Lleiddoedd am gael y cyflawnol, ac oedd yn yr ysgolwch, ac mae'n gwybod yw'r gweithio ymlaen nhw arall, yn cael ei gweithio y cyflawnol, ac mae'n gweithio eu cyflaceddau a'r cyflaceddau yn ymwylo'r cyfloddol a'r cyfloddol a'r cyfloddol i'r prinsidol a'r cyfloddol a'r cyfloddol a'r cyfloddol a'r cyfloddol. Ond yw'r cyfloddol wedi bod nhw'n mynd i'w cymdeithas, y maen nhw'n gweithio eu cyfloddol nad yw ydy'r swydd yn wneud o'r Brooklynd i'r ffordd, i ddyn ni'n yourr hwyl gyda gael안 cyffredinol, am how can we do that in a better way with people getting all together and addressing it? Felly, ydych chi'n sgwp yma sydd yma, ac efallai'n gweithio'r gynllun o'i gynllun o'i gynllun o'i'r gaf. Efallai'n gweithio'n gweithio'r hwn o'r gweithio, ac mae'n mynd i'r gweithio i gyd, mae'r gweithio'r gaf yn gwyfyn nhw, yn dweud, mae'r gaf wedi'i gweithio'n gweithio'n gwybodaeth gan GYsau Llyfr o'r Gwyrdd. Mae'r gaf' rhaid i gynllun o'r gweithio'n gweithio'n gweithio'n gweithio. Mae'r gwnaeth digon i gael ei ddefnyddio fy ngayl, ac so wedi am gyfwilio ar y dal o'ch gweithio gyda'i Edoedd, yn Helfkell, ac mae'r wneud, ac mae'n gwybod o gwaith o'r maean o'r gweithio i gweithio i gael. Mae'n gwybod a'r Gwyrddol i Gwyrdd o'r benedig, mae'r gweithio i gael o'r talus. Ond oedd yma, mae hynny'n gofio ar gyfer eu prif. When the NAFвIL report came along, it had confirmed to the figures in Alan commission, which we had shown in the Bevan commission, and added much more analysis and updated data to them. Then, that slide now has the welcome announcement only last week of additional funding for the NHS in Wales and that is going to make a difference, but not going to make a great difference…the great difference is up in our game, and having a closing gap, was I mentioned earlier am unig i gael ei wneud. Ond wedi cael ei gallu gweld i'r llunio ffondiol iawn, ac wedi'i gael ei wneud i'r llunio ffondiol iawn, ac mae'r ffondiol iawn i'r bwysig o'r ffondiol.  Mae gydag i fyng Nesbynydig Scoll, ac mae'n ddiwedd a'ch ddwyledd, soeddwn i'n eich gweld i'ch bod gyda nhw. Flyny tu'nny fyddaent o ei wneud y ffordd ac yn gychydig i'ch gwybod i'ch gweld i'ch roedd o'r cwmniadau barnet, maen nhw'n gofyn yng Nghymru ac behaeth gwysig iawn, ac mae gweithio'r leol yn gyntafol â amser, yn gweithio'r leol, gan myfyrdd o'r lle ei wneud. Mae Yw Wales yn cael ei ddaeth yn cael ei ddweud, ac mae'n gymaint ar gyfer gyfio'r rhain i LHS. Mae'r rheswm yn ymddiynt i ddweud yr achwymru, gyda dwybr iawn ac mae'r cyflogol. Mae'r correu aroedd amlwgau atig yddi, a pethau ddysgu ymddill, 5% i ddweud y cap. That was a huge amount and the Nuffey report has sort of made that little clear out and has estimated what it is that the different funding gaps would be according to how much money is put into the system from various sources. Roedd hyn yn eistedd yn gweithio i wneud o'r reidio arna a dyn nhw'n cymdeithas, ond rhai llyfr am yr unigio i ddim yn dweithio'r gwaith, o ran wahanol ehlrif i ni ddoch i ymddangos mewn gwirionedd, dargarwch honno'n llyfr o oedlau'r ffrifwyr, a'r hunrfrif oes yn gwneud i ddim yn ei ddweithneud. Dw i'n mynd i ddim yn syniad i ddweithio'r gweithio a'n hyn syniad i rydw i ddweithio'r gwaith? Well that was about two years ago I think that the risk is far far less now because many things have happened some of which have been happening in the last year in connection with puppet healthcare. And of course in the release of the extra funding which the Minister referred to yesterday. But this is the statement that I still I think is relevant. To close the gap without additional funding NHS Wales will have to improve efficiency. and will have to improve productivity because they are not the same thing. at a record rate, and sustain this for a period not seen either in the history of the NHS or any other country's health system, so it's still a very formidable challenge. The gap being the funding gap and the gap between what we do now and what we are very capable of doing which would improve the delivery of the service. Felly, we thought at the time and we've been talking to the Minister about this and his visuals, that we should look at the thing which we then call prudent healthcare. So, I'd like to just give up the rest of my talk about that and why now. Prudent healthcare was defined, as you will see there. It's a rather wordy initial definition, but it's trying to get a grasp of what it is we wanted to do and what it is we wanted to define, and what it is we wanted to capture people's hearts and minds. That was the first definition, but it's changed, although the essential principles are still there. Caution, that doesn't mean slow, it means thought through. Safe, wise, which is what the word prudent means, and of course, careful budgeting, but that is an issue which is part of the whole, rather than the only issue that we're addressing. The main thing is achieves tangible, measurable, material benefits and quality outcomes for patients. Our provisional principles, and let me make it quite clear that these are provisional. I'm taking you through the history of the evolution of the principles. These were the first ones that we articulated and the Minister accepted as provisional ones, and we said they're not written in stone. These principles are things that will evolve, and not only that, we felt it was in the beginning, but they needed to be fleshed out. Different words can mean different things to different people. Words are very important. We understood what we meant, but a bit more work needs to be done in that area. So our principles were treating greatest clinical need first. That's an equity question. Do no harm achieve measurable good, and I'll go into that a bit more. Do the minimum appropriate intervention to achieve the desired outcomes. Again, I'll talk a little bit more about that because people have misunderstood what is meant by the minimum intervention. Choose the most prudent care openly together with a patient. Now that fits in with number six, which is co-produce health with the public, patients and partners. And then consistently and appropriately apply evidence-based medicine in practice. Those are the first six principles. What happened then was we tried to flesh out what some of them meant. And when doing that, we looked at the conversation that takes place between the clinician and the patient and articulated these words, that agreement between clinician and patient, that the intervention is likely to affect a tangible beneficial outcome compared with other possible interventions. So this was going beyond the do no harm, and you're all familiar with that by now, but it's a major change. It's sort of revolutionary because we're saying, we're not adhering solely to the hepocatic oath. We're saying just don't apply to no harm, but achieve some tangible good, which is part of good practice anyway. And