All right, we are live. Good evening, everyone. Thank you for tuning in to what is purgatory. My name is Jordan Burke You may have tuned into the last webinar that we did. That was a smashing hit with Father McManus what our ghosts seem to be kind of a fitting follow-up especially in The in the current liturgical season Hopefully you all had a chance to go out to a cemetery and pray today. I know we did It's always a very touching experience But I want to introduce our guests because you are not here for me. Thank goodness Monsignor Charles Pope and Says here your interest in the priesthood stems from your experience as a church musician, which is fantastic He was ordained to the priesthood in 1989 Monsignor Pope has conducted weekly Bible studies in the US Congress and the White House Other ongoing assignments for Father Pope include being archdiocese Coordinator for the celebration of the Latin mass and coordinator of deliverance ministry You were named Monsignor. He was named Monsignor in 2005 He writes for our Sunday visitor and the National Catholic Register has published two books It says here 2011 you were named Exorcist assistant exorcist. I'm sorry for the Archdiocese of Washington That's considered to continue to assist in deliverance ministry since that time He blogs daily for the Archdiocese as a regular host on EWTN's Radio morning glory show Including I mean it goes on you've conducted numerous priest retreats parish missions and teaches at the Institute for Catholic culture Monsignor Pope is also the Dean of the Northeast Deenery Once you go immensely enjoys his work as a diocese and priest and parish pastor Thank you so much for taking the time to help educate us on what purgatory is Yeah, happy to be here. Thank you Well, we're gonna just go ahead and dive right in because I find it best to Kind of I'll put it this way We we scoured the internet all those who don't join the site all those who go to the avalanche Institute our various different outreach programs and we gathered a bunch of questions because it seems although I think a lot of Catholics understand that there is a purgatory and maybe some don't We'll we'll get into that but for those who do there seems to be kind of a misunderstanding about The depths of what it really is. What is what does it mean to our daily life as Catholics? You know, how do we approach this knowledge? How do we pray for souls and purgatory those sorts of things? So the first question I have for you is What is purgatory? Purgatory, you know, I just I'll go right from the cataclysm pretty safe to do that right right We'll start there and it says here that all those who die in God's grace and friendship, but still imperfectly purified are indeed assured of their eternal salvation But after that they undergo purification So as to attain the holiness necessary to enter the joy of heaven The church gives the name purgatory to this final purification of the elect Which is entirely different. They want to hesitate and don't hesitate to add, you know from this punishment of the damned. All right, so You know, I mean people like to get into crazy debates about You know whether purgatory is a place or a state, you know Human beings are in a place things, you know, I You know, we'll just it's a place, but it's a place where we undergo final Purification and again as the cataclysm says We're in friendship with God that is to say we're not aware, you know, we don't we don't die with mortal sin on our soul, but We all know that even when we don't have mortal sin like, you know, thank God as far as I know right now I'm in the state of grace. Thank you Jesus, you know But I can say that I am far from perfect and Jesus actually gave us a promise. He may not sound like a promise But he says that You must be perfect as the Heavenly Father is perfect Now that's not a threat. It's a promise And we are also again to strive for that, you know, the perfection And to have that faith without which it's impossible to please God So we're all called to and summoned to a perfection St. Paul said my God has begun a good work in you Bring it to completion. So the question then is if I were to die today as far as I know Again, I'm in a state of grace, but I am I'm far from perfect Something would have to change because heaven by definition is a place of utter perfection We have so many of these, you know, different passages and scripture But it basically it says that regarding heaven that nothing impure nothing imperfect can enter there It wouldn't be heaven, right? I mean, it isn't even just about our sins You know, it's Jordaness, it's it's about we all have hurts and painful memories and things that Well, we want them to go away, but they kind of cling to us, you know past traumas things and We have to let the Lord remove those things from us because it wouldn't if we could bring those things to heaven It wouldn't be having right. So there's a beautiful line by the way in the book of Revelation regarding that part where it says the Lord We'll wipe every tear from their eyes regarding the dead.  And frankly, I doubt most of us are, you know, because God's very holy And heaven is a very nice place so we're probably going to need a little gusty and up a little cleaning up and Purification and so that's what that's what purgatory is and and that's you know, where it is and so on in the life to come Right, right the way that I have explained a little bit to some of my friends is you know We say this every time we're at mass forgive us for what we've done and what we have failed to do Fail to do that's the that's the thing, right? That's the thing where we're not aware of what we are not aware of and so thank God that there's a place that helps us Cleanse us of those things so that we can bring our hearts closer to God's work So that's a fantastic explanation for those who are kind of within the fold so to speak But how would we explain purgatory to somebody who isn't familiar? Maybe we're talking to Someone who isn't in the Catholic faith. Yeah Well, I think really that's what we do need to begin with and reason with them First of all why purgatory is needed see a lot of them say well, there isn't a blood of Jesus sufficient to cleanse us from all sins Well, of course, but they're thinking of sin in a merely juridical sense But then causes wounds and hurts it causes darkness in our mind our intellect it leaves scars and Wounds and these things need to be healed And so we're beyond the question of juridical then clearly a person who's in purgatory Has been rescued by the Lord Jesus Christ by his saving action So then then we have to then I think reason with them from the scriptures by saying once again that I've already introduced that there is a There is a it's a very biblical teaching and it says here You know, I'll give you a couple of biblical things in a moment, but just start with that promise of Jesus You must be perfect as the Heavenly Father is perfect. You must be perfect Now again, there is this This understanding that having a place of perfect happiness and So to reason from that so what if I die and I'm not you know, I mean I still have rough edges to my personalities I still have hurts and heartaches so you could just ask them I would ask put the you know, they do a little socratic method What do you think happens to some of those rough edges to our personality? Now I'm not hard to live with Everybody else is Uh, we're all a little hard to live with those things that you know those little foibles and things that we still struggle with or hurts to hang on and Maybe little resentments and things we still carry and So to ask our our Protestant friend, well, what do you think has happened to that stuff? I mean something has to be done because you can't bring it to heaven. It wouldn't be heaven So, what do you think you know happens and so again um The next thing maybe we should always introduce too is that you know, a lot of people today miss a step when it comes to funerals I'm really concerned about this because we're not praying for the dead like we should But everybody's oh joes and Put jesus up there now and they're playing poker together, you know We do all this stuff. We just immediately promote people to heaven And we you know, I always say in all my funerals and I have a lot of Protestants that come to our funerals Look, I say, you know, we all miss a step heaven doesn't the bible doesn't say you die and go straight to heaven It just says no such thing and then they kind of say oh here comes the purgatory judge But actually no here's what comes next The judgment seat we have a little appointment to keep before we just march into heaven it's called the judgment seat of christ and Yeah, I mean at one level it's a judgment about heaven or hell, but there's also another judgment and question For i'll just use my name now charles is my work and you finished What remains unfinished see okay? Well, let's let's complete it now. Let's Let's remove and and urge away Those sins those rough edges those tendencies those attachments Let's uh, let's also take away some of those hurts and sorrows and regrets that you still carry Let's do that now. See let's purify that and Yeah, and so I think we start there now There are other biblical passages to certainly want to raise but I I don't want to rush into them if you want to But one way of obviously getting with the non-gatholic is to go to scripture and there are scripture verses That speak of the existence of purgatory and the need for it So do you want to look at those or do you want to go in a different direction? Let's no let's look at them We got time. This is perfect. All right Well the first one and that's it's the classic one that you know We have to we have to first go to is in 1 Corinthians 3 and verse 13 and following now Saint St. Paul is talking here. It's a complex passage, but it's really pretty straightforward at the end of the day He says here I'm again reading from uh from 1 Corinthians chapter 3 and verse 13 Everyone's work will become manifest For the day that's a capital D on that word day. That's the day of judgment our judgment For the day of judgment in other words, we'll disclose it and it will be revealed through fire And the fire will test what sort of work each one has done Now if the work of any man Was built on the foundation of Christ survives He'll receive a reward But if any man's work is burned up He will suffer loss Though he himself will be saved but only as through fire Now what he's really saying here is look, we're going to go Before the Lord and we pass through a judgment if you will and this this this judgment is a kind of a fiery judgment Wherein what is good things like gold silver and so on are purified Whereas things that are less less noble. They're not, you know, they're not grave mortal sins But they're more ignoble.  So whatever this fire is It's burning stuff up and we're suffering loss. So it's not heaven either It's somewhere in between where we're heading towards heaven But we're we're having some things burnt away from us. We're losing if you will certain things certain attachments and so on certain There there's some perhaps, you know, punishments still do just into what have you all of that Is burnt away through the fire and what's left is pure gold And we we enter heaven purified and and perfected by the grace and power of Jesus Christ the power of his cross To put us into death and bring grace alive but that's the classic go-to case and again I would ask, you know, use a little bit of the Socratic method read this and ask the Protestant friend Or someone who doubts purgatory Well, what do you think this means, you know, I would give them a little explanation and they kind of say well, I don't know about that Well, what do you think it means? Could it could it be heaven? Does that sound like heaven? Suffering loss things getting burnt up No, does it sound like hell? Yeah, it does Uh, well, but it says here you escape So what do you think that means and so I like to use the Socratic method Kind of put them we're always having to make all the answers You know sometimes turn the tables a little like Jesus did with the pilot Right. Are you saying this on your own or have others been telling you about me? And he gets pilot kind of gets put on trial not I mean to you know, just perk somebody But I think what we should do is ask somebody who was thinking about it What do you think this passage means? Where is this place? What is this? And let them kind of conclude, you know, make some I think some fairly obvious conclusions from the passage Now there's another one here This is a an interesting one It's uh, it's about a um, um, you know, whoever says whoever speaks this is from Matthew chapter 12 and verse 32 Whoever speaks against the holy spirit will not be forgiven Either in this age or in the age to come So in other words the the text implies that there is some forgiveness in the age to come Now wait a minute.  