Linda Pyle and I are going to talk about nursing management, symptom management, and we'd like to initially thank the KCA and the organizers for the opportunity to provide this symposium session. So I'm Laura Wood. I'm a clinical research coordinator at the Cleveland Clinic Cancer Center working primarily with kidney cancer. And I'm Linda Pyle. I'm a research nurse at the Royal Morrison Hospital in London and I'm predominantly working in kidney cancer with research patients. Thank you. We could have our slides. Thank you very much. So we thought that this would be a good opportunity for us to talk about how nursing can impact and improve patient outcomes. And as we've heard from a lot of the other presenters today, no matter what therapy you're going to initiate, no matter what subsequent therapy the patient's going to get, one of the most important things is to give that patient the best opportunity to have a good clinical outcome. And so a lot of that is what Linda and I are going to try to focus on in providing nurse education and patient education. So as far as the role of the nurse in the United States, there are a variety of nursing roles. We have nine members on the kidney cancer nursing advisory board and we've done some work to try to increase educational information on the website. The kidney cancer association website will talk about a little bit, but if you've not had much experience in it, please explore it. The nursing advisory board's done some work to try to provide easy access to information only for healthcare providers, but for patients and their families. In the U.S., the nursing role is to help with access to medications. So that may be not only the cancer therapy, that may be the supportive care strategies that we're going to be recommending along with a physician. Reimbursement is an issue, it doesn't matter whether you're in the U.S. or abroad, the process is different, but ultimately the goal is to get the patient the drug as soon as possible. There are many patients in our population who have disease-related symptoms and so it's important for us to intervene and assist with managing both disease-related symptoms as well as those from therapy. There are patients that Dr. Rainey or Dr. Garcia and I see and one of my comments to them is we need to get palliative med involved now to maximize control of disease-related symptoms or in spite of all my expertise, we're not going to get them through the cancer therapy. One of the primary things we always emphasize is early and ongoing communication. If I'm talking to a patient and a spouse, I'll talk initially to the patient and I'll look at the spouse and I'll say and if you think he should be calling and he isn't, you've got my number. So we really involve the family with the emphasis on it takes a team to get through therapy. As many of the presenters already today have mentioned, there is a learning curve and Linda and I have had a lot of experience with these drugs through the clinical trial process as well as many years of oncology prior to that and we know there is a learning curve as we try to get familiar and comfortable with these medications. Nursing management I think one of the most important things is education prior to initiating therapy. So whether they're going to get their medication from the pharmacy in our cancer center or two weeks later from a mail order pharmacy, a specialty pharmacy, they need to know what to do and how to manage that therapy. Written information and resources and there are often times when I will provide the same information to the adult child who does not live with the patient because they're also a very valuable resource. One of the things that Linda and I have done is to try to really help educate nurses and healthcare professionals on the class effects because it may be nurses or advanced practitioners that are answering the phones and we need to know what those class effects are for a given therapy to make sure that we're doing the correct telephone assessment and asking the right questions based on the type of therapy that the individual is getting. And is always a proactive approach to not only education but to assessment and intervention for side effects. And again, and I'll repeat it often when I'm talking with a patient and family, early and ongoing communication. Don't wait till Friday afternoon. My goal is to keep you working active on therapy, out of the emergency room and out of the hospital. And so we know that there are opportunities to intervene and provide that information. One of our treatment management strategies is making sure that we get that education with patients. There's nursing literature that documents that they only hear and retain about 50% at best of the information you provide them. So one of the things that we do at our institution is we have patient education folders that are already prepared. The majority of patients I see are on clinical trials but as these drugs got FDA approved, we recognize that those individuals that are not on clinical trials also need that same information. So we have folders down in the physician work room that contain a variety of educational information sheets. Who to contact, what the contact information is, as well as calendars and diary sheets and side effect management sheets. So I'll show you a few of those as well. We also need to make sure we're aware of those side effects that we may be able to prevent or that we can minimize the severity and the dose limiting potential of those and make sure those are some of the key things that the patient and family member know up front. During treatment, follow-up phone calls, early and ongoing assessment and intervention, identify those individuals that need to be seen more frequently. So we saw a patient this past week, about two weeks ago, got palliative med involved. This is a patient on a clinical trial who needs aggressive therapy, aggressive disease symptom management. So even though the clinical trial required the patient to be here once every three weeks, which for the majority of patients would be wonderful, my comment in discussing it with Dr. Rini was we're going to need to see this patient on a weekly basis. So the patient initiated therapy, we had a phone call the next day, we had a phone call the following day, we had a pre-planned clinical visit for one week after he started therapy, at which time we had a pal med consult. Next week when the patient comes back, we're going to have a nutrition consult. So we have the privilege at our institution to get these additional resources involved for the patient, but that is going to be our best opportunity to try to keep this patient on-dose on schedule. Promoting adherence is another key challenge with our therapies and it's not just the anti-cancer therapy, it's the supportive care strategies. I think one of the physicians earlier today talked about adherence with a thyroid medication. And we have had a very similar situation where the patient's symptoms were worse, but it wasn't because he wasn't staying on therapy, it's because he'd stopped taking his synthrate or his levothyroxine. So keeping track of the supportive care strategies as well is very important. And there's a lot of information about that and we have information sheets in our folders about adherence and about persistence so that they know that whatever we can do to help them maintain therapy is really a very important part of the overall treatment plan. Ways to increase adherence is to provide a calendar or diary sheet. Many of these therapies require ongoing home blood pressure monitoring. And so we provide those resources to the patient and give them specific examples of when we're to be notified for blood pressure. It's not if your blood pressure is high call. For you, if your blood pressure, and we'll show them what their typical pre-treatment blood pressures are, if your blood pressure is the systolic or the top number is above 150 or the bottom number, the diastolic is above 85, the first time that occurs, we need to hear about it. Then at least we're knowing early that there's the potential for hypertension or additional management. Are there drugs that need to be restricted as far as dosing and food intake? So that's one of the key things that I try to make sure gets across the very first time we see the patient. Can you assist me and advance my slide, please? Thank you. We do have some resources for pill boxes except for a finitor, which is important component of education that the patient and the family member knows that that drug needs to be left in the foil packaging until the time of dosing. For some of our older patients, it may be a family member that puts all their pills in a dispenser for the week. Therefore, we need to make sure that both the patient and the family member know for