the intervention must do more measurable good than doing nothing. Similarly, the objective of achieving optimum health, which the circumstances permit should the intervention be agreed and adopted. Those words can mean that various things to various people. We felt that if the intervention is justified, it should always be that which is the least necessarily required to bring about or to seek to bring about the agreed change. Many people have misunderstood minimum, meaning least, meaning minimal. It's not. It's the minimal, the least necessarily required based on the evidence which is likely to bring about a beneficial outcome. I think that explanation is what is needed with all the principles and any modification of them. The minister said policy-wise, two statements from recent speeches, which describes, to some extent, public health care. But the second one is, I think, far more important than the first one, because the first one is something that we were aspiring to anyway. We wanted to actually achieve this coming on. Let's go into limbo. To rebalance the NHS in ways to create a patient-centred system, we all talk about that, but we haven't yet achieved it. To remodel the user provider relationship on co-production. There have been conferences, there have been a thousand lives issued and the chief medical officer launched last year, I think it was, a paper on co-production. But that is a new issue, I think, that the minister wants to be included as prudent health care. We included in our first few principles. And the idea is, in another phrase that he uses, to redraw the relationship between the citizen and the state in Wales. Prudent health care action. Now, when I'm asked by the media to explain to them what prudent health care is all about, I can't really find the words to explain what I've been trying to get across to you. So I've tried to capture it in another way. And I call this Daily Mail Speak. Stop doing things where there's evidence they don't work. We don't always do that. We have been using interventions, not just in Wales, but across the developing and developed world, whereby we know that they don't work. There is evidence of inefficacy, and yet we still use them. Less so and less so, but nonetheless we do. Invest only in what it gives, what gets tangible benefits. That's important to just try and identify and classify the various pieces of evidence that support a particular action. Improve quality and clinical outcomes that's obvious and involve patients and citizens in co-production. Another emphasis upon that. How do we do this in Wales? Well, I use the word Big Bang, and the Minister also picked that up. Not place you'll change, but Big Bang does not mean everything will be sorted out by tomorrow. Will it? It won't. What it means is we're not going to slow down on this. We're going to progressively and progressively more and more develop prudent health care and get it spread across all Wales nationwide at once, not just having it developed in one particular area or one health board, get it across the whole spectrum of the country. And it's easy to be on. And cultural change. This is not going to happen unless there's cultural change.  Fashioning the principles. What we did, first ones, as I mentioned, were developed by the Bergman Commission as provisional principles. We then had the Minister's speech had added flesh to some of those and clarified some of the others. And in April 2014, there were prudent health care workshops to test the principles. This was done and there by a thousand lines in Public Health Wales. And there were four workshops, 30 delegates, as you can see the people involved there, identify opportunities, indicate methods, comment on principles, the original Devon Commissioner principles. Those were workshops dealt with adult aid management, medicine prescribing, adult hearing loss, disneyers and dentists, and knee and hip problems. We thought we'd better look at those in the first instance and how did prudent health care, did prudent health care, have any basis in taking forward these issues and better and more quality driven and patient safety manner? Sorry, yes. These were reported in a paper that was published by Pete Bradley and Alan Wilson and a number of co-authors and it looked at achieving prudent health care in Wales and I'm sure you all see that and you should refer back to that if you wish to gather any further information. And then what was launched yesterday and let me remind you, those of you who haven't got it, this is the booklet, this is the one about the e-learning that gives the comments of people who produced the 10 chapters where they talked about what prudent health care meant to them and how it related to their area. And I think this is a very important document and has already been referred to quite a lot by the Minister and I hope you will pick up not just this but actually use the website itself. And last of all I think the latest five for the moment but let's remember these are not yet in concrete. They are the ones that should drive us forward undoubtedly but they may need some change and the Bevan Commission has been asked if they would look at these principles are there other ones that need to be added and do we need to flesh out and identify what we mean by some of them? Now these are there and already there is one principle that is this five list which when we go out and talk to the people to people who are not informed to people in the third sector they do not understand or organise the workforce around the only do what only you can do principle. We understand it because we interpret it in our language, in our climate, in our culture they don't understand it and if they don't understand it we've got to look at it. So one of the things that we will be looking at is looking at that principle to see if we can articulate it in the way it's meant and intends to be. So those are there and the two metal officers showed us those yesterday. This is the most important slide I think and that is the prudent approach is not and should not be confined solely to the provision and management of healthcare. Prudent healthcare was the words that we used in the beginning it must also be applied to social care, health improvement achieving a step change in the health of the people in Wales and remodeling the relationship between citizens and NHS where it was based on co-production. It goes beyond that. I was very pleased yesterday when the Minister referred to some remarks that I maintained about let's have a social movement I think it's extremely important for everyone to own. There is a need for a social movement. So we have still a huge real financial challenge. We must develop and adopt the prudent healthcare and the prudent approach. It's everyone's business and we must develop and encourage a social movement.