Where does it make sense?  So where is it in that place? We call purgatory So again, I think there's another very interesting passage Um the And you know, I'm I'm trying to figure out exactly where it is. I'm so sorry. I don't have the exact quotation mark I mean the exact citation mark, but do you remember the story the Lord says oh, it's in Matthew seven This is where it is. He says settle with your opponent on the way to court Lester he hand you over to the judge and the judge hand you over to the to the constable And you'd be locked up and I tell you you won't be released until you pay the last penny Now first of all, you know what you've got to look up this parable in context You'll see that the Lord is kind of asking us to mind our way On the way to the judgment seat. So what's the judgment seat? Well, again, that's that's our last judgment who's the judge see and um the That's the Lord We know that the Lord the father not judged as no man But it's handed all judgment over to the son that the world may revere him. Now. What's the opponent? I'm gonna just tell you right now. I think it's our own conscience Hmm.  Ah, there's released from this place until you pay the last penny Where could this place be if it's about the life to come? Where could it be? It can't be heaven because you Don't you know, that's not jail. It isn't hell though either because you get out of it Once the last penny has been paid So again, I think these are some things that certainly um, you know assist us in seeing Uh, that purgatory is is is explained and hinted at also we read again As I say in the book of revelation regarding heaven that nothing impure Chapter 21 nothing impure or in perfect may enter there Now we are also going according to the book of Hebrews to strive for the holiness without which no one will please god so If nothing imperfect or impure can enter Uh heaven then something will have to happen to bring us to that kind of level of purity Um, also there is this book from the book of Hebrews. It says it talks about you've drawn near to mount zion To the city of the living god to the souls of the just made perfect Through angels and myriad gathering So so heaven is described as a place of angels of joy of glory and of the souls of the Souls of men of the just made perfect perfect See so I could go on but you start to see there's a lot of There's a lot of scripture that that either points to purgatory describes it Um, or at least in some way hints at the idea that something Must have to take place after death So I'm going to say right now. I don't even think you know any of us are humanly perfect But jesus says you must be perfect at the heavenly father's perfect. Whoa You know, that's going to take a lot of grace and mercy and I know I'm not humanly perfect let alone godly perfect So I'm going to probably just reasonably Need some cleaning up Uh, if I were to die today, which I don't plan to do but if I do I hope someone will pray for me because I could Probably use that as a judgment seat like anybody and um So I'll stop there. Uh, so for you to redirect the conversation Sure, sure So I want to rack up something you said at the beginning the the good The gold is purified And the bad is burned away and I've never heard it described in that way Of course, I've heard the bad is burned away, right? That's kind of the commonplace Understanding what purgatory is but having that good be purified. It's it almost it for me at least I hear that and it gives me an immense hope And I'm not one to fear purgatory by any means because I understand the process However, that that gave kind of a different understanding that I want people to really grasp onto It's like no, this is a very hopeful thing. This is a beautiful thing As painful as it it could be which is what we're going to get into So we started off explaining what purgatory is how to explain what it is and kind of Argue a debate so to speak using the Socratic method to people who may not be within the fold so to speak But let's dive a little bit deeper into some of the the myth of what it is or may not be For instance, because you know Some have described it as a spiral that there's levels to it So the lower you are on the levels the more time you spend in purgatory that sort of thing Is there any Reality to this do we have any any sort of and obviously we're stepping a little bit more Not necessarily outside of scripture may be more into the teaching of the doctor or doctor Yeah, excuse me the doctors of the church That's sort of the thing. But what's what's the what's going on there? Yeah, well, you know interestingly a lot of our understanding of these levels in in purgatory Or frankly if you go to Dante the both the the inferno the purgatorio and the you know, the They haven't one that they haven't yeah the paradeso They're the levels that all all three of these places now He's kind of though coming from a tradition that comes to us Dante wrote now. I think a good go-to guy on this is st. Thomas Aquinas And in in the supplement to the sumo this is dealt with at some length Where in god speaks and draws all I mean the sorry the st. Thomas speaks to god's Justice as explaining a lot of this So for example, just go to go to the bad place for a minute here.  It doesn't it wouldn't be just that a a genocidal murderer Would would be punished in identically the same way as someone who Was greedy and you know, I don't you know struggled with impurity There are just different levels there and so the punishment or if you will be The self-inflicted punishments are going to be just different And this same thing would be true in heaven that there are some who Live substantially glorious and holy lives and some of us who just barely get in under the bar You know and it doesn't make sense again The lord does certainly hint to us that there are places of honor at his right and left But there are places in heaven of particular honor that it isn't just that everyone's, you know, egalitary You know egalitarian and we all have the same exact experience of heaven Some people's hearts have been enlarged by great suffering and they can experience the joy and the glory St. Paul says that the sufferings of this world produce Produced glory in us way out of proportion to the sufferings. Well, let's be honest Some people have suffered a lot more than you or I And therefore if they're faithful They've earned greater glory. We're going to look up to the poor one day The souls who suffered might leave don't look on them to pity them befriend them because they're going to rule Many who are last are going to be first as Jesus. So we see that there's levels In heaven levels and hell that makes sense Just from reasoning from God's justice and therefore in purgatory too Not everybody needs the same purification. It's not as though well, everybody goes through the same car wash No matter what, you know You know, no There are some who need the deluxe right Wash and some who just need a rinsing but but I'm being silly but but you get the point which is that Clearly God would purify us in a way that's appropriate for us in the areas that we most needed Likewise the length of time that we spend there We can talk about the time question in a minute, but it would certainly certainly seem that um the the whatever the sufferings there are or whatever purification and I would also think There's great tenderness as well in purgatory That idea of the Lord wiping the tears away from all the of the eyes of those who have died That's very tender and letting go of being experiencing healing from some of those things that are just Just dogged us all our life, you know Regrets sorrows, you know those things so so I think that purgatory will be a combination of probably some suffering There's always suffering and change Already all things but there's also great release Big joy and a great sense of relief, you know that comes with it So I think um, it'll all depend a little bit on our condition as we get there and what's needed and I just think God's justice Would not just do this one size fits all kind of approach to things. Um, because it's different for each of us I'm not just making this up and I'm kind of summarizing a lot of what Thomas said sure But it's rooted in an understanding of God's justice to say that everybody good, bad, or indifferent at all get the same thing Isn't just so then how do we begin to you know, and we can't know maybe no every single detail like for example Dante again imagines the basic core sins that people struggle with and that what they The purifications they need are especially designed for them in purgatory Likewise the sufferings of those in hell are specifically related to the things that they Created for themselves through their refusal to repent from sins certain sins, especially Right well and everything that you're saying is perfectly logical I mean if we can understand that there's a choir of angels There's a hierarchy of angels It makes sense that there is there's some semblance of order there and then I just finished reading the dog of hell But I think it's father shrew I think is how you pronounce his name He's just you just repeated some of what he wrote in there about the punishment being Individual to the person and what kind of whatever they were struggling with and shows to A lot of ways chose not overcome. So it makes perfect sense that there would also be Levels and purgatory of some sort no matter if it's a staircase or something else But you had mentioned the time and that's where I wanted to go next with this because my understanding is You brought up something that's really important to me and a lot of what I work on Within the avala foundation Which is wounds right in healing? and so We're one of it's kind of a common phrase around the office around everybody that we interact with it's like Everybody's wounded in one way or another And you're either going to deal with it now and you're going to try to heal now with the grace of god Or you're going to have to deal with it some other time So that would be kind of a good segue into let's talk about time if we heal now Does that limit time in purgatory or is that not how it works or you get where I'm kind of going with this? Yeah, I should I should certainly think that it does It has a lot to do with well all the saints I say all the saints who have mentioned purgatory Um, and some who've had visions and so on of purgatory I'll say the same thing but it's better to handle things here than wait for purgatory All right, apparently because I'm going to guess that purgatory is a bit more of an intensive Experience in this life we experience kind of a combination of pleasures and sorrows and joys and regrets and I think in purgatory it's going to be much more of a focus and an intensity about getting this job done You know like you throw some dishes in the dishwasher You know, there's one there's one basic job here, you know get them clean Whereas, you know another setting you use them for this or that it puts food on them and so on or stack them But for now once you're in that thing, there's one job. So I think that the intensity is probably Why that would be the case? So again, ideally these things should be handled here and again We should never make it our goal to get to purgatory. We want to make it our goal to get to heaven Now most of us