a finitor it can't be taken out until the time of dosing. And ongoing during follow-up visits and telephone calls, ongoing reinforcement of the importance and the benefits of adherence. This is one of the diary sheets that we provide to patients. Again, as Dr. Renie mentioned earlier today, whether the patient's on protocol or not, if they're on a VEGF inhibitor, we're asking them to take their blood pressure on a daily basis. One of the key things in education is to tell them how to take their blood pressure. Sitting feet flat on the floor, relax for five minutes, then take your blood pressure. If it's higher than normal, wait a few minutes, take a second reading. Record that one or two assessments. The other key thing you'll notice on this diary sheet for SUTENT is in the fifth row, which is the start of the two-week break, it is written ideally, very clearly, stop SUTENT. I also highlight that because if they miss a dose somewhere along the way or we interrupt their therapy, they're going to go ahead and extend it. So the key education piece is that you stop whether you completed all your doses or not. And ideally there's communication with the healthcare team in regards to that as well. But these are some of the diary sheets that we use. On the left, you'll see the pazopinib diary sheet. Again, one of the things that we educate patients is don't get up, get out of bed and take your blood pressure. We want you up active if you're on a morning anti-hypertensive, take the anti-hypertensive and sometime in the mid-afternoon, prior to your SUTENT or pazopinib dose, we want you to take your blood pressure. If they're on exit nib, again, we typically will have them take their blood pressure once a day in the afternoon or early evening prior to the evening exit nib dose. We also on the right have a separate blood pressure sheet. If our patients have a local primary care physician or a cardiologist that's working with them, they may have additional requests to monitor blood pressure more frequently than we have on their drug dosing diary sheet. So we'll give them a separate blood pressure monitoring diary sheet. And there are patients who will fax these to us if they have changes if they're still working, they can fax them to us, I can review them with their physician and make recommendations if needed. So as far as side effect management goes, written information, the contact sheet of who they can call, who they call and how do they contact someone after hours. There may be 15 side effect information sheets in here. I'm only going to go over the top four or five because those are the ones that I want to make sure they understand how to use and how to have access to. And again, if it's an elder patient, I may provide one or two copies for their family members. Phone call following initiation of therapy, review dosing, what are their early side effects, what questions do they have, having the additional information sheets if they call on another day and they're having problems, we can talk about dietary management and diarrhea, what are the other resources that are available and again, determine if they need to be seen more frequently during the first or subsequent cycles. This is just a generic side effect diary sheet that we give to patients. If there's nothing going on, they don't need to document anything, but this makes a wonderful telephone triage tool so that the patient can call me and say I've been having ongoing issues with nausea. Tell me what you've been doing, when does the nausea occur? Are they on any kind of acid reducer or other medications? What other supportive care strategies can we do that may help their symptoms or their side effects? They bring these sheets then to clinic to allow the physician or the advanced practitioner to see them as well. Many of our side effects include hand foot syndrome, calluses depending on what the therapies are and we'll talk whether it's at the first visit or subsequent visits about controlling the calluses, comforting their feet with cushions, giving good supportive shoes and what kinds of creams or amoleans they may find to be of benefit. So there's information available to help them with those side effects as well so that the next time they come into clinic, they're not in a wheelchair wearing bedroom slippers and I'm going, I have a phone. So we really want to know things up front because those are those those limiting side effects that you really can have a significant impact on minimizing. We've done a lot of work to try to identify supportive strategies that may assist with the management of side effects. Many patients will fluctuate between constipation and diarrhea, they're on pain medication, so one of the dietary things that we have found and there is some information in the literature is on psyllium and using psyllium as a supplement with meals to help bulk up and prevent that dumping syndrome type diarrhea that occurs. We print these in color because for us there's another product, metamucil makes another one in a green label that has calcium in it. So this allows the patient to understand the instructions and which one they're getting because again, this is something that will typically come up on a phone call two or three weeks after the initiation of treatment, I can say go to your folder and pull out a sheet on metamucil and we can talk about that. Preparation H. So there are prescription products that provide topical anesthetics, many of our insurance companies feel that that's supportive and they don't cover it. Preparation H, as you can see from the active ingredients listed, very easy to access. If patients have hemorrhage or already have this product at home, we tell them make sure you're getting a separate tube and mark that tube for your hands and feet with a Sharpie so that they are distinguishing which ones for the rectum and which one is for their hands and feet. But this is another easy to access product that our patients may find to be very helpful and that goes, works with any of the VEGF inhibitors. The kidney cancer association, we've worked very hard, Linda's part of that nursing advisory board to provide resources for patients. We, as Kerry talked about earlier today, that we have kidney cancer book is available both as a download and as a PDF on the website. One of the things, and Linda will talk more about the conference we had this morning, is that what we're going to be doing is including and adding in some of the side effect information sheets in a new chapter in this book. So again, trying to improve upon the resources that are available. The kidney cancer association website, what we have done here is we have on the left-hand side drug information sheets. So what you'll do is if you click on that link, it will bring you up to this sheet which has not only the targeted therapy information that we have a standardized format that's created and validated with the package inserts from each of the pharmaceutical companies as well as a sheet on understanding targeted therapy and understanding lab results and several of the more common side effects. What I've done is I've printed the top side and the bottom side and these copies are out in between the two printers in the lobby. So if you're not already familiar with the resources that are on the website, grab one of these information sheets and this way too, this is something that goes in our patient education booklet. So what we're really trying to do is minimize the double work that needs to be done. Some of our institutions are allowed to continue to use the pharmaceutical company brand of materials. Others are not. So if they're not able to use it, they've got KCA, non-pharma branded, other than the reference, each of those sheets has the reference to the pharmaceutical website and the package insert. So what we're trying to do is for those community members also that don't get that many patients in their office, easy access to valid information so that they can also feel more comfortable in their own management of these patients as well as the education of patients and families. ChemoCare.com is another resource that Scott Hamilton, the Olympic Skater, helps support. It has, again, a lot of that same information as well as information on other chemotherapy treatments. Next slide, please. So ultimately the goal for the whole oncology team is to find that spot in which we can maximize clinical outcome, maximize quality of life, and maintain duration of therapies for patients. So that's what Linda and I wanted to help do today was to bribe you with some of the options that we use in the U.S. And Linda is now going to talk about other options that we can use to continue to broaden the horizons for our patients with kidney cancer. And we'll take questions at the end and I thank you very much for your time.