Hello and welcome to Around the World in 8 Minutes, a show from People's Dispatch where we bring you stories of resistance and defiance from across the world as the collective strength of the people fights back against the horrors of capitalism and imperialism and strives for a better world. For the first story, we go to Swaziland, where the police detained and allegedly tortured seven students, including the president of the Swaziland National Union of Students while they were returning from a protest march last week. The students were demanding scholarship for all students admitted to higher education. On August 15, students from the country's three major universities, the University of East Swatini, the Lim Kok Wing University of Creative Technology and the East Swatini Christian Medical University came together in joint action for the first time in decades. The demonstration was a part of the campaign launched by the Swaziland National Union of Students or SNUS in May 2017 to force the government to reverse its decision of cutting 60% of the scholarships, making the remaining 40% available only to selected courses. The students are demanding that anyone who gets an admission into an institute of higher learning after having secured the required grades must get a scholarship regardless of which course they choose to study. The protesting students also delivered a petition to the Ministry of Labor and Social Security stating their demand. The act was enough to provoke the police forces in the capital of Amabadi to launch an attack on the students who were on their way back after the delivery of the petition. In Swaziland, over 70% of the population lives below the poverty line of $2 a day. Without scholarships, higher education is inaccessible to the great majority of the masses regardless of how well they score in their secondary education. Journal reports have indicated that young students who are unable to feed themselves sufficiently are being forced to sell themselves as prostitutes. Exploiting these conditions, many local businessmen have made it a part of their business to offer university students as sex workers to rich tourists from neighboring South Africa. The government of King Maswati III refuses to allocate the required funds for their education and bring an end to this abuse of the young generation who seeks to study on the grounds that there is a shortage of funds. Maswati is the last absolute monarch in Africa who reigns above the law. The royal family of the king, who controls 60% of the country's economy, has 13 palaces, a fleet of luxury cars and motorbikes, and two private aircrafts. Condemning the police action against the students, the Communist Party of Swaziland said in a statement that they will continue to work with SNUS and the entire student movement in support of their demands. After leading a decade of peaceful struggle against the monarchy to bring about a democratic Swaziland, in the course of which the party has been banned and its mass organizations subjected to harassment and oppression, the party has begun preparing for an armed sabotage campaign against those industries and infrastructure that are crucial for the upkeep of the monarchy. The party argued that none of the demands of unions of workers or students can be met under a repressive monarchy. With the demand democracy now, it has urged the students to come on board to participate and contribute meaningfully to this engagement and ensure that the socialism they call for is implemented in their lifetime. Now on to a story of workers, Victorian Qatar. Thousands of migrant workers, most of them hailing from South Asian countries such as Bangladesh, Nepal and India, have won significant concessions and assurances from the Qatari government following two days of strikes and protests. Held in the first week of August, the workers were protesting against the delay and non-payment of salaries in human working conditions and threats of wage reduction. A local trade union activist said that the protests had taken place on August 4th and 5th, mainly in and across Labour City, where a majority of the migrant workers live as many of the big construction companies are situated in the area. On August 4th, workers belonging to the ISKCON construction and contracting company went on protests due to delays of over two months in the payment of their salaries. The following day, between 800 to 1000 ISKCON employees refused to report to work. One of the employees claimed that in response to the protests, the company's management threatened to deport workers who refused to sign the new contracts with reduced wages. The protests resulted in the workers entering into negotiations with Qatari government officials over issues and problems faced by them. Following the successful negotiations, those affected received two months of unpaid salaries from their companies. Qatari authorities also arrested company officials who were guilty of not paying the workers their dues. Many workers also registered their grievances regarding applying for and procuring no objection certificates. The certificate is a necessary requirement to quit a job without the employer's permission. Government officials issued such NOCs to the workers, allowing them to change their employer as a result of these protests. The protests reflected the precarious and desperate situation of the workers. The workers are employed under the kafala system, which forbids employees from changing jobs without prior permission of their current employers who have sponsored their work visa. The employers also have power over the workers' movements and can decide whether they can leave the country. Trade unions remain illegal in the country with a general ban on strikes. A trade union activist who spoke to the media on condition of anonymity clarified that the protests were not related to the projects for the FIFA World Cup to be hosted by Qatar in 2022, the anticipation of which is generally considered to have affected the government's response to the situation. Ever since Qatar was awarded the rights to host the prestigious football World Cup by FIFA in 2010, the nation's treatment of its migrant workers has received global scrutiny. Qatar has the highest proportion of migrant workers' population in the world, with 2.3 million of the 2.6 million inhabitants being expatriates. Most of these workers come from poorer South and Southeast nations and work under extremely poor conditions and for meagre wages. What brought attention to the condition of the migrant workers in the tiny Gulf state would be the high incidence of deaths among workers under the age of 50, often because of exhaustion and adverse impact of years of strenuous work. According to data revealed in 2014 by various sources as reported by Guardian, over 700 Indian workers and over 400 Limpali workers were estimated to have died in a span of two years since 2012 across the country. A 2013 report by the International Trade Union Confederation had estimated that if situations did not improve, then nearly 4,000 workers can be expected to be dead by the time the World Cup begins in 2022. Finally, we go to Turkey. The Turkish riot police on August 20 used water cannons and tear gas bombs to brutally suppress Kurdish protesters who were demonstrating against the government's decision to remove three Kurdish mayors on August 19. The mayors represented the Kurd majority cities of the Arbaqir, Mardin and Van in Southeast Turkey and belong to the pro-Kurdish People's Democratic Party or HDP. In the city of the Arbaqir, police were seen using high pressure water cannons on small groups of protesters who attempted to join and stand together in a bid to protect themselves. They were also seen making victory signs with their hands. Some protesters had gathered near the Arbaqir municipal building which was sealed off by metal barriers. Videos emerged of riot police brutally beating them up. Several journalists who were covering the protests were also physically assaulted with batons and tear gas. The police even used plastic bullets to crack down on the demonstration. Reports indicated the presence of over 500 riot police personnel meant to contain the roughly 200 Kurdish protesters who had gathered there. Armoured vehicles were also seen at the site of the protests serving as a backup for riot police. Several pro-Kurdish HDP lawmakers who were part of the protests ended up with injuries. The HDP leader, Cezayit Emili, told reporters, you can see here today a regime of pressure and persecution. We will continue to resist wherever we are because resistance is a legitimate right. Turkey had removed the mayors after accusing them of various crimes including being part of a terrorist organization and spreading terror propaganda. These accusations have been categorically denied by the HDP. The three mayors were elected to the respective mayoral seats in the elections that were held in March. The Arbaqir mayor Selkukh Mizraqli received 63 percent of the votes. Mardin Mayor Ahmed Turgh received 56 percent and Van Mayor Bidya Ertan received 54 percent of the total votes. Turkey had on Monday also detained at least 418 people across 29 provinces in the country on suspicion of links with the outlawed Kurdistan, workers' party and other armed Kurdish groups. So, this is all we have for this episode of Around the World in 8 Minutes. For more such stories and videos, visit our website peoplesdispatch.org and follow us on YouTube, Twitter, Facebook and Instagram.