if we're honest, they're probably gonna, you know We're we can be pretty mediocre Right and god is very holy But on the other hand, I would I think sometimes there is a legitimate criticism the weak Ethics are always talking about just get to purgatory And that's not an excuse to not drive for the holiness right now that god wants to give us now Not just, you know after some fiery judgment or after we die Now I also say this to a lot of people who are thinking about suicide So you cannot escape this issue you think you're going to take your life and you'll escape from it I'm going to tell you right now worse case scenario you go to hell and it's just worse there Better case scenario you go to purgatory But you're going to have to deal with this one way or the other and I'm going to tell you right now You can't take this anger depression sorrow whatever it is To heaven you just can't and you're going to deal with this either in in hell or in purgatory You're not going to get to heaven until it's you know, it's it's dealt with And let's hope pray that you know you get it to purgatory, but you see I say there's no escape From the healing ultimately that the lord wants to offer us and a lot of us frankly as a sloth But rather just be mediocre Right people don't want excellence. It's not our Not our troubles that trouble us or sorry or make us afraid. It's our gifts Right. Oh, no. I might have to use it, you know And again, I think we we do intrinsically recognize that getting holy is pretty hard work Most people want relief not healing Right, they don't really want holiness That's I'm gonna say I don't say that in just a depressed, you know, kind of broad declaration But sloth is a pretty serious flaw One of the seven deadly sins is sorrow or aversion at the good things that God is offering And some of us can't get our head on straight enough until purgatory But let's honestly aim for it now aim for greater perfection now And that should be always our goal, but You asked about the time question So Is there time in purgatory? Is it experienced there like it is now? um How does time there relate to time here A lot of that I don't know but I can say that I think there must be time because there is change And time is basically I'm simplifying but it's a measure of change. So there's got to be time Uh, this how does time here relate to time there? I don't know exactly Now we got a little bit. I think a lot of people got a little confused with the old prayer books That would say, you know 150 days You know at the end of a prayer or uh 300 days indulgence or planning or you know And so there was this idea that you get people out of purgatory for 150 days Or you know in other words you shorten their their sentence for 100 by saying this prayer doing this highest work And that's not what those numbers ever really meant They came from the very early church when a lot of the confessors who were in jail, you know for the faith and so on would Some people would go and say would you talk to the bishop for me get into knocks and time off of my penance and uh, you know, and so They're they're developed this kind of tradition Of the relative merits of certain prayers or actions But it didn't have to do with time or days in purgatory. Well, I don't know what's a day in purgatory Right like a day here. Who knows so in order to Kind of overcome this this confusion The uh, it's somewhere back in the 70s. They they changed it for just partial indulgence or plenary indulgence and hard to get a plenary indulgence, but the amount of effectiveness that an indulgence has Is indeterminate by the numbers it's it's more now a question of both the Merit of the person trying to obtain the indulgence plus the receptivity or the ability to receive it On behalf of the one to whom it's directed whether or not you're here So they wanted to avoid this idea of getting too Specific and because people were confused So yes, I think there is time in purgatory. Although it you know Thomas and others in the in the scholastic tradition had a kind of a middle time called ablum It's kind of like angels live in ablum, you know, we live in chronos clock time uh, and we experience a little bit of kairos time, which is um Kind of the elasticity of the fittingness of time, you know, this is now is the day now is the time kind of expected And then god, of course lives in aeon, which is eternity and eternity doesn't mean a long long long time It means the fullness of time so that for god past present and future are all equally present You know god is God is it's a very mysterious thing, but we can conceive of it if you just think of a clock And you look at the numbers out at the edge of the clock That's chronos. That's where we live And god though is at that center dot and you notice that 12 or three or nine or six are all equally present to that dot God sees time all the whole sweep of time at once it all intersects back to him And so he's not waiting He's not wondering what you and I are going to do tomorrow or even even if he knows he's not waiting for it to happen It's already present God answers prayers faster than right now and sooner than immediately You know, it's a quote from an old gospel song But anyway, just to get back though it's a purgatory I think that one final thing to say about it is I think an awful lot of saints have uh Said look the time we spend there is not It's not short usually for many people um Sometimes many decades, you know Sometimes some people some saints say will be there for till the end of time till the end of you know when when christ comes again in glory So I I don't know if we should be so close. I'm sure they're in heaven by now We sort of talk like these things and I think the best the best thing we can do for anyone of our relatives or friends Who's died whether recently or even decades ago is just Pray pray for them. They could probably use our prayers if they're in purgatory and um, I think one of the really big More heinous sins that we commit today is our complete neglect Of praying for the dead. I think right, but you know, it's just my purvely, but you know, gosh darn it You know I I have trouble getting people that have masses Said anymore or to dedicate their rosary, you know to certain intentions let alone the dead I mean it's very important for us to pray for them and we owe this to them because frankly most of us are Living in buildings. They built and driving on roads. They paved and you know Living of faith they proclaimed and you know, and we owe them a lot And we ought to pray and we just not good at that today And so I I try as a pastor to encourage people, but you know, it's just a weird cultural thing too Oh like that way man.  Well, you know, who knows Right well it goes back to the sloth you were talking about and and my dad has a Has a quote that I love he says uh, if you're aiming for purgatory you have a hell of a backup plan And it's like yeah, it's I mean why My and you know, it's it's all there. It's why would you aim to spend more time in purgatory I've I and if anyone out there wants to take this idea you're more than welcome Just come you check but I'd love to see an app where we could see like time in purgatory based on sins You've committed you can enter your sins. Yes, you know, it's it's kind of just you know, just as a reminder It's like, yeah, no, maybe this is a thousand years and maybe if you hold the door open for somebody It's like 30 minutes off of purgatory. Maybe if you you know that sort of thing So you're constantly keeping it right, right? So Now you you you kind of Started going in the path that I wanted to go which is fantastic, which is talking about Not just how do we serve those who are in purgatory but kind of the Interaction that we have with one another So first I'd like to ask you can souls in purgatory communicate with us So we covered some of this with father mcmanus and the what is the ghost webinar? But of course, everyone is curious if they want a little bit more information Yeah, I would say the answer is generally not but like father mcmanus I studied with him and I studied exorcism with him and We do have to distinguish in the exorcism community about about ghosts versus demonic infestation Or is it that or is it a haunting and hauntings would seem to be souls who are in purgatory that god Permits to somehow reach out to us not to literally speak Right or ask us questions And we should not ask some questions, but just to somehow kind of signal us that prayers are needed and uh, I think that um Therefore again, we should never try to conjure them Or any of those things, but they do occasionally appear I think there's just I you know, you can laugh all people these and ghosts What an idiot, but I mean, I I I've I've encountered it as it as an exorcist And I don't give you all the stories. I'm sure father mcmanus entertained you with many the wonderful friends Very entertaining a month was being very knowledgeable But I will say that I personally encountered things that I can't explain except to say it was ghostly and um very very obvious and um I will say that I think that the experience shows in the human family that there are ghosts This is a very common thing throughout every culture I don't think it's just made up fantasies or some weird psychological thing I think it's something that happens now I think that it's rare In the sense that I don't think most souls in purgatory Receives somehow this privilege why some do and some don't I don't know But I do think that yeah in some sense they can communicate. However, if if a soul If a ghost or you know, someone maybe from purgatory starts talking Right, that's not that's not a good that's just general norm. All right, don't don't engage them Um, that's not the point. You know, we're basically saying there's a need for prayer Uh, the nearby parish not so long ago about 10 15 years ago a former pastor started showing up And people staff people were seeing and like, whoa um, and uh And so again, there was a solution was The right news the parish I was assigned to at one time I it didn't happen while I was there But the answer was let's offer prayers for his repose and and it began to stop and it stopped I I visited several houses where again, there were very unusual things happening Even while I was there like it's going on and off Spotted suddenly coming on even my cell phone was lighting up with messages And um It was so again the solution We had Massa said and it be it ended So I think this is um, like what's going on. So can they communicate with us? Yes in those cases. Otherwise, no Um, I don't know if they can know in a general way what we're going through what's going on But the main thing in purgatory Another thing we say is that generally speaking the tradition says that they cannot pray for themselves. They can pray for us They cannot pray for themselves. So we have to pray for them Um, and uh, so that's what that that increases then our need Um, I mean, you know our obligation. I should say to pray for the souls in purgatory Absolutely. Well, and that's perfect. So we're going into the next portion here, which is what can we do? So you've already laid it out praying for them is a big part of it Having Massa's offer for them is a big part of it and you don't have to wait for somebody to You know, as you said, it's already rare, but you don't have to wait for somebody to appear That's even going to happen, right? Because it's that's not the norm We should be taking advantage of the fact that We have priests all over the nation who are saying Mass every single day And you are offering it for particular intentions Yeah, so why would we not ask them? Hey, can you pray for this person? Can you pray for this person? But aside from having Mass is offered in prayers Is there anything else that we can do currently to help the souls in purgatory? Yeah, well, of course good works have always been indulged as well. So I'm going to go I'm going to go work with the poor today or I'm going to take Mrs. Murphy who can't drive anymore to the store And I offer up the fruits of this work So our charitable works if you will can be offered up And sacrifice