Okay, my name is J. Merello, M.J.J., J. Merello, in Cipán. Thank you very much for being here. This is what I'm going to talk about. This is actually a drawing made by Paola, who was a student in my class this year, an undergraduate class. This is representing pretty much the feeling of my students when they were submitting their assignments to the system. So this is a continuous interest system. It was scanning. And they were holding for their life to get half just waiting for the assignments to get through. Okay, let's pick up. This is what I'm going to talk about. I'm going to talk about testing for testing. So I'm a professor in the university. I'm not going to name the university. I'm not very proud of my university right now. So let's just say I'm in academia. And I'm talking about my experience of using continuous integration in the classroom. Right? I'm also in Granada, in Granada, but we are going to have a workshop, a fair workshop in Granada, in a couple of weeks.  The caliper paper is still open. If you're interested, just let me know. This is what I have been doing. It's a cloud computing class. It's an undergraduate and also master level cloud computing class. This is my actual class. So that's me. So this is not the class I have been giving this year. It was last year. In the undergraduate class, I'm having a lot of fun. In the undergraduate class, I'm having around 40 students, something like that. In the master's class, I'm having around 12, 15, something like that. So it's a smallish class. It's not too small, but it's smallish. And I'm using something called flip learning. Have you ever heard about this? Never? So it's learning as people actually learn. There's a saying that goes, you don't teach, people learn.  But the thing is that what you have to do for people to actually learn is to make people learn, autonomous learning. So you give them a series of objectives. You give them material. You give them some class notes or whatever. And then you let them learn. And you are there guiding them, helping them or whatever. So it's not like I'm standing in front of the class for two hours. It's like, I say, I put a slide with the objectives of the particular session or the week. And then I wander around the class telling people, who are you doing? What are you doing? Do you have anything to ask? Do you have any problem? I see them working with the material of the class. I say, OK, I see you are assembling onto this. Please check that out. So it's a different way of giving class. That's not really related with the rest of the thing. But I just wanted to put you a little bit in context. So it's a different way of teaching. As far as I know, there's not many people in my university who's doing that. There's not many people in other universities who are doing that. For me, it's been just wonderful. And I keep asking the students whether they want this kind of class or what is called magistral class, the traditional one. And they keep saying, 90% of them, no, no, we want this way of giving class. Of course, they can wander around. They can get in class at whatever time they want. They can get out whenever they want. So I mean, for them, it's quite relaxed. It's not so stressful. It's nice. And then another thing I wanted to do is to be as real as possible. So I don't want to give them assignments which are just boilerplate things where they have to fill in the blanks and they say, OK, this is OK. So they eventually end up filling the blanks and not learning anything at all, but trying to make the thing as real as possible. So not like these astronauts who are in a carnival parade, but real people doing real deployments in the cloud because it's what I'm teaching. It's cloud computing. So at the end of the day, they will have to go to a company or whatever to get their own company. And they will have to do deployments in the cloud. So I want them to do real deployments in the real cloud. I think that class is going to be a metaphor for real life. So when they will do deployments in the cloud, when they are developing software in a company, they're going to undergo code reviews. They're going to use continuous integration.  But why not use it in class? So in class, you will have to use code reviews. You will have to have continuous integration. All that kind of thing. Then I use GitHub. I've been using GitHub for a long time. So like, I think like four years or so, I mean in class. Yes, please? You're going to ask something? Oh, OK. So GitHub is my learning management system. So everything they do, it's in GitHub. That's absolutely amazing. It's very nice. So this is the actual page they use for turning in the assignments.  This is the actual page that I have been using here in master class. So they put their project. They do milestones in a project. Ito means it's not here. Somewhere. Ito is milestones. So they do milestones in a project. And they submit each milestone. When they are going to submit the milestone, what they do is they change this particular file, which is in my repository. It's in the repository in class. And they add the direction of the repository. It's always the same. Also the version. The version is important. We'll see that later on. GitHub is very good. It's amazing. It's much better than any other LMS you may think of. I'm talking about this because I think that everyone, at one point of your life or another, you're going to be a teacher. You're going to teach something. And since we are in technology, since we are in programming, we'll probably have to do something like this. We'll have to, you know, onboard new people in our company. We will just, you know, we are between jobs. And we go to some community college to give class, whatever. It's something that you have to do. So my intention was to use this kind of technology and to see what kind of things could be done to make your experience a little bit better. So I have been doing this for, as I said, quite a long time. So the people were turning in assignments. And I was checking out this page. And I was correcting it. All of a sudden I had a new beginning, 2017. You probably know that I was director of the Free Software Office in the University of Grenada. That took me around 25 hours a day, 25, 26 hours a day. I was fired. I still keep my job as a professor because, I mean, Free Software Office was an appointment. It was in a job. All of a sudden I had a lot of time in my hands. At the same time that appointment implied a reduction in the number of classes I had to do. So before I had a teaching assistant at TA. All of a sudden I had no TA at all. So I needed to do all the things that my TA was doing. My teaching assistant was doing. And then I thought, continue to say integration to the rescue. I'm going to use continuous integration. So I'm going to use the milestones as code review. So I'm actually going to review what people are sending. I was doing that a little bit before. But not very stensily. Basically what I was doing, it was checking that there was no conflict. So when people were modifying the file, they were not conflicting with each other. Maybe if I saw something coming very, very early, I took a look at it and told them maybe you should do it this way or that way. But all of a sudden, remember, I had no TA. So the TA was checking things. So I said, per, it's my TA check. So I was using per for doing continuous integration. All the checks that were done before by the teaching assistant, I'm going to do it using continuous integration, which I wasn't using before. So before, people were doing pull request. I accepted all of them, except there was no conflict. Now I was doing something completely different. I was writing tests for what people were submitting. So might fly or not. It says, all checks have failed. I'm not accepting that pull request. So that means that the student has to go back to his repository and fix whatever was being done before. What are we checking? It's important. Taking into account that the product is completely free. So they can use whatever language they want. It's not boilerplate. It's absolutely not boilerplate. In fact, people were using, most of them were using Python. But even the people who were using Python, they were using different frameworks, because they had to deploy web service to the cloud. Some of them were using Flask. Some of them were using Hug. Some other people were using Node.js, and they were using Express. Some other people were using Ruby, and they were using either Sinatra or Cuba. I think that, I'm not sure. I think that both of them were using, one of them was using Go. No framework at all. So it had all kinds of different languages. I didn't have to look at whatever they were doing, but the effect, the actual effect, the real thing. So if you're deploying a web service, I want to see if it's working. So what do we check? The first thing, and this is quite