This systematic review assesses the appropriate technique for laparoscopic cholecystectomy, LC, in situes inverses, SI. Finding that left-handed surgeons may find LC in SI easier, while the fastest technique for right-hand surgeons is the American mirror technique with some modifications to port placement. This article was authored by Muhammad Ali Chowch, Hitcham Jireya, Muhammad Weiji Dugas, and others.


An announcement was made recently within Egypt, pertaining to an amazing discovery made within an area of the Giza Plateau that for a number of decades has been conveniently shut off from the public. Although the location is claimed to be a military training base, archaeologists have apparently been secretly beavering away within this remote slice of antiquity. Just by the Supreme Council of Egyptian Antiquities, Egyptian authorities have apparently found the mysterious traces of the legendary Fourth Lost Pyramid of the Plateau. This provocative announcement stirred up a gale of protest among many Egyptologists, and the reason for this may be because the discovery might turn out to be highly controversial. Although the pyramid is in a very bad state, and this may be due to its immense age, and these surviving blocks clearly displaying evidence to indicate that the missing blocks have simply eroded away over the eons, this ruin may not be the most important find in the area or indeed the purpose for the video. Along with these pyramidal remains at the site is another amazing anomaly. In the middle of this mysterious desert, an enormous staircase has been found, plunging into the desert floor, seemingly excavated before this announcement and left for those who were fortunate enough to get access to the area to rediscover and photograph. This enormous staircase plunges straight through a limestone basin many meters in depth. This surgical slice has revealed an astonishing implication. It has revealed that the Giza Plateau does indeed extend this far, not only that, but it demonstrates the sheer, unimaginable cubic size of this area of stone, a block of stone that was apparently man-made. Where this staircase actually leads to is as yet unknown, although it is thought to drop far below that which is currently visible, and preliminary scans of the area are suggesting that it plunges through the plateau deep into an ocean of groundwater below. By examining the pictures of the discovery, it appears that the site has indeed been excavated from the sand, having most likely been submerged from view beforehand. The question is, who did these excavations? Who built this unbelievable structure, or indeed, the mind-bogglingly enormous Giza Plateau? Who built the pyramids and sphinx upon it? Where did such an enormous stone plateau come from? How did they shape and carve such mysterious structures with such blocks? Or perhaps, most importantly of all, where does this staircase lead? Did whoever undertake this excavation task manage to discover where it led? More research and exploration will undoubtedly be undertaken over the next few years. We will, of course, keep you posted. Did the great sphinx once witness the bottom of a sea? There is evidence. Things we have covered on this channel in the past, which would suggest just that. Who built these astounding structures found dotted all over the earth? When were they built? Were they really, like academia would like you to believe, built by primitive civilizations with the use of primitive tools, often made of copper and notoriously soft metal? Or is there a possibility that these structures were made by a far more ancient, far more capable, world traversing civilization? Built in areas of geological interest, most often the center of a landmass or placed upon key lines? Although there is a large number of artifacts and archaeological factors which strongly suggest this exact scenario of events, we feel there is one collection of artifacts, or rather evidence of this people's past existence, which, just like their clear originally intended function, could tie these monuments neatly together. Known as the missing ancient metal clamps, given their predicted age and metallic composition, the fact that they are no more should come as no surprise. However, the carved seats that these clamps once sat within are still present in the stonework of many ancient structures found all over the world. Within our own modern day society, a society that can travel the world in a day and speak to the other side in an instant, technological advances are often copied or shared between nations. The concepts being the same, yet the manufacture slightly differing in form, and the metal clamps display this exact phenomena. Slight variations in manufacture that can be seen dependent on the landmass the ruin is found upon, yet the concept behind the construction of these amazing and perplexing structures, often constructed using blocks we have no explanation as to the placement of, remain the same worldwide. Dry stone walling often accompanied by these clamps, made with such skill, the blocks are now often perceived to have been made to measure. The clamps once functioned as seating clips, after the fresh construction of these stone structures, the builders were clearly very aware of shifting, which can be seen, as blocks settled over the following years. This offers a presumption that these structures were intended to last many centuries, if not millennia, and the metal clips were also designed to indeed rust away to nothing after their function was served. Amazingly, it seems that out of the countless thousands used, a few of the clamps have somehow managed to survive. The clamps from pre-Columbian South America that have been examined show them to be made of a very unusual alloy, 2% arsenic, 95% copper, with traces of iron, silicon and nickel. This composition is particularly interesting within Puma Punca, because there is no source nickel anywhere in Bolivia. The clips are clearly a compelling link between these ancient structures found all over the world, but more importantly, the builders of them. These amazing artifacts clearly deserve much more attention. Thanks for watching guys, and until next time, take care. The enigmatic remains of a creature discovered within a bare layer along the freezing banks of a river within Yakusha, Russia, turned out to be that of a perfectly preserved lion. However, it is a species of lion which died out over 50,000 years ago. Known as a cave lion, it had recently been released by ancient permafrost, which is currently melting within the area. The find has predictably attracted a lot of attention, and it seems a group of South Korean and Russian scientists believe it is so well preserved it would make a great candidate for an attempted cloning program. Like something straight out of Jurassic Park, they want to attempt to use its extremely well preserved DNA to recreate an entirely new branch of the species, based solely upon this one small cub, which died over 50 millennia ago. Quote, The cave lion was a predatory animal, a coval of woolly mammoths that lived in the late Pleisocene from 150,000 to 10,000 years ago, and became extinct at the end of the late Pleisocene, about 10,000 years ago. Valerie Plotnikov, PhD in the study of mammoth fauna, Academy of Science, Saka Republic, told Sputnik.com. The cave lion was slightly larger than the modern one, but it didn't have a mane and there was no tassel at the end of the tail like the one modern African lions have, the scientists said. In the late Pleisocene period, this beast had no rivals. Bears, wolves, and other predators provided him with no significant competition. According to Plotnikov, the cave lions mostly fed on reindeer, nobel deer, young mammoths, wild horses, and musk oxen, and most likely let a solitary life. Dr. Albert Protopapov, head of the Department of the Study of Mammoth Fauna at the Academy, told the Siberian Times that the preservation of the lion cub remains may allow for a future cloning attempt. However, according to Plotnikov, there are no plans to clone the cave lion just yet. Although they strongly believe the process of extracting the cave lion's DNA and then splicing it with the genomes of our modern-day African lion, the closest modern relative of this extinct feline would be a success. What do you think regarding the cloning of extinct animals? Scientific breakthroughs? Playing God? Or maybe a Pandora's box waiting to be opened? Let us know in the comments.