as well You know in some churches they used to have these things called purgatory in societies Now I think You know it's interesting today We we focused on the grieving and it's nothing as good as good that we do We have sometimes these steven ministries or different ministries to people who've recently lost a loved one And we try to minister and help them But again, I often wonder well, whatever happened to the purgatory in societies Now purgatory in society would basically be people who enter into it sort of take on an obligation To first of all themselves give a certain minimum of prayers at least for the dead on a regular basis, but also then to foster to foster the We call it the you know the the praying for the dead So in other words, it's something that you're you're working to say will you pray for you know And and for the dead with me and and so on so I think that we should consider Maybe the word purgatory in society is is not the one to go but but um, but again, and we'll call it just for now Just a working title, you know pray for the dead a society the pray for the dead prayer group will be meeting At the local cemetery In the church hall, but I think that we should do that and um, the other thing would be Regular things that help us remember the day we have the month in November. We have all souls day Now for example, one other thing we do in my parish is but we have a lot of funerals here I got out 35 to 50 funerals a year And we put the funeral the pictures of everybody in their name Who had funerals in the last year and people I tell you It's an amazing thing people go and they look at that. Oh, I forgot he died this year. Oh, yeah Oh, I didn't know he died. Oh, you know, and so it's an amazing little thing We do it in November, but as I say, we also throughout the year Have a little area in the back of the church in the vestibule where we put the recent funerals and we said, oh, oh, thank you I didn't know and um So again, I think these are the kinds of things that to remember that in one final thought People don't go to cemeteries anymore, right people that used to be a routine thing on certain days feel like memorial day or You know, you name it.  There we go and just pay a visit Um, and that's kind of largely gone and I I think there's a there's a lot of What do you call it merit in walking through a cemetery? And it's very in a way Important because it reminds us these people had all the troubles I had and more besides And now look see and likewise they had all the glory and all the stuff I thought I was riding high and now again at the end at the end this this this will come to me You know at every funeral I say to people you are going to die And you've got to get ready for that So anyway, I think these are some things that we could do I find it troubling a little bit at memorial day We have masses in our catholic cemeteries also on the piece of our lady of sorrows And the numbers of people that attend that have dropped dropped dropped. It's just not on people's radar Well, you mentioned Offering of charitable works for souls, which I I'm thankful for because I've never I've actually never heard that before The one that's more common that I want to get your input on that I've heard is offering suffering Is that can you also offer your suffering for the social?  It's wasted suffering Or a meaningless suffering, you know, we live in a world That has that sees no meaning whatsoever in suffering It is a horrible thing to be avoided at all costs and paradoxically to the point of taking your life to a physician That says it's suicide if it gets to that point and that is the it is just it's a world where there's General meaninglessness, but particularly when it comes to suffering And I should never have to suffer and I can even kill a child in the womb If it means that I won't have to suck, you know, we do this is what we are like And we forget and I often remind people when I do the tv mass for the shut-ins, you know, I say please Pray for us your prayers have never been so powerful Offer your prayers up for the souls I said because you know, you might think well And I was much more productive in the old age I could get up and work and But no listen, even lying flat on your back. These may be your most powerful and important moments And even if you have trouble concentrating just every day make an act of faith that says lord Just give it all to you for the salvation of souls and you know, it's powerful powerful Right. I mean, maybe this is another topic for another conversation, but it strikes me how People forget so often that Jesus said you must carry your cross Yeah, and I've given talks. I said you don't understand what that entails I mean, you know what the crucifixion is, right? There's nothing easy about carrying your cross And yet it's absolutely necessary and every ounce of that suffering that we Experienced during that time can be offered for something more. I love what you said You know, the the worst thing is wasted suffering. That's that's so true. It's so powerful That's an old joke by the way. I stole from pulling chain Okay, well, I go Of course, you said it with you know flair that works in a world is a suffering That's pretty good. I like that. I like that. You just need the purple cape, right? Oh my yeah, yeah All right, so we're going to get into the questions that have been sent in from those who are currently watching this live This has been fantastic, but These always have a little bit more to them that different things that you know, we on our own can necessarily come up with So we're going to go with this first one here says Can purgatory happen while still on earth? well in a way what what Should what would otherwise happen in purgatory could happen here But earth is earth and purgatory is purgatory. So uh, I think that uh I think the I think there's a very Yeah, so let's let's I understand the idea but Purgatory again, as I said earlier most of the saints kind of caution us That purgatory isn't really for the faint of heart. Don't just postpone stuff Because it's better to deal with it here It's easier and better Ah, it's harder and more intense and uh So I don't want to turn it into a mini hell. It's not the catechism is clear. It is a place of healing Uh, it's a place. We know we're on the way. Um of great joy and hope and anticipation, but there is a suffering there and So ideally we can try to deal with a lot of it now. So we don't have to deal with there So I prefer uh, earth is earth and purgatory is purgatory even though there is purgatorial dimension That we experience here on earth. Yes Let's go to the next one, please Do canonize saints go through purgatory as well? Yeah, you know I'm afraid I didn't I never understood that this might be offensive to pious years But I've had people really like shock. Oh my god. What are you saying? But you know those who are canonize saints now I don't think we argue that they never set foot in purgatory But we're saying now based on evidence because miracles are happening and prayers are being answered and you know Based on other externalities while they were here. Namely, they lived a holy life They were exemplary and they're heroic in their charity and uh, they uh group of people developed around them Who admire them and so there's certain criteria about their life here, but It it what we're really saying is we we know by faith and the church's power to and discern this That they are in heaven now. Does that mean they never went through purgatory? Probably not likely I would imagine even some of the great saints had a little time there um It's none of my business how long or what that was about. Um But as I say, I think that um I'm afraid that that may sound offensive to some pious years But saints aren't you know, they don't just fall out of the womb Perfect and and they they struggle and make their way like we do they're in the Uh, kind of the they're wayfarers like we are and at some point they reached a great level of Sanctity, but if if if if everything wasn't resolved at the moment that that's shortly the Lord also Time and help to purify them, but we know now When we declare someone or canonize them that we can indeed presume and and and and Believe that they are in heaven and can intercede for us Fantastic Let's go with the next one This person says that they were involved in homosexual relationships. Is it possible for them to get to heaven? What penance? Should they do? There's only one sin that can't be forgiven and that's a sin. We don't want forgiven um You know, that's kind of the sin against the holy spirit of final unrepentance so of course anyone who's committed even The heinous sin or sin murder murder or something if they if they repent No one it turns to me calls on me. Will I ever reject says the Lord? So that's the first thing I think that the key point is that we're repentant now one of my concerns of joshua for this this world of jordan. I said for this world today is There is such defiance That's evident today.  God doesn't care. I don't care. I don't care what you say You know, it's the defiance that worries me because this is where people are Well, first of all, they can't get mercy because they don't want mercy Right and and repentance is the key that unlocks mercy and just to show that it would be weird for god to off to force mercy What if I came to you um, jordan and I said I forgive you for the terrible thing you said about me yesterday You're like, well, wait a minute. Uh, what thing? Oh, oh, well, I think you needed to hear that You know, so you don't Mercy or forgiveness isn't something you force on someone or but you offer it But they themselves have to admit first of all their need for it for it to really take effect And so I think uh our questioner. I'll get back to this idea. What can I do? But I I think that I'm not worried about him. It sounds like or her or whoever I'm not worried about Someone who's repented as much as I worry about Those who just are defiant I will not put what to do and there's nothing wrong with this It's just that the church is uptight or whatever, you know, now all that said I I don't know. I mean, I think any of us who have had struggles with certain amounts of sin in life. Um We I suppose there's certain special things we can do Let's just take a different example that maybe a person who struggled with alcohol and finally broke free of it Can start to I don't know either reach out not being preachy but help others who they might know who are struggling and give them hope Maybe are they required to do that? Not necessarily um, maybe, uh, you know, someone who struggled with sexuality at any level whether heterosexual sin or homosexual sin whether ornication adultery homosexual acts pornography or whatever Can particularly um do some bodily penances like uh fasting or so on or But I I don't I don't think that it's it's absolutely required that we say you must follow the following regime to get to heaven if any grace and mercy and if god shows you a way you can reach out and help people go do that but Once a sin is forgiven it's forgiven And even if god himself has to bring some healing out of The effects has had on us, uh, you know, there isn't there aren't a lot of hoops to jump through and we got to be careful about that So if god inspires you to encourage other people maybe by joining a chapter of courage or something, but Fine, but I don't think that there's some special thing that you must do now because you know, I just hope you're into confession I hope I've been all of us have been to confession about whatever we're struggling with that's the key goal right, so if I was to sum it up it's Doing your best to live a life of virtue Yeah, as defined by scripture and catechism on those things And do your best to live out the call that god has called you to whatever that may be Yeah, great What is the next question there producers? Are souls completely dependent on our prayers to help shorten their time so souls and purgatory are are they completely dependent on prayers? No, I think that they're completely dependent on god's grace right like we are Uh, but it helps. I think