a very good afternoon everyone today we are going to speak on a very important topic that is recurrent abdominal pain medical and surgical management. It is a very common problem that you see in your day-to-day openly practice. I am Dr. Sukhla Satsena. I am a consultant pediatric gastroenterologist and hepatologist at Manipal Hospital, Tauraka and I have with me Dr. Sabdwal sir as well he's a senior consultant and heading periodic surgery over here at Manipal Hospital. So I'll be talking about the medical aspect and he'll be discussing about the surgical aspect of abdominal pain. So it's always a dilemma whenever the abdominal pain children come to your clinic or OPDs because children are often unique and they are different from adults because they have a deep immune system and they require additional support as compared to adults. So treating a chronic abdominal pain is not only challenging for the pediatrician or the physician itself but it's very very challenging for the child who's suffering from the condition and the pain because they are always worried that there might be some underlying condition that the child may be suffering from serious conditions and why the pain is not getting better wherein the pediatricians are always in a fix that you know when you treat it on OPD basis and you know when to order certain diagnostic tests if the pain is not getting better. So today I'm going to throw light or you share with you how to differentiate between functional abdominal disorders and what all to look out for if you're suspecting an organic person and a generalized approach how to go about a diagnosis and management of chronic abdominal pain. So if we look at the terminology it's an intermittent or constant pain which could be functional or organic in etiology and it should be present at least for two months. Most you know it can most criteria define it should be present for a period of three months but it should at least be present for a period of two months. Important thing is that it encompasses the recurrent abdominal pain which is defined by four criteria that there should be more than three episodes of the abdominal pain. The pain should be sufficiently severe to affect the activities and the episode should occur at least a period of three months without any organic cause. In terms of functional disorders in which the which are the condition in which the patient can have variable combination of symptoms in sign without having any identified organic condition. Usually it is because of the interplay of regulatory factors which are there in the entry and the center nervous system. So a lot of factors interplay for example there may be visceral hyperalgesia which reduce threshold for pain abnormal pain referral after rectal distension or there may be impaired passive relaxation in response to needs. Now if you look at the epidemiology chronic abdominal pain occurs in up to 10 to 20 percent of children in the age of 4 to 6 years. There has been studies done in middle and high school children which have reported 17 percent of them have reported BT episodes of abdominal pain. So it is quite a common problem in childhood. In 2015 a meta-analysis was done of 58 studies which show an overall prevalence around the world of functional abdominal pain of up to 13 percent. Now how and why this pain occurs. So let's look. There are two types of pain receptors which are there. One is in the MISRA and one is in the Karaita, Karaita phalton. So pain receptors which are there in the abdomen usually they respond either to the mechanical stimulus or the chemical stimulus. So whenever there is involvement of MISRA the visceral pain is usually induced by the mechanical stimulus in the form of either distension, contraction, traction or compression. Whereas mucosal receptors which are present in the mucosa primarily responds to chemical stimulus for example predigining, substance the saboteurin etc. And we all know that the chemical stimuli are released in response to inflammation or skin. Sometimes what happen all these different stimuli whether it's mechanical or chemical they can add together and they can influence the perception of pain. For example usually we see that gastric mucosa is insensitive to pain. However when the gastric mucosa gets damaged or inflamed then these stimuli may cause together pain in the gastric mucosa as well. Also the threshold for perceiving the pain for visceral stimuli varies amongst individuals and that's what results in the chronic pain which can be triggered by a initial result. For example a child with functional abdominal pain the brain communication is altered by distortion in visceral sensation. So normal process for example like normal paracelsus may be perceived as painful in some children as compared to others. Also there is visceral hypersensitivity which can occur through peripheral sensitization at the point of inflammation. Then there is central sensitization or recruitment of non-involved adjacent neurons. These all mechanism together may predispose to chronic pain even after the initial stimulus has been resolved. This is just an algorithm how biological environmental and psychosocial factors affect the possession of pain in an individual. The second one is the leopard pain. So sometimes the pain which is originated in the bistra is perceived to originate at the distant side and that pain is called as leopard