important, is that the assignment is, you have only modified a single line in the file. Because they have to modify a file, and sometimes what they did, sometimes they had an old version of the file, so they changed things, and they submitted the wrong file. So I had to check that actually, there was only one row in the table you have seen before, that was to be modified. So I could extract a single URL from that thing. That's the first thing to check. So if they had a wrong version of the file or whatever, it was caught right here. And so the repo URL is correct. So it's a GitHub repository, and it's actually correct. So people sometimes submit something with typos or whatever, and it's not working. So that's the second thing I have to check, if it's actually correct. I do it with spare, right? This is the first thing I do. It's the first test they are passing. So the first thing is I use this Git module, which is, it's a weird thing, because it comes with Git, but it's also in Cpang. So it's a module that's called Git, and what I do is I get a diff, so I get a diff between the previous version of the file and the version I have now. I check that it's only one line, right? And then I also check that they have modified the correct file, all kind of things. If it doesn't follow that regular expression, they fail. But if it follows a regular expression from the diff file, I extract the information on the repository that I'm going to check later on, right? Right now, the only thing I'm using is this Git. Second thing, is it a single line? That's important, because if it's not a single line, there's something wrong with the file. There might be a conflict. There is another subtle error that is on time. They change the codification of the file. So when they get the file, they edit it. Sometimes they change this codification from Latin 1 to UTF8 or the other ground. So they change the whole file. That happens quite a lot. Sometimes I had to fix the whole file, and it's been quite, quite, quite really bad. The worst thing was to find out who was guilty for that and maybe take out some credit or whatever. But the important thing is, is it a single line? So are they modifying a single line? Because that's kind of a sanity check. And then, of course, you have to download the repo because this is all being done in, let's say, the class repository. It's a single repository. It contains the check and everything. Then you have to download the repo and then start to do things on them. So I am using the system git. I'm using Travis. So there's a git there. I mean, it's installed already. And, well, I start the user of the name. I put everything into a temporary directory. It's Travis. I mean, it doesn't really matter what happens. I don't think about using something else next year, but we'll see. And then eventually, we create the repository and we start to get all the files in the repository using git commands, right? So far, so good. Follow with me. Any questions so far? OK. Then I'm using test more. Very simple test module. You know it already. You probably have used it. I could probably use something else, but I didn't want to put more things into the Travis because just imagine, people are physically waiting for the outcome of the thing to get out. So the more modules I use, the more they have to wait. And sometimes I wait, too. So I get an email telling me that somebody has some Apple request, and then I go there to see if it's working or not. If it's not working, I try to guide them towards doing it a little bit. But basically, those two things are the only per modules I use for the time being, right? As I said, I am using Travis. It's a relatively simple configuration file. It's not going to get any better. Anyway, below that, it's only prove-c. The only thing it does is it installs test more, test harness, git, file slab, and some other modules. It does prove because the test is included in the repository. It's not some external test. So the file, they are going to modify it to submit assignment. And the test, it's a single script. It's right there, right? So they start to check. This is the actual history, real history. You see milestone four, fail, fail, pass, pass, pass, fail, right? So they submit it. It fails sometimes. Sometimes it goes ahead. Of course, when that happens, if I am available, I see it and say, OK, it looks like this is the thing that has failed. Take into account that I write the name of the test. So sometimes I realize that the name, the test that has failed is not too informative. So I go back to the script and change the message that is issued. It's saying, OK, it's the JSON in your service is not right. Whatever. I try to make it as informative as possible, right? So that they know exactly in which step they have failed. I'm also checking presence of files and their access in the repo. They have to do something like, first, they have to deploy to a pass, like Heroku. Then they have to deploy to another different pass using containers. So I have to check whether there is a Docker file, for instance. Then eventually, they have to submit something using some deployment tool like Fabric or Capistrano or whatever. So I have to check whether there is an actual file that does that. I have to check whether there is a background file. I have to check whether there is a readme.md. All those files, I check it, right? At the very beginning, I check three things. First thing is they have a readme. Second thing is they have a license because this is all free software. So whatever they do, I tell them from the get go that it's free software. So they have to understand that it is free and they have to respect the license and everything. So there must be a license file. And then they must have a .gittig in our file because it's something saying and it's a best practice for. So that's kind of the thing to do. You can see all that in the directory. And then I get the readme and I tell them, you have to tell me where is your Docker file in Docker Hub using this format. You have to tell me where you have deployed your project using this format, right? And extract everything from that. So if they tell me, I have deployed to Heroku in this address. So I extract that using regular expression from the readme and I check it. I go to Heroku, I check it, right? Using LWP simple, right? Test files, sometimes files, for many different reasons. First reason is that usually people are not acquainted with this kind of thing. For your students, they have never used tests. They have never used Travis. They have never used Gitt, which is absolutely appalling. Actually, the first assignment is they have to open an account in GitHub and modify the file and do it with Gitt. So sometimes I have to give it. They don't know what's a web service. So they are in the last year of their undergraduates.  So they tell me, so it's like the web. I know PHP. I say, no. That's not so. I mean, they have all kind of things. Besides, you know, this is a parallel script. That's in a directory. And you can actually put that parallel script into your own thing, right? There is only one student that has on that. Only one. The rest hasn't done a single thing. They haven't realized that there's a per script. They can check to see everything that happens. Anyway, it's not a big deal. It's already in the description of the assignment. They say, you have to include this in the file. You need to have this thing. But, I mean, at the end of the day, they're using this as an actual test for their assignment. So they are actually throwing it, you know, like spaghetti to the ceiling to see whether it sticks or not, right? I do scraping. Why do I do scraping? Because at the beginning, something they have to do is they have to actively use milestones and issues. Milestones, issues, and commits. So they have to put every issue in a milestone. They have to close every single issue using a commit. So they have to organize the project. As I said, in the beginning, in real life, right? In the beginning, I was intending to use GitHub API. But you probably know that if you're using, if you're doing a pull request in Travis, you can't use environment variables. Because it could be a security hole. So I can't use any kind of environment variables to use my API, I mean, my GitHub API token so that I check the GitHub API. So instant API using scraping. I check milestones and issues and commits. It's relatively simple. For instance, you get the milestone info. It's just a very simple regular expression. You get if it's open or if it's closed or whatever. Then, as you can see this very well, but anyway, this is in my repository too. Anyway, what I do is also scrape the milestone page, I scrape the issues page, I scrape the commit page, I extract whether an issue has been actually closed by a commit or not. All that using very simple regular expression. Then I have to check