you know just just just talk about you us here You know if I say um, would you please pray for me? You you may or may not But I guess am I utterly dependent on you praying for me? No, but it was your help Right, it could be a great help and um, so I think that well, we should see it that way Um, I think we can we god has told us that you know, we can pray the prayer changes things that um that you know, we can um You know, uh, make a real difference in people's lives through praying for them or Through good works and and so on so we ought to do them But to say that everyone well, you're not the savior thing that's not the way to answer that question Right, we're not the savior The lord is that's been that job is filled but as far as assisting, um, that's that's always to be It's always helpful And even if the person's already in heaven, maybe the music can be applied to somebody else, you know, right? Those souls will have no one to pray for them Right, right, right All right next question there producers Does it matter if you're cremated or not for the end of time when your soul is reunited with your body? From god's standpoint, no The only reason that you know the church for bad cremation for a long time Was that it was tied to this sort of the free masonry and and this idea that the body was not going to rise Um, in fact in that there's also of course not just free masonry But all sorts of gnostic notions that the body is to be disdained And so on but again our glorious human beings is that we combine two orders of creation Namely, uh, the material and the spiritual that is our glory Angels are pure spirit animals for example are just you know There's a there matter, but we have these souls That are linked with our bodies and so it is the it is very important for us to revere the body Now cremation is there's a cultural dimension to it in some cultures cremation Like india, you know, it's very common. There is this is actually very considered very holy But uh for us we had the tradition of burying the body, but the church in recent years has permitted cremation But still prefers the burial of the body as a sign Uh, a faith that the body will rise Now the problem with this thinking though is that we don't want to absolutize it. We've never done that We we understand that sometimes for example, uh, a person's body has decayed and just nothing but dust Um, or this not like god's gonna be saying now, let's let's see, uh, time to raise them from the dead I'm looking for that right tibia Right i'm also around here somewhere Right, you know and and again so there's burials that see that we we've always had to do these things sometimes again In times of plague bodies even had to be burned then, you know These are the things that I think we we want to make sure that we don't have a cartoonish notion Of the um resurrection of the body that skeletons will come out and suddenly start dancing and flesh will come on and so on Rather this I I think the best way to understand the resurrection of the body Is that it is our soul's form or nature to form a body We as human beings we have a soul that is part of its nature is to form a body and therefore God will release once again this power And our our our souls will again gather this matter that makes up our body And whatever of our body physical body still remains perhaps in the tomb or whatever obviously This would be included Now but even now I mean I don't have the same hair on my head that I did seven or eight years ago Or certainly as a child. I have a lot more of some cells You know that I used to have and maybe one day I'll slough those off But you know that it's a nature of most of ourselves to replace themselves anyway over time So the body's constantly sort of sloughing off cells and renewing.  I don't I don't know. I don't know all the medicine But I would just say that our bodies Our soul form bodies and this is the power that will be released to us again at the resurrection of the dead God will raise up whatever remains of our body, but it's not like he's going to be wanting and running around looking for You know the left elbow Right, you know femur or something like that So we I hope that helps I We need to avoid a cartoonish notion But a notion that references the fact that our bodies our actual bodies will rise They would be truly our bodies because they'll be formed by the same soul that's forming my body now some of that body is sloughing off cells and the soul is Replenishing them. So you see what I'm saying we hope that it's I'm upset. Right. No, it makes total sense and I you know, I've I've I've had people ask me You know about the cremation aspect before and my response is usually well Wouldn't you want to make it easier to be? Determined a saint with an incorruptible body, right? So hopefully we get to that point And they dig you up and they find you incorruptible. It makes it a little bit easier for you So there you go. There's that aspect. Yeah another right, right? So let's go with this last question here. Okay How do we avoid purgatory? Well simply put by responding to grace and turning away from sin But I say even beyond sin itself. There's attachments to sin that we we haven't had, you know much time to talk about And that's a whole separate area of moral theology, but attachments to sin. Well Let's just put it this way We don't despise sins the way we should sometimes we're still sort of attached to them, you know, okay Yeah, I know I can't do that. It's wrong, but I sure I sure could use a drink or boy that that young lady, you know, you know You know and so on, you know, we're still sort of attached And so we don't detest sin and so what we want to try to do like st. Teresa It uh st. Teresa and the interior castle those first three mansions are about dealing with mortal sins certainly venial sins, but then also other attachments and things that just root us in this world and then make us less apt for the things that God had actually offered and We um we have to um You know, I would I would just say we have to be very uh open to that as well and that's why I think that Uh, some of these things may wait for purgatory But meanwhile, like I say, what can we do to avoid it or altogether would be Obviously repent of our sins and be responsive to God's grace to not just be free of sin but growing in holiness and grace And bring ourselves also from various attachments to this world right Fantastic. Well, I very much appreciate your time. This has been very enlightening and and I hope sincerely that it has really helped People understand the reality of what purgatory is and it's it's not I mean, it's tough, right? Because it's something that we'd like to avoid if at all possible But it's also not something to be feared. You know, it's it's a beautiful. It's a beautiful thing And that hopefully we would all after listening to this would be inspired to strive more for virtue And to take care of all these things now these attachments and sins these wounds Utilizing all the gifts of the church so that one day we could be joined in heaven with christ Touching our heart to his heart in the most pure possible form we could we could be in So the other thing jordan, it occurs to me to say I'm not sure how old you are, but i'm 61 And I came I was living right at the end of an era But I will say that some of the older notions of purgatory were truly frightening It was really no different than hell except that somehow it was temporary And um, I think that some people Rejected the doctrine the dogma of purgatory. It is it is the doctrine of the church, you know I don't think that you know people are like this today, but um, but I think what was happening is that that what was being rejected was perhaps not As accurate of an understanding of purgatory that we we should have which is like you just said earlier Not to be terrified or afraid of it. It is a place of healing. It is a place of some suffering But so is this world right We know about suffering, but at the end of the day, I think that some of us The some of us You know, we'll we'll be there, you know, but but we ought not like you say be afraid and it ought to be something that In a certain sense we look forward to even if we have to go we look forward to heaven Even if we have to go through purgatory because we're on the way man. That's great. We know we're in Right, absolutely well for those who want to Hear more of your teaching if i'm understanding correctly, you're going to be teaching a course for the avalanche, too Is that right angels and demons? Yeah, uh-huh coming up. I forget sometime in january. I think uh, but yeah, so Apply by january 5th. It starts january 12th To get into that course. You can find that at avalanche institute.org And then also as we already said, uh, ewtn's radio morning glory show And uh, where else could people find? I think we have catholicexorcism.org. Is that is that another resource? Yeah, and there and also I would say actually morning glory is no more, but um, okay I'm on the sunrise morning show a few days every couple of weeks. Um Also, you know, I get around the radio, but I mainly on these days. I'm primarily a writer. I have a face for radio and I uh And for writing so I think that I uh, but you'll see me occasionally on ewtn tv or the radio and um, I I just well, I love to teach and I love us people and I am a motormouth as you can tell And uh, but I like say to catheter sienna. She always wrote long letters, you know And she would always say at the end of the letter. I apologize for the length of this letter But I have written out of the abundance of my heart That's awesome. Do I speak? I'll be abundance of my heart Good Anyway, so but you know, I I love it and I'm looking forward to teaching on angels and demons And um, I've I've taught this kind of a course and several other occasions And it made me here in the parish or at the st. Michael's center And I'd be happy and be excited to be able to offer it for the avalanche, too Fantastic. Well, I was just at the st. Michael's center I got a couple maybe a month ago and so I can't speak highly enough of everybody there. Yeah And and I encourage everybody to go check that out. That being said, would you mind closing us with a prayer? Lord, we do ask your mercy and grace upon us First of all, we do pray for our beloved dead made the souls of the faithful departed Through your holy mercy, oh lord rest in peace. I mean all the souls of the faithful departed Through your mercy indeed rest in peace lord. We ask also now your mercy upon us who are still Journeying on the way. We are wayfarers. We ask your grace your mercy. Yeah, we ask you to keep us faithful unto death We ask also now a rich blessing upon us that we may be a blessing to others And so may almighty god bless you all the father the son and the holy spirit Amen And then thank you again. Good night everybody


The Australian government has used a semi-mechanistic modelling framework to track the spread of COVID-19 during the pandemic. The model uses behavioural data and case data when disease activity is present to estimate the transmissibility of SARS-CoV-2 from periods of high to low or zero case incidents. When the virus is active, the model recovers the effective reproduction number, which helps to monitor progress toward controlling large outbreaks. When the virus is not active, the model estimates the risk of reintroducing the virus into the population. This model has been used extensively in Australia to inform public health policy decisions and guide the country's response to the pandemic. This article was authored by Nick Golding, David J. Price, Gerard Ryan, and others.


Two brothers have been buried in Kenya on Friday after they were beaten to death by the police for violating Covid curfew. The brothers are bent in on June 22 and Imaro Motura, 19, died over a week ago. They had reportedly opened their pork business at a Kenyan market despite the curfew, imposed to curtail the spread of the novel coronavirus. Brothers from different political groups gathered at the brothers' parents' home in Kitangari village, Emble North sub-country to condole the diseased families.


