environment is responding as though you are someone else that doesn't make any sense so you need to get away somewhere where the environment will respond to who you really are then you can be free you can be your true self instead of being someone else's version of you your reality needs to be in line with who you are if you want to cope with the situation until the time when you are able to leave start getting back into that person you used to be ask yourself what would the old you say about all of this what would they tell you to do in this situation how would they react to all of these narcissistic idiots listen to your true self because that's who you really are start listening to the songs that you were listening to back then if you are eating good healthy foods start eating that again healthy eating will make it easier for you to raise your emotional vibrational frequency if you are craving any real human intimacy or connection just watch videos on youtube especially videos from countries in the eastern world or south south america it seems to be less narcissistic over there in my opinion watch asmr videos remind yourself of how it feels to be intimate how it feels to connect this will help to get you back to your true self this will allow you to practice self-preservation as much as you can try to do the same things that you were doing before you got involved with these people go to the gym start working out if you used to enjoy swimming but the narcissist told you you're no good don't listen to them start swimming again everything they told you you can't do or you're no good at that's exactly what you should be doing that's exactly what your body needs and that's exactly what will help you to practice self-preservation so pay attention when they tell you something you shouldn't do or you are not good at if you listen to your true self the person you used to be that's exactly what they will be doing everything the narcissist is trying to control or prevent you from experiencing is exactly what you need to practice self-preservation practice mindfulness pay attention to your thoughts and feelings in your environment or when you are around certain people practice self-love look in the mirror and start loving everything they told you was not good or not right they were they were only projecting their own insecurities onto you you are most likely a beautiful person with an amazing personality that's why they had to create this world to control you they had to place limitations on your life because of the perceived limitations in their lives forget about everything they said forget about their criticisms and distorted perceptions they were wrong they just didn't want you to be you because witnessing your beauty witnessing your amazing personality made them feel envious and jealous of you don't let them control your life it's your life you are given free will by god they have no right to take that away from you that's the mordekin itself so you start meditating on the person you used to be before you got involved with them remember that person and start living as them now remind yourself of the beliefs values and principles you once had about yourself the world other people and things start playing those old songs again so you can start feeling the way you used to feel go to the places you used to go do the things you used to do just start learning to be you again this is what helped me to find myself again I hope that it will help you thank you for watching please like comment and share I'll talk to you soon