IPs. I have to check REST APIs. I have to check URLs. As I said, they have to upload a Docker file to Docker Hub. So I have to check whether it's actually there, whether it's working, whether it's actually being built. This is actually a lot. You see that they are cloning, whatever, milestone one, milestone two, milestone three, then whatever. I think this is actually, you see that URLs, this is Amazon URL. This is site.co URL. Heroku URL must be up there. So all that is done. You have to do things like this. What I tell them is you have to deploy a web service. What they do with the web service is they need to have a root. That's a status that returns okay. Of course, most people, not most people, but a lot of people, they deploy a web service that does only that. So a web service is a single root. So we have to think about that next year. So maybe do some kind of, I don't know, maybe describe using, what's the name of that thing that you describe with services? No, it's not GraphQL, it's OpenAPI. No, OpenAPI. Swagger. Swagger, that's the thing. What I'm going probably to tell them next year is I'm going to try to do a small hackathon from the very beginning so that they program the web service, meaning different web services. They test them and everything. I will tell them to describe it using Swagger. For the time being, the only thing they have to do is to deploy it using a status. Which, I mean, it's not easy. It's not easy for them. They really have to, they have to really do that. And for them, it's something that they have never done before. I mean, my subject, my class, is not about web services, it's about the cloud. So I have to kind of, you know, teach them all kinds of different things I need to do at GraphQL. And something I do that was actually very nice. They have to use Amazon, AWS, or Azure for deploying a virtual machine. They have to tell me the IP of the virtual machine. I have to check that actually the virtual machine is working. So I use NetPing, which is incredibly nice. Just a couple of things. I use port 22 because that support that actually has to be running. You need to, at least that port that you can connect from outside. Actually, they have a limited amount of resources on Azure and AWS. And what they do is, as soon as it passes the test, they turn it down and that's it. So they save money. And they can use the rest of the money, you know, to mine Bitcoin or whatever. Thing is, it saves me a lot of time. So it actually is really, really helpful for me. When I get something that's correct, I know that it's got all the basic things that have to be there. So I can go to the beach. It's four kilometers away from my home. I can spend the day there. I can dip my toes in the water. Actually, this house over here belongs to the former queen of Belgium. It's called Villa Astrid. Belong to the former king of Belgium actually died there. And I have got an apartment there and I'm going to be not moving because I live in the city, but I go from time to time to check if it's actually being built because it's not being built yet.  I couldn't do that before. I literally couldn't do that before. I mean, it saves hours, literally hours. But I'm the professor and the whole point of doing this kind of thing is not for the professor to go to the beach. Could be, but it's not. Is it good for the student? That's a very important thing. Whenever you do something in class, that's the first thing and last thing you have to ask. Is it good for the students? Are they learning more? This is a graph of the number of students that have actually turned in a milestone. This is this year, and these were the two previous years. This is the number of students. So let's look at this one, for instance. I started with around 55 students. Second milestone goes down. Third milestone goes down. Last milestone was even downer. Students were dropping out of the class. They just said, no, this is not for me. I can't possibly do this. So it's not something I can do. Last year it was like this. I had less students because, of course, some of them said, this is impossible. I can't do that. So I got about half the students this year. This year I got even less. But I said, OK, I've got to do something. You see that the drop-out rate, the decaying rate of the number of students, is very, very mad. You are going to always have students that drop out. For reasons that are completely unrelated to your subject, because sometimes they are right. This is in Spain, the degrees are four years. I get the students, a lot of them, who still have classes and subjects from first year. Algebra, physics, because, of course, you need physics to do a web page or to do a web service. You have to first put electricity into those damn chips. All kinds of things. Some of them have some reasons I mean algebra is difficult, but they make absolutely no... I'm telling this because my daughters are doing computer science in my same school. So I know from firsthand what they do. Anyway, I get many students who have subjects from other years, so they have to go to exams, they have to turn in assignments, and they just say, OK, I just can't do this. We also have a telegram group, and I actively... OK, I'm going to put this might be... After every milestone, if I see that the student hasn't turned in his milestone, I ask him, what's the matter? Is something wrong with you? Do you need help? Please come by, get to my office, we can talk, whatever. I have been able to cite some of them using that. So I'm not going to say that this is precisely because of what I've been doing, but it probably helps. Funny thing is, I also use Perl for this. You have everything in the repository. So what I have done, I have published to Cipan this module. It's called Git repo commits. It's only to examine the commits. So what I examine is the author of the commit, the date of the commit, or whatever. So I can get very nice statistics of what's going on in my... And this is also... In general, this is called learning analytics. It's something that lots of people talk about, very few people do, precisely because the problem is that the platform that people are using, which is Mudo, usually doesn't allow you to do this. Mudo has a very nice API. Most universities, for security reasons, they close the API. In my university, it's even better because they close the API for everyone in the university, but they open it for a bank that has created the official app for my university. That's why I'm not going to name it and not proud of that. Just imagine. No single professor, no single student, no single staff in the university can access the notes in the Mudo using the Mudo API, but the database of grades of every single student in the university is open to a bank.  Anyway, my point was that you can do learning analytics on Mudo, at least in my university. I can do very easily learning analytics using this parallel module, which is available in CIPAN. I just released version 0.1.0. So I got, for instance, I checked the milestone, which is basically a file. I checked the commits. I see who has been the cometer, and I can count the number of authors. I can count the date, whatever. I see things like this. How many modifications of the file have been done? This year, this particular year we have introduced this in green. The others are in blue and red. So the two previous ones. What do we see here? At the beginning, people were doing lots of changes. Every person was doing lots of changes. Why? Usually because of conflicts. They were still getting the handle of the system. They did conflict. This year, that didn't happen. There were no conflicts and I was checking that they were only doing a single line. So conflicts are almost impossible. It can happen if there is some race condition, so that there is a pull request, and there is another pull request, another pull request, I haven't accepted the first one, so the third one might be in conflict. That usually doesn't happen. In that case, usually I also fix it myself. But as you proceed with the number of milestones, this is the last one, you see that people this year, this particular year, they are doing more resubmissions. Why? Because they are submitting, they say that it fails, and they are doing it again, and again, and again, until it works, right? That's good. I mean, why not? They are learning. They are learning in the process. They are submitting something. They are saying, this doesn't work. So without compromising their grade, they are improving and they are learning. So that's something, it's a point I'm going to stress a lot. For most people, evaluation is just grading. Evaluation is learning. You have to create the process of evaluation so that people actually learn with it. You can just say, I'm going to do this exam in October and then in February I give you the grade. That's impossible. You don't learn anything out of that. Whatever