with us. So he's a staff ideologist at Jerevenski Hospital of Hamilton Health Sciences. He's an assistant professor at the McMaster University. His specialty is a breast and body imaging and areas of interest are cancer imaging and resident education. He'll be speaking on MRI or ads. Thanks for joining us and may I know would you? I'll just stop my screen share. Thanks for the kind introduction, Gauri. And first of all, thank you all the organizers of the 21st MRI teaching course. It is it is my privilege to present my cases and some of the teaching material here. After we have such amazing talks about pancreas and all other areas of body imaging, we are going to switch gears a little bit and go to one of the hot topics of the current date, which is MRI or ads. So let me share my screen and make sure that everything works fine. At any point, if you have any questions, feel free to use the chat and Q&A session. Even if I'm not able to answer the questions live, I may take them later on in the interest of time. But let's see how we do today. So without any further read, let's jump on to today's session. I have basically titled it as MRI or ads and what radiologists need to know. I know that all these American College of Radiologists and RADs have been an interesting thing to look at. Sometimes it's big, it becomes a little bit too too obtrusive to your workflow. If you're not doing these RADs very often, for example, PyRADs, PyRADs, then TyRADs, then ORADs, all of these RADs can be a little bit of a challenge. So I just try to summarize the most important or key point which you can take away after today's session. So I don't have any financial disclosures, but some of the sections of this presentation have been borrowed from one of our exhibits, titled number E-1881 in the American Brian Gendry Society's annual scientific meeting. So learning objectives of today's sessions will be to provide an overview of the MRI or RADs, look at a few of the pathologists, look at some of the physiologic, peritoneal, as well as tubal cystic processes, how we can classify them using this tool, then review the standardized lexicon, which is provided by the ovarian adnexil reporting data system on magnetic resonance imaging, and then how to characterize these pathologies there, then overview the ORADs MRI stratification system. Let's start with some quiz questions. Let's see how we do with these. So the first question is that, when will you use MRI or RADs? So case number one here on the left side of your screen is a woman in her 30s with BRC mutation. You have this coronal T2-weighted imaging of the pelvis, which shows you a large multi-locular cystic mass, which has multiple septations, and the septations also carry few papillary projections. Case number two will be your young woman with acute pelvic pain and fevers. It's in the center of the screen. This is an axial T2-weighted image. You can see a portion of the uterus, maybe it has some fibroid, and you can see that there is a lesion in the right adnexa. It looks like it is a, again, looks like a multi-locular cyst, but it has thick irregular walls, as well as septations and papillary projections. Then case number three is postmenopausal woman with bleeding normal CA125. This is the actual post-contrast image. You see the uterus, and also an enhancing left adnexal mass. Which of these you think is when you will use MRI or RADs? I'm seeing some options here. Most of you have gone for case number A, or the case number one, very few have gone for B and C. Let's go to the next question. The next question is that, when will you use OR RADs score five? Case number one is adnexal mass with peritoneal mass. This is an axial MRI from the upper abdomen. You can see that this is the section of the liver. Those are the kidneys. I know that this is obviously our OR RADs talk. I'm not showing any pelvic image here, just because the fact that you can see all of this soft tissue deposits, which are in the hip adrenal space, maybe a little bit of soft tissue in the adjacent to the falciform ligament, as well. Then you have a sagittal T2 added image, which shows a large cystic mass in the pelvis with a regular solid component, which is not T2 dark, and it shows enhancement better than the myometrium on post contrast imaging at 30 to 40 seconds. In case three is multi-locular cystic mass with thin enhancing separations. That's the uterus, which is pushed posteriorly by the mass effect of this lesion. Which of these you feel is an OR RADS five or a definite OR RADS five? You can go ahead and answer. We have a little bit of a split in this case. You can see some of you have gone for A, most of you have gone for B, and some for C. This is very good. This is going to help us for the discussion of today's talk. At the end of the session, you should be able to take some of the points and then classify these lesions appropriately. I know that there are lots of OR RADS, but it is important to go through the history of MRI OR RADS. To begin with, I don't know if some of you have joined for this session, sometimes in the last week of May or early June, we talked about IOTA, Simple Rules. IOTA is International Aware and Tumor Analysis Group. They started working on adnexal lesions and specifically focusing on ultrasound and how it can help in classifying certain lesions. Even based on these simple rules or 10 simple rules, approximately one fourth of adnexal lesions can still remain indeterminate and they need further imaging to classify them. That's why you can see that the OR RADS MRI score is useful in these indeterminate lesions as you can assign them an OR RADS MRI risk score or a category. This helps in preoperative characterization as well as stratification whether some lesions can be handled by a gynecologist or do they essentially need a gyne oncology consultation. Remember that if you refer each and every patient of adnexal cystic mass to a gyne oncologist, their services are going to be overburdened and there will be unnecessary delays in patient management. Obviously with MRI, you're going to have higher spatial resolution which improves characterization and studies have shown that these indeterminate lesions with ultrasound, you can see that there's reduction of these indeterminate features from 20 to 25 percent if you use the ultrasound and an MRI that drops down to 5 to 7 percent. So MRI actually does a very good job at classifying these lesions. For evaluation of contrast enhanced imaging, you definitely need to use MRI in this particular case. In a study by Tomasin et al, I have given the reference here, they saw that OR RADS MRI was 93 percent sensitive and 91 percent specific in diagnosing malignant lesions and that's exactly what you want. You definitely want to handpick those malignant lesions and make sure that they are fast tracked for their management. And this is in cases where these lesions were sonographically indeterminate and the likelihood of malignancy in those indeterminate lesions were less than 0.01 in lesions without post-contrast. So if you do pelvic ultrasound, see an indeterminate lesion and recommend an MRI and if there is no enhancement whatsoever, the likelihood of malignancy in those cases is going to be less than 0.01. So you can see that MRI does an amazing job in rejecting the benign lesions and showing the malignant lesion and that's exactly what you want to do with OR RADS MRI scoring. Another important fact here is that you should adhere to lexicon and additional descriptors because once your report goes to another radiologist or a gyne oncologist or a gyne oncologist, each and every one knows exactly what you are talking about. For example, looking at other descriptors such as a cytos, peritoneal and mesentracoronometrial no reality, all of these are going to help you in completing local staging of the disease. So what is the clinical problem here? In consistent lexicon, for example, lesions described as complex adnexal mass, they can be benign and malignant both, right? So not all of these so-called complex lesions will need urgent surgical consultation or urgent surgery. For example, you may have lesions which look like a hemorrhagic cyst with some peripheral smooth, thin wall enhancement. Technically, that is not even malignant, right? Even though it shows enhancement. So you have to watch out for what kind of terminologies you are going to use. Then what happens because of this is that there is a big dilemma about management. So you may have unwanted surgeries, delayed referral to gynecology because the services are now over bombarded with all these complex lesions going there. And then there could be possibilities where you may see benanophorectomy. For example, endometriomas with an expected rocket and skin nodule, even if it shows enhancement, it is over ads too. If the volume of the enhancing solid component is significantly higher, only then you can start to think about a malignant transformation. So not all enhancing rocket and skin nodules means that it is malignant. So you have to be very careful when you are using your lexicon so that it helps in management of the patient. So how to fix the problem? This is when the research started to go on in this topic. So they first started looking at this in the IOTA group, International Ovarian Timmer Analysis Group, a paper which was published in 2000 by Timmerman et al. talks about terms, definitions and measurement techniques. This was the first attempt at standardizing terminologies. Then we saw ultrasound simple rules and adnex models, which basically stemmed from this research. Then a morphology index was published by University of Kentucky, then GI rides from Armour et al. in 2009. Then a Society of Radiology Consensus statement in 2010, which was further revised in 2019. Some of the things which you have to consider in this case was that for GI rides and SRU consensus, they did not address the issue of inconsistent terms and they excluded solid masses from their assessment and descriptions. So that technically does not represent the entire gamut of pathologies that you will see on pelvic imaging. To improve standardization, ACR ORAD's committee was set up in 2015. Initially it started with ultrasound and then later on MRI was also added to the subcommittee because MRI is going to be a problem-solving tool and both working groups were created. The most important thing to consider here, what causes problem or what caused problem for all of the previous versions of this attempt to standardize was lack of widespread use and poor acceptance in clinical practice. So it is our responsibility that we start using lexicon appropriately so that there will be less issues of inconsistent reporting. So now let's look at how ultrasound most of the times helps you. So for the first modality, most of the times it's going to be ultrasound. So you see simple cysts less than three centimeters, then you see corpus luteum cysts with even ring of fire kind of appearance, then normal follicles and polycystic ovary. All of these are normal findings. ORADS 1, no need for MRI. Ultrasound does an amazing job. These are just benign processes consistent with normal ovary physiology. But what happened is that you start to see cystic masses which are greater than three centimeters or less than or equal to three centimeters, but going all the way up to 10 centimeters. So all of these cystic masses need some kind of a follow-up, but they fall under the category of ORADS 2, which is almost certainly benign. So in pre-monopausal age group, you technically do not need any form of follow-up, even if the cyst is up to five centimeters. This has been reiterated in many other guidelines such as SRU consensus statement. However, if the patient is post monopausal and the lesion is more than three, but less than five centimeters, you need some kind of follow-up. Then between five to 10, if the patient is a pre-monopausal, you need a follow-up in eight to 12 weeks, but if the patient is post-monopausal, then it's some kind of follow-up in one year. However, if the cyst is more than or equal to 10 centimeters, then it becomes an ORADS 3. It has low risk of malignancy. So see how the malignant potential changes, and we are going to come back to this in a second. So till now, we see that Ultrasound is doing an amazing job in picking up benign physiological findings as well as some of the benign lesions. Some other examples of typical benign findings include