Oh, that's a chunk. How's it going everybody? Dato Doi here with another Dragon Ball Fighter's ranked match video. Today we got Krillin and Piccolo on the same team. I wanted to see if we can make him work. As you can see, I even changed my Z-Union to Piccolo for the occasion. My friendship has officially ended with Ginyu. Now, Piccolo is my best friend. And the only reason Piccolo is not at the forefront of this team is because I just feel like Krillin makes a better point character and you know, Piccolo could use some bar for the other things. Piccolo's assist is also a little better. Overhead Goku? Oh, no. Oh, what are you doing? That is the that is the easiest punish in the book. Very jump back. Catch him on the meaty. Oh, yes, Krillin. It's been too long. Oh, we didn't touch the ground fast enough. That was my one worry. Oh, he's backing up. He's really backing up. Get off of me by the way. Alright, just just let's just go behind him. Oh, no. Alright, we need to vanish. Oh, that's probably a bad idea. Every time I get in the corner, I'm just so excited to maybe hit that Piccolo combo. It's just the coolest in the game by far. Ooh, we saw the Super Dash coming to extend the block pressure. We might be dead. Oh, we are dead. This is gonna hit. We're not dead. Boom, what a healthy snack. Oh, God, Tien. It doesn't matter what the quality of Tien player is. It's just if it's Tien. So be it. I will get wrecked. I'm surprised we haven't seen a switch in here. Wow, landed on the wrong side, Krillin. I hate to see that happen. Okay, can I can I down tech out of here, please? Okay, that was awkward. That was a little awkward from the Tien there. I'm not sure why that happened, but hey, I'll take it. I'll take it every day of the week if possible. Hit him with an overhead light. That's gonna be enough to get the ball rolling here. Let's see, how do we do this? Yeah, okay, I'll take it. We don't have the extra bar anyway. I thought if I had enough, maybe I'd go out in a piccolo. All right, there's the first shot fired there. We're going overhead. Had to go with the cross up with it. I didn't know what else to do, even though we were getting close to that corner. Piccolo for the hard knockdown? Yes. All right, this sets us up for some great things here. Please don't spark. Ah, there it is. No super dash here. Oh, just a random slug. Oh god. All right, just get him out of there, dude. Operation safe piccolo for the future. Okay, not too much to be afraid of here. All things considered, Vigito. Not too scary.  Oh my god, I just got to get prepared for it. It's always the attacks that I don't think they're going to block for sure, that they just end up getting hit by and I'm never ready to convert off of those. That could definitely be something I do just improve on. I'm trying to hit this piccolo combo to be completely honest with you. That's my goal and that's what... That's what I'm gonna do. Unfortunate there. Oh my god, almost unfortunate for me, but we keep it together just long enough. All right, let's get that piccolo assist rolling. Psych! Oh, that's the wrong number. That's the wrong number, bro. Ah, come on. Impromptu, impromptu little extension there. I like it. All right, up a character already. Tien, though, does scare me. I'm gonna go for the sliding into piccolo. All right, that's fine. Oh, come on. That was the first part of it. Oh, just... I'm not touching the ground fast enough. Oh, wow, I didn't tech that either. Damn. Oh, he didn't... he didn't do it that time. Kind of thought I was gonna get punished for that. That's not gonna work, but he'll probably just block it. What are you doing, my boy? Reflect, reflect. Just trip him, piccolo. Piccolo ran up with a... with a purpose on that one. All right, let me see if I can't call in... Oh, whoa. Hey, hey, relax. Relax, dude. Relax. All right, hold on, hold on. I just need a little bit of dinner and I'll be good to go. That's it. Now you've done it, bro. Missed my meter and the sliding knocked it... Oh, and we get stabbed. Oh, no, help piccolo. Oh, we got stabbed. What else could I say, dude? What else can I say? Brilliant time. Oh, wow, another pair of keyblasts came out there, which is unfortunate because you know that's not what I was ordering. I was hoping for a nice Salisbury steak. That's us. Overhead. Oh, I'm glad I didn't click that button. Actually, yeah, see, that just would have happened anyway. Oh, he's pretty patient with that. Not gonna lie.  Oh, the legs are two definitely longer than Krillin's tiny T-Rex arms. So we're getting flipped. Really interesting. That's not going to give a hard knockdown. It'll do a decent bit of damage. Oh, the rock didn't go where I wanted it to. I also really didn't want that rock. All right, we're just going to assault. Oh, that was beautiful. I'll give it a... How do you feel about five random destructedists? That's right. Not one, not two. How do you feel about two more random... Oh, why is he running at me? Why is he scaring me like this? Oh, why is he just running at me, dude? That was... what an assault. What an assault. All right, that's it. We're taking into our own hands. Oh, this dude is playing smart right now. Well, he was. Damn, that was good. At the end there, I was getting nervous. I was like, is this real? Is it really happening? All right, two zero. That's how much we're up. Xbox world, you know, we got to climb our way up slowly. I agree. I agree with the stamp. It's a good stamp call. Again, for the second time, I've never tried a Piccolo combo. I mean, we make it work, though. That's why this team is great, because we make it work. Uh-oh. That's a chunk. Why do you... I don't know if... I don't know if I agree with that character being the one switch, dude.  You better block. It was all a trick. I was trying to grab him. That's the truth of the matter. Hit me. Is that going to hit? No, it's not going to hit. What are you... Pierce this? Were you looking a lot like Raditz right now, Vegeta? If I so... if I may. If I may bring up his name. All right, hurry up. Hurry up. Eat the lunch. God, jumping light is just so good, dude. All right. Anchor Tien, who cares? Uh-oh. Just when I muttered my catchphrase. Just when I muttered my catchphrase, lightning strikes. He confirms off of it with a light. He could have gotten a lot more out of that, but still, very scary that that happened. Is Tien coming back in? Tien's back in, boys. He said, you're right. Who cares about Anchor Tien? Not me. He's not interested. He's not interested in anything. Oh, he takes that. Okay. Do we confirm? Nope. The lag confirmed didn't really work out too well for us. Oh, wow. He just bumps into our Keyblast, sends it flying. Try to get that one. I expect a dragon rush. What? You said it out loud, Dato. What are you doing? Really, doesn't...  Really, dude. Come on. Let me in there. Let me in there. Oh, you got to be sitting with me. Oh, no, dude. There we go. Geez. I got to bust out the old TE2. I think I'm too rusty on this one. Turn around, Goku. It was seven minutes. Goku had his back turned to Vegeta for seven minutes. Is it gonna... Yeah, I got me. Okay. Snagged me out of the air. We're downsparking. This is actually a super bad situation for us. Don't let my confidence demean it for you. Uh-oh. We're dead. Sliding. There we go. He's just... He's trying to rush things here, which is fine. I'll take advantage of that all day long, by the way. Oh, we jumped to get away with it, but away from it, but that's not going to get it done. Double three. I agree. Piccolo, you lasted out the sparking. I can appreciate that at least. That's why you're my best friend, man. You definitely couldn't have done that. All right, Krillin. Let's clean it up, baby. Let's clean it up the only way we know how. Through sliding knockdowns and getting stabbed. Truly, truly the Krillin main way. Oh, I didn't expect it to be with a down heavy. Destructo disc. And that's going to be all for this video. We didn't accomplish our main goal of getting the Piccolo combo, but you know what? Krillin and Piccolo work together so well. I'm surprised this happened. Maybe I will become a Piccolo main. Piccolo mains out there. Hit me up with all the tech I need to know. All the stuff I need to be doing in neutral that I'm not. What do I got to do? You know, send me some video.  I got a hurry. Screen's cracked. Thanks so much for watching this video. Let me know your favorite moment down below in the comments. I got some other videos if you want to watch even more. And as always, I'm Dato Doria, I'll see you in the next video.