you were doing there, you completely forgot. In this case, they are learning while they are, they have this epiphany, okay, I'm doing this wrong. In many cases, they are purely mechanic things like, you know, the URL is not in certain query, but in some cases, they actually start to understand what they, what's requested from them. And they are doing that through the test process. And this is a little bit difficult to explain, but let me see if I get it right. First thing, once again, green is this year, red and blue, previous years, right? Don't look at the dates. The calendar has changed anything. Don't look at the dates. Look at the shape of the card. First of this year, that means that one day before the deadline, they started to turn in the assignment. There's a few of them. The day of the assignment, they did bulk of them, were submitting it, and then after the assignment, of course, some people did it. They can do that. I'm kind of flexible with the dates, so if they turn it like on the late to the late, whatever, I say, okay, but it doesn't matter. If they do it one week late, I will put a penalty of one point, but it's no big deal. But the shapes previously were very, very, very sharp. This year, what happened? People, and this is just one milestone, it was the last one, but it pretty much happens everywhere. What you see is that people start to submit assignments way before the deadline. Why? Because they want to have time to fix it before it's actually graded. So they say, okay, I'm going to do this one week before, even two weeks before the assignment. I will just do it. If it's wrong, I don't care. The test is going to tell me if it's wrong. It's not going to go through to the professor who is going to tell me none of this fails. So you have to turn it again, right? Check it out. I mean, this is December 15th, so I think that the deadline was December 21st, so it's pretty much around here. Then during Christmas, people were doing turning in things. Then eventually, there was another peak here. So people were doing it whenever they saw it fit. So they were using it, they were incorporating the thing in the learning process. And they were also trying to do things so that they could have time to fix everything. They were learning much better. They were organizing their time much better. Learning outcomes were, for me, very, very good. And actually, students told me that. So I asked them, whenever they have to turn in a milestone, I always do a survey. I ask them what they feel, what they feel about the way of doing class, what they feel about the subject, whether they think that it's going to be useful for them or not. But in the last one, I asked them what they thought about this system. This says, it's not complete, but what it says is it helped me to submit something that's correct already. You remember when you were a student, you put it on assignment or whatever, you were waiting for the grades. Maybe one week, two weeks, one month, whatever, maybe before the final exam. That was absolutely appalling. People were stressed out because before the final exam, they didn't know whether, when they do this, except if they are actively trying to cheat, they know that they are going to get six, six or seven or eight out of them. They know that in the very moment that they have tournaments. So that's the thing that they like the most. They say, it complicates my life, four of them said that, or of 20 students, I can understand that. But sometimes it complicates the life, it's not ideal. It's because they didn't read the specifications correctly, so they put the URL in the wrong place or whatever. It helps me, I think this one, it helps me to be sure of the grade I have. So that's another of the value. So they feel empowered with this kind of thing. So they don't feel disenfranchised, like this is a machine, a machine is turning things, because after that I have to grade. But when I grade, I know that pretty much everything is in its place. The semester is over now. It's not over. Actually yesterday and today I'm still getting, because in Spain we have a regular exam and then we have a special exam. So some people who have failed because they didn't turn in their milestone on time, they're still, so yesterday I had to accept like four or five pull requests and today I saw a couple. So it got stuff to do. So I got my assignments for myself. First one, I want to create a SIPAM module. Why? Several reasons. First reason is I don't want the code to be in the same repository so that some smart student can look at the code. So they will have to go another steps, maybe to SIPAM and see what's going on. And anyway, the problem is I have two subjects and it was all hacked together. So I have a lot of common code for the master I have one escaped, for the other I had one escaped. I was moving things back and forth. Not nice. I also want to do tests of the code. So right now the test was the first student that was submitting their assignment. I told him, okay, hold on there. It's everything okay. I had to check this. It's okay. It's okay. So I usually give them a beta tester grade and also stickers because everyone loves the stickers. Everyone loves grades too. Stickers are nice. Then I want to send tests. I mean, think about it. You can do pretty much everything. You can check. You can do spell check. I don't know if I want to do this because spell check is going to be just terrible. I can actually check the commits. So I can check whether they are doing the whole thing like milestones and commits and everything. I should check using Swagger, the full rest API so that they have to declare the rules or whatever. Check for plagiarism. I have found lots of students who cheat. You know, people do that all the time. Okay. Lessons learned. You have to innovate, but only to improve student experience. You don't have to innovate to save time. It's good, but you have to do it to improve student experience. And you have to check if it does. No, you look at the students. They seem happy. They smile. They like the stickers. No, no, no. You actually have to ask them anonymously whether you are doing okay or not. The scripting goes a long way. And that's it. Thank you very much.


This is stock number 10642, we are here at Summit Automotive in Fond du Lac, Wisconsin, your new and used Ram and heavy duty truck headquarters. Today we are checking out this super clean 2016 Ram 2500, Crew Cab Short Box. This truck has the 6.7 liter Cummins diesel. It has been fully safety and inspected by our service shop has a fresh oil and filter change all the fluids have been checked and topped off. The truck has been gone through mechanically 100% and is 100% ready to go. Brilliant black crystal pearl is the color we shoot all of our videos in 1080p, 60 frames per second so if you have HD capabilities on your computer, tablet or smartphone device turn them on right now because it's definitely your best way to check out the quality and condition of the vehicle before seeing it in person and if you'd like to check out more photos of this truck in the upper right hand part of your screen is a link right to our website, click that and check us out there. Comes with the 20 inch factory painted alloy rims with the chrome covers and this one is going to have Nitto Exo Grappler LT28560R20 tires with right around half the tread left on them, frame and under body is in excellent shape, I didn't see any major dents or dings on that front fender, front bumper is in nice shape, it comes with a go rhino grille guard or bumper guard, factory fog lights, chrome trimmed grille, the hood is in really nice shape, passenger side fender is in nice condition as well and it has those go rhino steps that are the full length separators all the way to the back as well, passenger side rim no scuffs or scrapes on there and as you go down this side of the truck take note of how clean that body is, how reflective and mirror-like that paint is, we take these HD videos so if you are far away or even if you're close by and just cannot make the trip down but you're still interested in purchasing the vehicle, you can see the vehicle, hear the vehicle and have confidence in what you're looking at before you even get here so that when you do get here there's absolutely no surprises, it does have the cargo cam and that is why we offer the Summit Auto Fastpass option in the upper right hand part of your screen, a link right to our website where you can apply for financing, get pre-approved, see a payment quote, even appraise a trade all from the comfort of your own home, those go rhino steps are in really nice shape and the frame and underbody on this truck is an excellent condition, it has all the remaining factory exhaust so it hasn't been altered in any way shape or form and those lower rockers all look really good, this back rim is an excellent condition as well and the back tires