hemorrhagic cysts. So you see this lace-like reticulations in this cyst, which are typical of hemorrhagic cysts. Then you see this retracting clot in this hemorrhagic cyst. Again, Ultrasound is doing an amazing job. This is an example of typical dermoid cysts with the dermoid pluck or rocket density protuberance. So you see this cyst in the adnexa, which shows a low level echoes within it. And there is a rounded dermoid plug within this lesion. So this is just a sine loop or a sweep through the adnexa in transvaginal grayscale Ultrasound. You can see how it has those low level echoes and the dermoid plug. And on this MRI, actually, with a sequence, again, it shows the imaging in a better fashion. If I go back to this sine loop, you can also see that there are shadowing calcifications in the wall. Again, in keeping with our dermoid cyst, you can see here, those are echogenic foci with calcifications. Then this is just the actual CT of the same patient, which again shows you that there is a fat-containing lesion dermoid plug as well as these calcifications. So everything looks amazing till now for Ultrasound. So why do we need MRI? So let's look at some scenarios. So you have this scenario one when you have a perivernopausal woman with pelvic pain coming with elevated C125 levels and the sagittal ultrasound showing a large unilocular cyst. So in this case, it was more than 10 centimeters in size. What happens now is that you may understand that with Ultrasound and large cystic masses, you may see some reverberation artifacts at the bottom of the imager. And that can cause a little bit of a problem. So this same patient underwent a pelvic MRI examination. This is coronal T-dweller image and the blue arrow actually points towards a papillary projection in the cyst wall. So given this location, maybe it was difficult to visualize on this ultrasound and then this lesion turned out to be a cyst adenocarcinoma. So the important teaching point here is that small papillary corrections may be difficult to visualize on ultrasound, especially if the lesion is too large because of the reverberation artifacts. And this brings us back to this important point here is that why suddenly the risk of malignancy also changes when the lesion becomes larger in size. This may be one of the factors as well as well as the size of the lesion. So now let's look at another example here scenario two. If you do the ultrasound, if you see on ultrasound, it looks like there is a pelvic mass. So that's the uterus and it's kind of in the cul-de-sac as well as going into the left adenica. So it shows that there appears to be a multi-locular cyst here on this imaging. It shows low-level echos. There was no vascularity at this ultrasound. So how to put it into two or three category here? And when we do the actual, when we do MRI of this patient, this is the actual T2, actual T1 and T2, sorry, fat suppressed image, you can see that there is, there are bilateral cystic lesions and they contain incomplete septic with hyper intense T1 signal, which is in keeping with fallopian tube dilatation with non-simple fluid. So whenever you get non-simple fluid and dilated fallopian tubes, it becomes ORATS category three. If there is simple fluid and dilated fallopian tubes, even if there is smooth wall enhancement, it becomes ORATS two. So MRI really helps in risk stratifying some of these lesions. So obviously MRI is going to give you improved characterization and helping in management decisions. Let's look at some of the nomenclature of physiological processes. So we looked at some of these on ultrasound. So normal benign follicles on this sagittal T2 weather image, then a corpus duty assist, which is going to have somewhat of a smooth, peripheral wall thickening. Then you have this sagittal T1 weather image, which shows a hemorrhagic cyst, which is less than three centimeters. And then another hemorrhagic cyst with fluid levels here less than three centimeters. So remember, simple or hemorrhagic cysts less than three centimeters can be considered as normal. This is a very important point to remember. Then characteristic benign legions. So now here you have this large, this is a sagittal T1 weather image here, large homogenous T1 hyper intense unilocular cyst. It is in keeping with an endometrioma. Then you have a case here with, we already looked at this, it was a dilative fallopian tubes with incomplete separations and T1 hyper intense fluid contents. It got classified as ORATS category two. Then you have this peritoneal inclusion cyst. Again, they are typically benign ORATS two, but you need to have some kind of surgical history, which suggests that the patient might have this inclusion cyst. This is an actual T1 weather image. You see the dark uterus here. And this is a left adnexil mass, which is kind of slightly posted to the uterine fundus here. It shows T1 hyper intense contents. It was nothing but lipid. So in keeping with a mature dilatoma without solid tissue. An important teaching point here is that whenever you see cystic masses also look for papillary projections. And some of those papillary projections will help you classify these lesions further. So if the lesion has T2 dark components, remember, you have to look at T2 and diffusion weather imaging. If it is dark, don't consider it as solid tissue, even if it shows enhancement. It has to be non-dark component to call it a solid. Any cysts more than three centimeter with any type of fluid and no wall enhancement fall under this category as well. The only exception here is an endometrioma that may actually show smooth wall enhancement. Whereas for the other categories of cystic lesions, they do not show enhancement in this category of ORAS2 lesions. So now let's look at some cysts with non-simple fluid. So here you see some examples of cysts which are larger in size more than three centimeters, as well as some cysts with non-simple fluid. For example, this is actual T1 verifersive prismage, which shows hyper intense contents in this right over right adnexil mass. Then you also have this multi-locular cyst with multiple smooth separations. You have this unilocular cyst with a papillary projection solid component. Look at this. This is T2 and it is not dark. So you have to consider this as a solid component and look at its enhancement. This is a sagittal T1 post-contrast image. It shows a large ovarian cystic mass. Multi-locular shows smooth enhancing separations. So the take home point here is that unilocular cysts with non-simple fluid and smooth enhancing walls, multi-locular cysts with any type of fluid contents and smooth enhancing walls, all of these are going to be ORAS category three. Even smooth enhancing separations, ORAS category three. If you see any solid tissue in cystic masses, but it shows a low-risk dynamic contrast enhancement curve, it is going to be ORAS three. So for these lesions to fall under category three lesion, you need dynamic assessment. If you don't have dynamic assessment, you may not be able to classify it as ORAS three. So let's look at another example here. This is a transvaginal pelvic ultrasound with a large mass which is labeled here. That's the ovary and you have this color Doppler flow. An important point to remember here is that whenever you're performing pelvic ultrasound examinations, you want to you see such kind of a mass, you want to make sure whether it is arising from the ovary or not. So for example, a benign finding such as a broad ligament firebird may also have this kind of appearance. However, to assess that further, you have to just do manual push and pull on that mass with your transducer. So if you push or do allotment, if the mass is not ovarian, it will separate from the ovary. Whereas if the mass is ovarian, it will not move separate from ovary. As in this case, that's the ovarian mass. This is at rest. And when you exert pressure and push here, the ovary is again not separate from the mass, which means that it is arising from the ovary. So this is a very important point when you're doing this pelvic ultrasound to make sure what is the origin of this mass. So in this case, we did post-contrast imaging and this is dynamic post-contrast axial MR with subtracted image. So that's the myometrium and this is the ovary. So in this case, as you can see that the solid component is not enhancing as much on this 30 to 40 second phase. But moving along, if you go to the systemic or the venous phase, you can see that the solid tissue has started to enhance. However, even now it is not enhancing as much as myometrium. But this phase is most crucial 30 to 40 seconds after injecting. In this case, the final diagnosis with Merkle cell carcinoma, it's a very, it's kind of a very atypical appearance. However, they can arise anywhere. But this patient had a history of previous exhesion in the left axilla and chest wall. Dynamic assessment and lack of acoustic shadowing in this case definitely helps differentiate ovary tumors from adenis fibroids. So remember that don't walk into this kind of a pitfall and use your dynamic assessment with ultrasound as well. So what is this dynamic perfusion curve? So this is an infographic form our exhibit as I described at the start of the presentation. So what you have to do is on the 30 to 40 seconds of the post injection contrast phase, that's the time point which coincides with most of these peaking of contrast enhancement here. And then that's the ROI, which is in the solid component of the ovary. So low risk curves are nothing but, so if you see the blue is myometrium and green is low risk. So the lesion does not enhance as much as the myometrium. The intermediate risk is obviously when the lesion starts to show more enhancement as compared to the low risk ones, but it is still not going beyond the myometrium. And then high risk is technically going above and beyond the myometrium, especially around the 30 to 40 seconds after injection. So if you can, if you can consider this as your breast MRI dynamic assessment time intensity curves, it is basically somewhere on those lines. But even till this date, not many centers are doing dynamic contrast enhancement assessment of pelvic masses. Even those studies have shown that this is preferred over non-dynamic, but let's talk about non-dynamic contrast enhancement now. So what do we do in non-dynamic contrast enhancement? We can only classify them into two groups, less than or equal to myometrium or greater than myometrium. So you have a couple of examples here. So actual post contrast image here shows that the myometrium is enhancing more than the left adnexal mass. Then this is another example. The patient has multiple pelvic lesions. They were bilateral adnexal masses, but the solid component actually enhances equal to the myometrium in this 30 second post contrast actual image. And in this case, sagittal post contrast image shows that the solid component enhances greater than the myometrium. So using non-dynamic, you can only classify it into one or two categories, whereas with dynamic perfusion curve, you can classify it into low risk, intermediate risk or high risk curve. So with this in mind, let's look at the stratification and management guidelines which are published by American College of Radiology. So this is a very busy slide, but let's touch at least some of the important points. So you can always go to ACR website and download this risk stratification table and start to use this in your day to day practice. But we have basically touched upon some of the important findings here. For example, we looked at benign processes in normal ovaries such as corpus luteum cysts, follicles, hemorrhagic cysts less than three centimeter in the prima, the puzzle woman, then any cysts which are classified as follicle less than three centimeters. So we looked at these examples. Then we looked at unilocular cysts with simple fluid or endometriotic fluid components. They may have smooth wall enhancement. Then we looked at lesions with lipid content in one of the examples suggest a benign teratoma. Then we talked about dark T2 or dark DWI solid components which is technically not solid tissue and it should not be classified as solid tissue because those can be just retracting plots. Then we talked about dilated fallopian tubes. If it has benign or simple fluid content, it becomes category two. If it has non-simple content becomes category three. Then we looked at para variants. We did not touch upon this, but again para variances also fall in the category two. They do not have enhancing solid tissues here. Then we looked, let's look at some of the ORADS 3, 4 and 5. So what do we need to know is that if you see any solid tissue and if you have dynamic contrast enhancement with you, it needs to show low risk curve only then it falls in the category three lesion. However, if you do not have this particular feature, then you have to look for non dynamic curve and in that case, it falls into this category. Then you can have smooth septae. We looked at one of the examples with enhancement and then smooth enhancing walls of the system. It may also fall into this category. The most important take home point from this slide is that whenever you see peritoneal misentry, corromental nodularity or irregular thickening with or without a cytos, it automatically becomes category five. It does not matter if the enhancement is greater than equal to or less than my metrium. It becomes ORADS 5. So that is one of the examples we looked at in our quiz questions. One of the patient had metastatic disease, so that puts into a category of ORADS 5. Now let's look at some of the examples of each ORADS category. So these are typical examples of ORADS category one.  