Hi friends, having understood the sono anatomy of the scrotum which included a good b-mode ultrasound as well as color doctor of the scrotum, let's move with the cases which we commonly see in our day to day practice. The most common presentation for which a patient will present in your clinic will be an acute scrotum or pain in scrotum. Let me take you through this series of cases that how you will view approach cases of acute scrotum in day to day practice. When we evaluated this case, we could see that this ovoid structure or a homogenous organ was the cell legion was lying in the scrotal wall and the testes were completely normal. In fact, if you see these are hypoechoic dermal elements whenever any very human body you see something like that, legion lying in the superficial subcutaneous soft tissue, unless proved otherwise, you can make an antipini diagnosis of an epidermal inclusion cyst. Now, some interesting cases. This was on a Sunday where a nephew of an MD physician walked in with sudden onset scrotal swelling in our one-year-old nephew of hers and that clinically suspected torgen of the testes. See the clinical picture. Entire testes was edematous. In fact, there was penile edema also and the MD physician was very scared that this is nothing but torgen. Now, when we started evaluating this case again by systematic approach, what we saw that the testes underneath were completely normal. In fact, the vascularity within the testes was also well preserved. So, definitely not torgen. But what we picked up that the scrotal wall was completely edematous. In fact, we could see fluid in between this scrotal wall layers. Now, looking at both testes being normal, both epidermis being normal, you know that this is nothing but a scrotal wall edema. So, these are panoramic images where testes were completely normal. Penile edema was seen. This condition is nothing but scrotal wall edema. Now, see this 17-year-old male who presented with high-grade fever and pain and swelling in scrotal. When we started evaluating this, the testes bang were completely normal. The epidermis was also surprisingly normal. Day one, when we scanned him, we picked up this ill-defined hypoechoic area in the scrotal wall. I alerted the surgeon saying that this look area is not looking good. It looks infective in origin. The surgeon started the patient on antibiotics. But see on day three, there was a complete breakdown of this hypoechoic area and it was nothing but scrotal wall abscess in evolution seen on day one and day three. You see internal echos, moving echos, unless otherwise the legion is lying completely in the scrotal wall.  This was a patient who had undergone fistuline aeno surgery and suddenly developed right scrotal wall swelling pain. He was having a discharging sinus at the base of the scrotum. Now interestingly, when we started scanning him, what we picked up that there was lot of scrotal wall edema. So by now, you know that there was scrotal wall edema in this case as we have seen in previous cases. But what we saw here was that in the scrotal wall, there was this hyper-reflective area with dirty posterior acoustic shadowing. By virtue of imaging, we know that this is nothing but air. So there was air in the scrotal wall. Then when we evaluated his contralateral left side, we saw that he had a cryptorchid testis in the left inguinal canal. This was the base of the perineum where he was having this discharging sinus abscess, which seems to be the culprit for causing the scrotal wall infective etiology with air. This was the air seen very beautifully on ultrasound. Then when we evaluated his testis, he also had epididymitis on the same side. So we gave a diagnosis that this looks to be a very bad infective etiology where the scrotal wall is filled up airy course. There is epididymitis on the right and the culprit for this wall seems to be the massive infection at the base of scrotum.  And when we started scanning him, his liver, gallbladder, kidneys were banged normal. Again, when we went to the area of interest, we saw that the testis were completely normal. And again, see at this scrotal wall here, we saw that there was air echoes again in the scrotal wall. Now see, this video is running here, how beautifully ultrasound can demonstrate air in the scrotal wall. There was a significant amount of hydrocele, which was reactive. And if ever you see this air shadows in the scrotum, this is nothing but four years gangrene in a diabetic. Now, trust me, this patient by day three or day seven completely deteriorated. There was shameful exposure of the testis and by day seven, the patient died in ICU. So you as a radiologist can make so much difference that we alerted the physician that this seems to be a bad infection in the scrotal wall, mostly an impending four year gangrene and see the actually by day three, day four, the patient landed up with this. So how ultrasound can be of such a paramount importance to pick up these bad infective pathologies. Now this guy was very smart. He was trying to concede his area of pathology. He was sent for abdomen pelvis evaluation, where abdomen pelvis was completely normal. So he said there is left sided pain, left sided pain. So out of interest, we screened his in vinyl areas, which was surprisingly normal, but patient was looking sick and he was completely pointing out to the left side of the groin. So out of interest, we told him to requested him to see that we also wanted to evaluate the scrotum. See what you can see here. We were shocked. The right testes was completely normal, but here the left testes is completely hypoechoic inhomogeneous areas within the testes. Then the epidermis on the same side was engorged with increased vascularity. We switched on. This was the B mode appearance. We switched on the color Doppler. No flow within this hypoechoic inhomogeneous area. This was the game changer, where we picked up and evaluated his cord and every area of that cord showed a nice whirlpool, which was seen in this case. Our own Bhupati Sir has beautifully described this as a real-time whirlpool sign. I all want you to read this article given by Sir. It was a game changer in way that we looked at acute torgents because every case of acute torgents showed this whirlpool sign. See this one more case, severe onset pain and scrotum, the child got up from sleep. When we saw this, the testes was normal. See here, the axis of the testes had become horizontal, hypoechoic testes. Then when we saw this, this also showed no flow within the testes. This is a normal contralateral side. See this peritesticular flow. I was telling you because the testes get supplied, the wall gets supplied from other areas, you will see a kind of this contradictory flow around the testes. The epidermis was engorged and even this turned out to be torgents. So this is that beautiful whirlpool sign, which you should search in each and every case of torgents because tors testes can be beautifully picked up on by picking up this whirlpool sign. So another case which stresses the importance of this whirlpool, testes normal, in-homogeneous hypoechoic