have just as much tread as the front tires, frame and underbody back here looks good and as we come around to the back of the vehicle, the rear bumper is in absolutely perfect condition, I didn't see any dents or dings on that, has the backup parking sensors and you can get a really good idea of that brilliant black crystal pearl with the metal flake in it, has the backup camera and locking tailgate, you do get a spray and bed liner, the fifth wheel and gooseneck prep package as well as the seven pin wiring in back here and it does have the LED bed lighting, that is an excellent condition, I didn't see any dents or dings on it, looks really good and as you go down this side the truck just as clean as that passenger side see just how glass like that paint is, very very clean on the box and for full disclosure this back rim is in great condition too, down the rest of the side looks really good, I didn't see any dents or dings on the doors and those go rhino steps are in nice shape on this side as well, it does have the heated foldout tow mirrors, they also fold in, I'm not sure if they're powerful or not, you also have window edge security, so I don't know if you can see it there but it's got a number that's etched into the door or into the window, that's on every piece of glass, inside the bighorn package gives you the gray cloth interior no rips or tears in that seat, power driver seat with lumbar, weathertech floor mats throughout, auto headlamps, radio controls in the back of the steering wheel tilt, power windows, power locks, power mirrors and these are power folding mirrors so I always like showing both sides to make sure that you know that both sides are working good and as we hop inside the truck here you can see that this one has 54,437 miles, you get a digital speedometer, outside temp and compass display and that instrument cluster is extremely clean comes with a heated leather wrap steering wheel, cruise controls on the right, Bluetooth and information center controls on the left, like I said before you get those audio controls in the back of the steering wheel, the six speed automatic transmission with the optional tap shift, this one has the 8.4 3C radio so it gives you AM, FM and series XM radio capabilities, you also get a CD player on this truck and that is in the center console here, that's the factory CD player, now what's cool about this radio is that if you wanted to add navigation to this radio you can do so and it's $595 and we can do it right here at our store so talk to your sales professional for more details but you got all your apps and stuff there, the cargo cam which is a really cool feature you can see what's going on in the bed or if you're lining up a gooseneck or fifth wheel that's a nice thing to have and then you can check out your backup camera as well so you can do your controls, your heated seats, heated steering wheel as well as those cargo cams and you can do your climate controls here as well, notice you do get the dual climate controls and if you don't like doing all the stuff on the screen don't worry you can do them down here on the tactile buttons including your volume and tune controls, you have your factory brake controller, heated seats and heated steering wheel buttons down here as well, stability control, tow haul, factory exhaust brake and you can turn those backup parking sensors off, turned out four-wheel drive, 115 volt, 150 watt plug-in and the passenger seat and floor mat are in excellent condition as well, this truck's never been smoked in, smells extremely clean in here, actually smells like new, headliners in great shape, got your map lights, power side and rear window and your home link buttons for your garage door security systems and lane systems, you also get 911 and assist buttons in that rearview mirror, those are features of the vehicle that you never have to pay a subscription for, we'll take a quick look at the back seats and then we will check out under the hood, the back seats just as clean as the front seats, no rips or tears back here, these seats look like they've hardly ever been sat in, has latch child safety system for any child car seats you may have, power side and rear window, like I said no rips or tears back here, very very nice, you do get a load floor underneath those seats, which is nice you've got packs you can put both sides down, they got a nice flat place layer, if you got muddy boots or tools you can put them on there and they're not going to get your seats dirty or if you're a hunter you can put both sides down, you got a nice flat place to store your shotguns and they're not going to teeter on the hump there, anyways there's storage underneath the seats and looks like you have a drop down hitch that comes with this truck, you also get in floor storage here with removable containers for easy cleaning, you can put ice and drinks in there it's like you got two mini coolers wherever you go, you get the child safety locks on the back doors as well and we'll take a quick look under the hood, I would personally like to thank you for checking out the video today and hopefully from this HD video you'll have been able to tell just how clean this truck is all the way around inside, no under the hood here we have the 6.7 liter Cummins diesel engine bay is very clean, runs very smooth this truck has been fully safety and inspected by our service shop has a fresh oil and filter change, all the fluids have been checked and topped off the truck has been gone through mechanically 100% and is 100% ready to go see more pictures of this truck or one of our other 450 new and used cars, trucks, SUVs, minivans, wranglers, half tons, three quarter tons one tons, you name it we got it go to our website www.summitauto.com full pictures and descriptions of every single vehicle from two locations all at www.summitauto.com and if you'd like to check out more HD videos you can go to www.youtube.com slash www.summitauto.com remember to like, subscribe, and share on this video and all the videos that you see there in fact in a second you will see a link to subscribe to our YouTube channel on your left a link to more Ram 2500 truck videos like this one on your right if you have not been to our website on the bottom link to this vehicle on our website click those check us out and we really look forward to helping you with this super clean 2016 Ram 2500 Crew Cab Short Box Big Horn Cummins Diesel thanks again


Hello everyone, I am Dr. Parimal Phuket. I am one of the directors and constituent radiologist at Precision Scan and Research Centre in Nagpur. Today we are going to discuss the imaging of brachial plexus. The clinical investigations of brachial nerve lesions are routinely involved in nerve conduction studies and EMG. The role of imaging is traditionally limited to excluding vocal nerve lesions or extensive completions. MRI, because of its excellent soft tissue imaging, can identify structural changes in the nerves as well as the secondary neurogenic proliferation which occurs in the subtle muscles. This greatly enhances its use in differential diagnosis of peripheral nerve lesions. Before moving on to the imaging part, let us first revise the cost-sectional anatomy of our peripheral nerve. Each peripheral nerve has got a covering called epineurium, inside which there are multiple bundles of fascicles, which are separated by the intervening fat as shown here. Each fascicle has got a covering of sheep called as perineurium and inside which there are multiple bundles of mildly red axons. These axons are separated by thin sheeps called as indoneurium. So we got indoneurium, the perineurium and epineurium.    