So it just has simple fluid contents. So this is typical ORADS 1. Then you have hemorrhagic cysts here. So remember hemorrhagic cysts up to three centimeters are considered benign. The cysts which are larger than that, you have to look at other features such as wall enhancement. Even if it has smooth enhancement, it can still fall under this category. If it becomes more than three, it becomes ORADS 2. Then let's look at another example here, just a benign fat-containing lesion. Young woman presents with, again, on ultrasound, it was just labeled as complex adnexal mass. But on MRI, you can see that it is bright on T1.  It's a very small component here. And then on ultrasound, you can actually see that there is lots of echogenic content with shadowing. So this is in keeping with a benign endometrioma. So again, falls under the category of ORADS 2. So remember, these may also have rocket and ski protuberances, which is expected with teratoma. Don't make them as ORADS 3 or 4 just because there is a rocket and ski protuberance. Then let's look at another example here. So 27-year-old with pelvic mass, CA125 was around 10. So you have actual T2, sagittal T2 and sagittal post-contas T1 where it imaging with fat suppression technique. You can see smooth enhancement of the septae. So this is a multilocular cyst, smooth enhancing septae, no solid tissue ORADS category 3. Final in this case was cyst adenoma. So remember, these are probably most of the time is going to turn out to be ovarian neoplasms. It's just that they are not malignant. So the only risk here is that there may be times when the lesions turn out to be borderline and that's the only time when the surgeons can have a little bit of a difficulty, especially if the cyst fluid inadvertently ruptures in the baritoneal cavity. But always remember that it at least gives you for the most part what is going to be the risk of malignancy. So for ORADS 3, it's approximately 5%. So post-menoplasm women with bleeding and coming with normal CA125 levels, we have this actual T2 where it image, you see this T2 hyper intense lesion, which is solid in the left adenosa. Remember, this is not a T2 dark component, correct? So you have to look at its enhancement. So this is actually T1 where it image, this is T2 fat suppressed, again remains fairly bright. Then you have this T1 where it image venous phase and dealer phase. And then you can see that the enhancement is kind of always less than the miametium irrespective of what phase you look at. So this was classified, obviously as ORADS 4 category, solid tissue component enhancement less than miametrium. This ultimately turned out to be a fibroma of the left ovary. Again, for certain conditions where you can be fairly specific irrespective of the ORADS category, you can give your diagnosis, as in this case, you can be fairly conferencing that it looks like a fibroma of the ovary. So it's not that you assign ORADS score, and that's the end of the story. You may still want to give some descriptors or some of the typical lesions of adnexa. For example, even disc germinoma, as you can give it in your diagnosis, because you know that it's going to be disc germinoma based on the imaging features as well as the presentation. Let's look at another example here. 64 year old woman with abdominal distension, again CA125 was not really elevated, but that's the sagittal T2 image. It shows a large unilocular cyst with solid components. So look at this T2 imaging sequence here, it's not T2 dark. So which means that you have to look at its enhancement. Again, this is axial T2 axial diffusion. So both show that it's not dark here. So you have to look at enhancement. So this is a sagittal post contrast T1 image. It shows you that that's the myometrium here. Those are enhancing solid components. And one of the portion of the solid component was actually quite hyper intense on the T1 post contrast phase. And when I put ROI, this component is almost having a signal intensity of 1300 versus myometrium of just 1000. So it shows that there is enhancement of greater than myometrium. So this patient did not have peritoneal disease, but the solid component showed enhancement greater than the myometrium on 30 to 40 seconds image, which means that it is ORATS 5. This turned out to be a cisternocarcinoma enhancement of the solid component should be assessed only if it is not T2 dark or DW dark. Remember, this is a very important point. Let's briefly talk about some governing concepts of ORATS before we wrap up. Remember, this tool works the best or has to be used when you have a patient with average risk or no family history, or the patient does not have BRC mutation carrier. This is very important to talk about because if you remember BRC mutation carrier women's always have a higher risk of ovarian lesions as well as breast cancers. So those will not be average risk women. Then the patients usually are not having any acute symptoms because irrespective of the score what you get. If somebody comes in with acute symptoms that needs urgent surgical intervention, your recommendation is always going to be that irrespective of the score. For example, if the patient has acute fever, spades and lots of other systematic issues going on because of biosulphins or a complex process because of infection, those are the situations where the patient needs urgent medical attention. If you see multiple lesions, you have to give separate score of each lesions, but the management is driven by the highest score. For example, if a woman has a right adnexal dermoid cyst, which is typical ORATS2 score, but there is a multi-locular cyst with smooth enhancing separations in the left adnexa, which is ORATS3, so the management is driven by the ORATS3 in that patient. Always remember that you look at characteristic lesions with other with fat. They fall under the category 2 and other features of benametrotertoma, despite enhancing separations or rockiness in audio. If there is a large amount of enhancing solid tissue, that is when you start to wonder about malignant transformation. Talk about typical diagnosis such as determinomas, lymphomas, peritoneal pseudosys, irrespective of your ORATS score. Then dynamic contrast enhancement is favored over non-dynamic contrast enhancement, but even if you don't have dynamic, you can start working with non-dynamic as at least it will give you a good idea whether it is ORATS category 5 or 4 lesion. This is a very nice table from ACR website. So these are the three situations which you will probably have to deal with most of the times and you can use these guidelines to make sure that you can follow and classify the lesions accordingly. So always talk about physiological processes and classify them as ORATS1. ORATS2, we talked about some of these examples. Unolocular cyst with no enhancing wall or no solid tissues, then characteristic hydrosulfins, including cysts, endometriomas, pyrotomas, no solid tissue. Then solid tissue with very low homogenous signal on T2 or DWI. Remember this can be just a retracting clot. All of these are ORATS category 2. Then ORATS category 5, definite peritoneal or mental thickening has to be 5. Then lesions with solid tissue, high-risk intensity, high-risk type of enhancement. Or if you have non-dynamic assessment, then solid tissue enhances more than myometrium at 30 to 40 seconds. So let me show you one quick case here. This is a sagittal T2-rated MRI. You see that there is a large adnexil lesion. It looks like it is non-simple fluid with T2 dark components. And then as we go through it, it almost has this dilated tubular kind of appearance. That's a uterus. If we go to the other adnexa, you again start to see dilated tubular structure with fluid-fluid level. So what is your diagnosis here? Again, you see dilated tube spilaterally with non-simple fluid. In this case, the MRI with contrast did not show any enhancement. So this is in keeping with a typical ORATS MRI-3 lesion, because it is dilated tubes with non-simple fluid. So let's talk about some of the limitations. With all the good things, there's always a little bit of a star there, like radio instructions carefully kind of a thing. So the limitations with ORATS MRI is that differentiation between suspicious and enhancing solid components from other solid components, this is where historically, some of the papers have found that there's a lot of variation, because if you consider Rokritansky protriburans, you can call it as ORATS-2. But if you call it as a suspicious finding, because of its enhancement, it automatically bumps up to ORATS MRI-4, which is kind of an inadvertent move, but that happens. Then inadvertent assignment of retracting clots as solid tissue, because sometimes they can show enhancement, but they are technically not solid, because they are T2 dark. Then what if the patient has hysterectomy? How are you going to compare the enhancement of the solid tissue? And if the patient has adenomasis, the myometrial enhancement is going to be fairly atypical. So all of these basically turn out to be limitation and ongoing research is going on in this field as to better standardize in these situations. To conclude, there is a good risk stratification given by MRI-ORATS, which helps in patient management. It is important to have knowledge of lexicon and terminologies, which helps in scoring and predicting the risk of malignancy. It is a key tool for deciding management plan in a resource constrained environment. For example, when to refer patients to gynecology, when to refer the patients to gynecologist for management. So standardization also helps to increase the accuracy of region characterization and improves communication between radiologists, clinicians, and allows a high impact research. So with that, I'm going to conclude and stop my screen sharing. I'll take some questions. I think I can see some questions here in the Q1A box. Okay, I think there's just one question. So I'll just take that and with that, I'll close it. If we see papillary projections, not T2 dark, but no post-contrast enhancement, how do we go about it? We can't classify a solid component. So important to remember is that if the solid component or papillary projections, if they are not T2 dark, you have to treat it as a solid component. And if they don't have enhancement, so this situation is going to arise when you have patients with endometriomas. You may sometimes see papillary projections in them. One of the typical examples is decibelization of endometriomas. They may or may not show enhancement, especially if the patient is pregnant. So in that case, you have to look for the kind of enhancement. And if the enhancement is not greater than the endometrium, sorry, the myometrium, then it is going to be a low-risk category lesion. So remember that you have to look at those as solid components. If they are T2 dark, then that's the end of the story. Don't even look at the enhancement. So I hope that answers that question. So with that, we can end the session. If you have any questions, you can always reach out to me. I will leave my email in the chat section here. And once again, thank you all for inviting me for this session. It has been a very