testes, no flow within the testes. So again, here in fact, we picked up this whirlpool beautifully on B mode and trust me, this video and the in-drop picture was just the same. Always stressing that we followed this Bhupati Sir's article. All of you should read it because it was a game changer in picking up torgen cases in day-to-day clinical practice. When you talk about torgen, you know that there is going to be some certain degree of twist. The testicle is going to get twist around its axis. Now, if you read literature on torgen, they say that the torgens extend from 90 degrees, 180 degrees, 360 degrees and 520 degrees. Whenever the twist is going to be so bad that it has crossed 360 degrees, it's going to cause complete torgen and most of the time it leads to non-salvageable testes. But anything less than 180, 90, all are going to lie in the category of an incomplete or partial torgen, which you sometimes may pick or may not pick up in your practice. So, see this another interesting case where we picked up the origin in this case. There was a reactive hydrosil with inward septation. But what was sitting at this upper pole of the testes was this hyper-echoic area with cystic areas within it. We were flummoxed by what this lesion could be and surprisingly even this lesion was devoid of blood flow. There was a lot of ecogenicity. Now, trust me by imaging, we knew that this is epididymis and it was a tors testes. We called up the surgeon and when he operated, he gave us a follow-up that this was a testicular and an epididymal torgen, both. So, that can also happen in practice. Then infant pediatric age group presenting with bilateral inguinal scrotal and again clinical suspicion was of torgen. So, this was asymptomatic side where there was this bayonet shift collection. Looking at this, you know that this is nothing but hydrosil. But when we again scan the symptomatic side, one, axis of the testes had completely changed in homogeneous hypo-echoic areas seen within this testes. Axis shifted no flow within this testes. In fact, what interestingly we saw that this whole testes and this collection extended up till the external inguinal ring. Putting two into perspective, this is the kind of picture we had. Axis altered no flow and this going up till the external inguinal ring, we gave a confident diagnosis of torgen of the testes. Now, stressing for last 10 minutes about torgen, why are we trying to tell you to pick up torgen so early in practice? So, if you look at this chart, it clearly tells you that if you are going to pick up testicular torgens in the first five or six hours, you are going to do benefit for the patient because if you operate in those first four or five hours and untwist or whatever you can do, you can almost have an 80 to 100 percent salvage rate. But as time passes and as the time goes by, you will lose most of the time the testes and hence it's very critical to make this diagnosis as prompt as possible. If you go back to all my cases, you know that we saw one pediatric torgen and we saw some adult torgen. So, very simple to remember that there are two types of torgen, the intravaginal and the extravaginal variety where in pediatric age group you will always see an extravaginal torgen which is occurring because of motility of the entire tunica vaginal is extending all the up till the external inguinal ring. As against at puberty onset or adult onset, you will always see intravaginal torgen which typically occurs because of bell clapper deformity where you must have read that the testes get suspended on a long stop of the spermatic cord. So, adult patients intravaginal torgen, pediatric infants extravaginal torgen. So, this is the way the twist goes and if it is extravaginal, it goes up till the external inguinal ring and if it is intravaginal, it limits itself down there. Now, pathologically what happens at the level of the testes is that first there is always going to be a venous outflow obstruction followed by the arterial obstruction and once that has occurred, it starts causing complete vascular engorgement and leads to completely a non salvageable testes. So, some charts for you to remember that if a patient comes to you within the first six hours, many of the times you might land up reporting it as a normal looking testes because the inhomogeneous appearance is not there in the first six hours. But whirlpool will always be there. Many a times you will see just hypoechoic testes. So, therefore, stressing the importance of looking contralateral asymptomatic with symptomatic side is that that hypoechoic ecotexture will alert you. But always, always you will look for whirlpool, you can promptly diagnose this condition within the first six hours. But if patient is going to come to you in your clinical practice after six hours, most of your time the job is easy, where you're going to see a heterogeneous hypoechoic testes straight forward diagnosis. You will see scrotal wall thickening, reactive hydro seal. You will see no flow on color Doppler, but you will see again a whirlpool, very easy diagnosis. Most of the time it's going to be a non viable testes. When we tried to prepare this lecture, I was trying to read up that can torsion occur in undecended testes? In a cryptorchid testes, it had a patient presented with the emergency and there was no flow within it. And the post-op appearance, there was a undecended testes lying in the deep environmental ring which had undergone torsion. Now, we saw over last five minutes that we talked about color Doppler evaluation, look at flow, look at whirlpool and pick up torsion. Now, can there be a theoretical situation that there is a torsion of the testes? You're still seeing color flow and there can be a torsion. Yes, it can happen. So, the whole importance of taking spectrum within the testicular parankaima is due to this, that in all cases of incomplete torsions or torsions which are less than 180 degrees, spectrum analysis is one of the most critical way you're going to evaluate acute scrotum. So, how does it help in practice to pick up incomplete torsions or torsions which are less than 180 degrees? See this case, 17-year-old guy, look at these testes. It shows this normal seesaw kind of pattern, good flow, asymptomatic side. But here, contralightly in the symptomatic side, we are seeing color flow within the testes. But when we did sampling or did a Pw evaluation, see what kind of pattern we are getting is that typical dampened monophasic waveforms, the way we see in critical ischemic limbs in the lower limb arteries. Looking at this spectrum, you know that this testes is undergoing some amount of ischemia. Sometimes in some cases, we saw that the diastolic component is minimal as it becomes less. So, always remember that in every testicular torsion, arterial flow need not be present. In fact, three patterns which you should remember is that if you are getting dampened monophasic waveform or a reduced end diastolic flow or reversal of diastolic flow, you will go and search for whirlpool. Even if you don't see whirlpool, twist and twist has occurred, you will write this finding in