pain. So usually the leopard pain is located in the cutaneous dermatone same as shared by the spinal cord level as the bistral input. For example the nausea septic stimuli for gallbladder they enter the spinal cord at the T5 and T10 level. So usually whenever the gallbladder pain is perceived it is perceived with the scapula. Similarly if when the overlying parietal peritoneum is involved then the pain will be referred to the right upper quadrant in case of acute polycystitis. This is a dermatomal distribution which we all know that pain from abdominal bistra which are referred to different sides. This is very important that we all know that they localize according to their embryological origin. So four gut structures usually the pain is referred to the upper abdomen for that is the structures which are originating from mouth till the first proximal half of the diodenum. Then the structures from distant half of the diodenum to the middle of transverse cologne the pain is referred to the perium likeus and the perium likeal region. And then for the hind gut structures like the remainder of cologne rectum and the genitio urinary organs the pain is usually present in the lower abdominal region. And radiation of pain may provide the insight into diagnosis for example we have already seen for the gallbladder for pancreatitis the pain may radiate to the back during the gallbladder disease the pain may radiate to the right shoulder or the scapula region. But this is not a hard and fast rule it will you know it will only depend what type of underlying ecology is there. Now it's very very important whenever a child presents to you to take a detail history and look for the location of the pain to rule out an organic ideology because then only you can decide about what investigation to order and how the child would be managed. So it's very important to remember that we always look for any underlying organic cause for example if it's an esophabic disorder usually there will be a history of early morning pain or the pain of waiting the child at night with early society like londia or foul smelling or sour breath or burping they could be occasional local blood and stool as well. And usually the typical location of the pain is in the epigested region. If there is carbohydrate mileage option for example lactose intolerance it's like a crampy pain with diarrhea but usually probably stool bloating with a lot of bloating and gas related issue because of the mileage option of the carbohydrate. And it is aggravated by eating dairy or dairy containing products. Again the pain is very unlikable or it could be in the lower abdomen. In celiac disease so the presentation can be a crampy non-specific abdominal pain. In celiac cases child may present with chronic diarrhea and oryxia distension but in certain cases the child may just present with poor weight gain or weight loss malnutrition. They can also present with constipation and island deficiency in anemia but mostly the pain is in the epigested region. In constipation most of the times you will have a history of periabilical pain but you will see a lot of time the child consistently gives a history of left sided abdominal pain and there will be additional history of incomplete evacuation of stool in infrequent stooling in fecal incontinence or history of large stool once we have given our suppository or some kind of treatment to the child. Again in adolescent age group it is very important to look for dysmenorrhea history of menstruation, gastroesophageal influx. This is very very important because sometimes the respiratory symptoms like chronic curve of easing doesn't get better so it's very important to remember that there could be a underlying influx which may be causing this easing of chronic curve. If in a bigger child they may have associated epigestric or upper abdominal pain then there could be muscle stale little pain if the child has got hernia or hematoma so the pain usually occur with some kind of physical activity they could be underlying muscle tenderness or positive carnal site. I will not go into the details probably sir will be the best person to you know tell differentiate how he differentiate between an abdominal wall and organ pain by using the carnal site. Then there are pain which is related to infections like but those children have associated diarrhea or exposure to history and they usually present with diffuse abdominal pain. Also important to rule out less common causes of pain like endometriosis and adolescent girls. This is very very common with food allergy, rising incidence of food allergy. Kids come with usually upper abdominal pain they may have a history of vomiting or dysphagia or food infection or they may not have a history. Similarly for food allergy as well if it is IG immediately then the abdominal pain is immediate in onset usually within minutes to hours of addition of food and the diarrhea also follows. Whereas if it is non-IG immediately then it can present with chronic diarrhea or weight gain or blood or mucus and stool for a long time. Other less common but important organic disorder is very very important because a lot of time inflammatory bowel disease especially Crohn's may present with just lower abdominal pain with some kind of you know gross or awful blood and this too will short stature and poor weight gain. They may not have always classic history of diarrhea weight loss