When we speak of nerve injuries, we generally follow the seton and the simple line classification, which divides the nerve injuries in different categories. Going on from the least severe to the most severe, we have got neuropraxia, axon remasses, neuron remasses, and nerve transfection. The simplest of injuries is neuropraxia, which means nerve stretching or edema. There is no loss of continuity in the axons. The axons are intact. Mildly issued around the axon might be restricted, but the epineurium, the endoneurium, and the perineurium all are intact. These patients potentially have worked rapid and concrete recovery with no rate of surgery. They don't have an incipital or valentine degeneration. Moving on to the next type, which is slightly more severe, axon remasses. In axon remasses, we have got partial disruption of some of the axons. The endoneurium might be disrupted, however, the nerve fascicles are intact and the perineurium is intact. So these patients will have some mild neuro deficit, most of them will have concrete recovery, some of them will have mild neuro deficit. Again, surgery is not largely indicated in these patients. Moving on to the next type, the neuron remasses. Now, this is a slightly severe form of injury in which there is partial nerve tear. So there will be disruption of the axons as well as some of the nerve fascicles. They will be breached in the endoneurium as well as the perineurium. But the epineurium will be intact, so the nerve structure is generally maintained. These are patients who will need surgery many a times. They might have some permanent neuro deficit and a security of valentine degeneration. And moving on to the most severe type, nerve transaction, there will be complete breach in the penalty of the nerve so that there is break in the epineurium. These are patients who will require surgery immediately after the injury to have a good recovery. So these patients are likely to have permanent neuro deficit and a security of valentine degeneration. So why do we need to do imaging of patients who will be able to do the surgery? And what do we tell the surgeons after doing the imaging? So this is an illustration showing the different forms of injury. The image on the bottom here shows neuropraxia. The nerve rootlets are intact. The nerve itself is intact. There is some stretch in the axons for edematostring in the nerve. These patients have complete recovery. Second image here shows axon tuberculosis. There is partial disruption of some of the axons. However, the nerve epineurium is intact. These are patients who will generally have some deficit. But good recovery is possible. Surgery generally is not indicated for these patients. The third image here, you can see that there is complete nerve transaction. So this is a severe form of injury. This will be severe axon neurotomyosis or nerve transaction. There is a complete breach in the epineurium. Again, these are the patients who should be subjected to early surgery to have a good prognosis. The fourth image here shows what we call as nerve root abolition. So you can see that the mental nerve rootlets here are adverse from the insertion on the cord. These again are patients who will need surgery on a urgent basis to have a good prognosis. So when we do imaging of these patients with brachial plexus injury, almost 10% of patients will have severe injury in the form of nerve divulging or nerve transaction. And 90% of patients will have less severe or minor injury in the form of neuropaxia or axon neurosis. So these 90% of patients generally don't need surgery. 70% of them will have complete recovery. And around 30% will have some neurodificit. But the whole idea of imaging patients with brachial plexus injury is to identify this 10% of patients who will need surgery and who can have a good prognosis after surgery. The actual nerve regions was a T2 hyper intense signal at and distance to the region side. This correlates with ballet degeneration and navelima, prolongation of the T2 reaction time and gathering the enhancement of denominated muscle developing parallel to the development of spongebob activity on EMG. And these are the consequences of capital enlargement and increased muscular blood volume. Similarly, when we do imaging of these patients, we also see changes of muscle denomation. These can be acute denomation, muscle denomation or chronic muscle denomation. And how do you differentiate these? So actively denominated muscles show prolongation of T2 reaction time. There will be increased intensity on T2 and star images. But the muscle volume is directly maintained. Whereas in chronically denomated certain muscles, there is apnoxy and fatty degeneration. And these muscles will show increased intensity on T2 and star images. These are patients to different patients with two sequential episodes of foot rock affecting the peroneal nerve distribution. The first image here shows the axial development of the image. And in the peroneous brevis muscle, we are seeing there is hyper intense signal here which suggests fatty degeneration. So this is chronic muscle denomation. Second image, second patient here shows there is edematous changes and slightly increased volume in the peroneous longus muscle.  The mental technique of the click-excessive imaging and the sequences that we take, both 155 tisla and tata slime rm machines are good. But as we know, tata slime rm scores over 1.5 tisla in terms of vessel signal to earth ratio and availability of newer 3D imaging sequences. We use specialized RF coils, surface coils or face diacons are used. T1-rated images are good to show detailed anatomy and they are used to define the bone structures and tissue planes surrounding the nerves. Eye resolution and fast pinnacle T2 images are good to express pathology. Fat separation techniques using FS sequences or stir sequence, these will detect early changes of edema, inflammation and they will make the pathology more conspicuous. Gat-enhanced t1-rated imaging is useful for evaluation of peripheral noctimals plus infestation and in identifying adiapathic intramural disorders like parsley, stung, and so on. And very importantly, 3 tisla MR neurography. So, when we speak of MR neurography, we need to take 3D sequences like 3D stir sequence, 3D GRE and now these 3D different sequences. So, this enhance the imaging and will help us in getting reformative images. What are the imaging planes that we take when we image the brachial plexus? Now, we have to keep in mind that the imaging plane should parallel the nerves, the bones of the nerves. So, when we take a coronal sequence, this is the oblique coronal, this is the actual slice here. We are going to take the plane which parallels the nerves as they exit from the neural pharma and travels and know laterally towards the axilla. So, this is the imaging plane to get the coronal images. So, for actual image, the imaging plane should go laterally and infinitely because this is the bones of the nerves. And on sedative, the imaging plane should cut the nerves at right angles. So, if the nerves are passing in this direction, the imaging plane should be so that the nerves are cut in right angles. Coming to the anatomy of brachial plexus, we know that when we speak of brachial plexus, we speak in terms of roots, trunks, divisions, cords and branches. When it comes to roots, we have to speak in two terms, the ganglionic part and the post-ganglic part. So, what does that mean? So, this is an illustration. This is a C5 root section. So, this is a ventral rootlet of C5 nerve. This is the dorsal of the posterior rootlet. Both of them join here to form the C5 nerve. Just before joining, the dorsal or the posterior rootlet has got a ganglion. This is the dorsal ganglion. So, the part before the ganglion is the pre-ganglionic part, the part here called in green. So, this is the ventral rootlet dorsal rootlet of the neon ganglion. This comprises the pre-ganglionic segment and the part in orange is the post-ganglionic segment. So, this is the C5 nerve itself and then it divides into the ventral ribose and dorsal ribose. So, we have to keep in mind that only the ventral ribose of C5, C6, C7, C8 and C1 nerves will come away or will take part in formation of the brachial plexus. The posterior rmi will not take part in the brachial plexus. Sometimes, we have got contributions from the C4 nerve and the D2 nerve. So, this is the action which is very important to image this part also. Generally, when we do brachial plexus imaging, we tend to forget to take action sections or 3D sequences to evaluate the rootlets. So, we have to take a 3D space or fiesta sequence. In this machine, we have a space sequence or a set sequence and the G machine will have a fiesta sequence. So, take a 3D space or fiesta to the existing neutral throne. So, this is the image here which shows the ventral rootlet on the right side. So, this is the right ventral rootlet, the posterior rootlet. This is joined together to form the existing nerve here. This nerve again will be divided into the ventral ribose and the posterior ribose. In nerve divergence, we will see that this segment is lost and there will be a formation of a pseudo-meningosal in this region. We will come to these images later. So, this is the patient who has got nerve divergence involving right-sided C5, C8 nerves. So, we have taken action to be space or fiesta sequence here. So, this is at the level of C5 nerve root. We can see that the ventral and the dorsal rootlets are seen on the left side but they are not seen on the right side. Again, same at the level of neural fragment. The C5 and left-sided rootlets are seen. The right side root is not seen here. Same case at C6 level. At C7 level, same thing here. And additionally, we are seeing that there is a cystic area here in the epidural space in the lateral resist and neural fragment on the right side. This is, in fact, a pseudo-meningosal. So, this is the classical case of nerve diversion with pseudo-meningosal formation on the right side. At the D1 level, we can see both the ventral and dorsal rootlets on the right and left side here. So, the D1 rootlets of the roots are intact.