your report and tell the clinician that this testes seems to be undergoing ischemia and needs a close follow. So, see this case, reversal of diastolic flow, absent end diastolic flow, very minimal reversal senior, all these are nothing but as incomplete torsions or ischemic testes. Stressing the importance of ultrasound with Doppler, best tool in today's time to evaluate torsion of the testes, almost having an 100% specificity and 97% accuracy. Now, there are always going to be an overlapping many pathologies which are going to mimic torsions. So, what that could be? Any infective pathologies like epidermitis, epidermal orchitis, spreading contiguous infections, involving the tunica vaginalis and things like that. There could be a tunicitis and all going to present you as mimics of torsion. Trauma which we have seen can also mimic a torsion. So, see this case, we did 14 years old with pain in right scrotum. So, when we evaluated him, left testes was normal. Interestingly, what was seen at the upper pole of the testes near the epidermis, we saw this ovoid hypoechoic area which was showing peripheral vascularity and this fine ecogenic foci within. See this case, similar case given by Ravi Sir from UAE where testes were normal, epidermis normal, again an ovoid ecogenic area, peritational flow. Testes was normal. Whenever you see something like this sitting at the upper pole, very, very painful, unless proved otherwise, these are torsion of the testicular appendages. Now, there is some overlap that how you pick up torsion of the testicular appendages versus epidermal appendages. So, simple rule, anything at the upper pole of the testes and that ovoid ecogenic area is going to be torsion of the testicular appendage but similar kind of pathology lying at the tail of the epidermis unless proved otherwise these turned out to be torsion of the epidermal appendage. Sometimes you scan a testes and you see a segmental hypoechoic area like this, cleavage kind of hypoechoic area, flow senior, no flow senior. These are testicular infarcts. Now, testicular infarcts, whether pathology is mainly arterial thrombosis or an arterial vessel has got thrombosis. So, always there is some kind of a background history which the patient will give. Torgens in the testes typically occur because of venous occlusion or venous outflow impairment but testicular infarcts are always always arterial in origin where the arteries are got embolized or thrombosis. You will have a patient with sickle cell or you will have a patient of epidermal arthritis and where one of the areas has suddenly undergone infarction and you will see that area devoid of blood flow. Now, the problem area is that any other such pathology can it mimic a testicular infarct. Yes, if you see a mass within the testes even that's going to look as a avoid hypoechoic area. Now, what happens in practice is that testicular infarcts will be completely devoid of blood flow in paladoplar as well as paladoplar but neoplasm within the testes will show some degree of blood flow. So, that's the way you are going to diagnose it in practice. Now, going to few interesting cases. I think you all are very confident of picking up epidermitis in day-to-day practice where most of the time you have an incidental history of a patient having underlying urinary tract infection or GU infection where you see echogenic inflamed epidermis typically lying at the upper pole of testes when you switch on color, increase vascularity, compare it with the contralateral side unless otherwise this turns out to be epidermitis. Now, epidermis is one of the cryptic side for all areas of infection. It can spread to the testes and cause arthritis. It can test go to the cord and cord having connective tissue gets inflamed and that leads to funiculitis. So, in practice you could have a very overlapping picture between epidermitis, epidermal architis as well as funiculitis. So, you need to go systematically and see this case. Now, see this case testes was completely normal and see this when the cord gets involved we are going to label this confidently as a epidermal architis with funiculitis. Now, this guy was a very, very close friend of mine. He came to my clinic and he said he had some vague trauma and pain and he is having severe pain in the right testes, some kind of malaise and fever. Now, when we evaluated this, we saw that the testes showed this hypoechoic areas. If you look at it with the previous slides, the most prom diagnosis you would make is a segmental testicular infarct. His epidermis was normal but when we switched on color, we were shocked that this area which was hypoechoic ill-defined should increase vascularity like this, putting two and two picture. This is nothing but focal architis. So, any inflammatory pathology causing this kind of hypoechoic area, increased vascularity, trauma being background history, you can confidently give a diagnosis of focal architis. In fact, he came after four weeks of antibiotics and was this legion completely disappeared. Then, sometimes history and clinical presentation is very easy to make a diagnosis. So, bilateral submandibular swellings with right scrotal swelling and high-grade fever. When we evaluated, testes was hypoechoic, increased vascularity, epidermis was engorged, inflamed. You know, this is a case of epidermoarchitis. But if you look at the area of interest, which was a submandibular glands, which was also inflamed and large hypoechoic, surprisingly, the parotids were preserved, putting two into picture. We said that this is nothing but epidermoarchitis sequelae to mumps.  Now, see this interesting case given by Hemal Banyar, my fellow colleague, the patient landed up with him with an acute swelling and replacing these testes was a disorganized testes with this ecogenic cystic area with fine ecogenic echoes. Contralateral right testes was normal. Again, beautifully, we could pick up air in the scrotal wall. I said, Hemal, this looks to be infected. We saw that this definitely is looking like air echoes, but air echoes within the testes. Then we screened his epidermis and patient had bad infection in the scrotal wall with scrotal wall air. But this testes, which was the symptomatic side, was replaced by this cystic collection with this fine echoes within it, which was giving an appearance of air. I told Hemal that this is definitely a bad infective pathology. They too, in fact, Hemal scanned that patient again and trust me, this was a bad scrotal wall infection with involvement of the testes. That time I scratched my mind. I said, why is the testes full of air? I did some Google research that time, and then this work has been done by our own fellow colleagues, Anita and Prabhakar, where in IGR, this article is that this entity is called as emphysematist, epidermoarchitis, where in diabetics, the epidermis and the testes is so badly involved that it gets completely replaced with air. Just out of interest, we took a radiograph of the scrotum and we could see air fluid level there, and this was nothing but a bad emphysematism or epidermoarchitis typically usually seen only in diabetics.