and blood and stool. So it's very important to remember to rule out these disorders as well. Similarly pelvic inflammatory diseases in adolescent children and UTI which is again a very common cause of abdominal pain in children. This is again a summary of alarm findings. So what you will get in history is and any history of involuntary weight loss probably will point toward malabsorption. Difficulty swallowing or painful swallowing which points towards eosinophilic esophagitis or any kind of esophagitis or ecclesia. Significant vomiting so significant vomiting can be associated with esophagitis disease or cyclic rheumatic syndrome or eosinophilic gastroenteritis. If it is really severe then ball obstruction is another option. Then it present in it is present in hepato-villary disease and cholecystasis as well. Chronic severe diarrhea think about enteric infection, food protein, inducements of the inflammatory bowel disease, urinary symptoms, back pain. So child usually presented with acute back pain and abdominal pain think of chronic pancreatitis and accordingly we have to order the investigation. Family history of IBD, CVF or Peptic ulcer disease is very very important because usually these conditions doesn't especially IBD or functional bowel disorders don't have specific treatment. It's very important to diagnose them right first. Again IBD have variable presentation in the form of bloodied area as well. Then look out for melena, skin changes in different conditions. In examination most important is to plot their growth. So if there is any decrease in the growth or delayed growth or delayed poverty it is very very important. Ulcerations which is common in IBD look for localized upper quadrant tenderness in hepato-villary disease or right lower quadrant tenderness in chronic appendicitis or varian cyst. Left lower quadrant pain as I said earlier in constipation it could be a mass or ulcerative colitis, supra pubic tenderness in UTI, organometallys or post-ovartical left ankle tenderness. So in all a very good history and a clinical examination is must in child presenting with recurrent abdominal pain to look out for any organ. Now there is room for diagnostic criteria which shares with you the functional abdominal pain disorders because we have looked in the organic disorders. Now these are the disorders which are functional in nature and they have been categorized into functional dyspexia, irritable bowel syndrome, abdominal migraine, then function abdominal pain which is not otherwise specified and functional constipation. Each of them is an entity in itself and they need a long discussion because we are always confused that when to label them as functional disorder and how to treat them. So I'm just going to summarize and give you a rough idea what exactly they are and how we should go over. So usually all the functional disorders they are ill-defined and poorly localized or perium-like in episodes of burn usually last less than an hour. They resolve spontaneously. They may be accompanied by pallor nausea or dizziness or may be triggered or exhumated during stress. The most important thing is that child is well and functional normally in between the episodes. So there are no alarming signs in such disorders. And another important thing is there might be family history of positive GI disorders like irritable bowel or blood circulation. If you look at the overall prevalence, so this is again very important slide. The most common functional disorders is functional constipation which shall the highest prevalence around 10% out of all of them followed by functional dyspepsia which is 3%. Functional abdominal pain is again 2.4% and irritable bowel syndrome is 2.3%. So when people ask about abdominal migraine, so it is not a very very very common condition. The overall incidence is only 0.5% out of all the functional disorders. I'll just share one or two cases with you to give you a rough idea what exactly is functional dyspepsia. So 14 year boy with 2 month history of positive post peregral fullness, early satiety, epicastric pain, epicastric burning with normal physical examination, normal screening labs, all labs have been normal. Now should we do a rheological testing in such a way? No, till we don't have an obstructive sign and symptoms it is not needed. Should we go for an endoscopy? Yes, if there is evidence of vomiting or weight loss, if there is evidence of any positive screening tests like the celiac screening or allergic screening, often does not relieve the anxiety. Should we do a pyloric testing? If there is a family history or if the symptoms are really acute, then you should go for a pyloric testing. Now this is the therapy which has been recommended. Total confirmable inhibitors have less than 50% response. There is no increase in response to high doses. Anti-H coli, H pylori drugs have only 10 to 15% response and there is no improvement with repeated process. There is no role of prokinetics or anti-small or anti-dip present in this disorder. The second one is irritable bowel syndrome which presents with abdominal discomfort or pain usually associated with two or more of the following. It may improve identification. It is onset associated with change in stool frequency or stool consistency. There is no evidence of any other disorder and it should be present for two months or more. A lot of studies have been done on various supplements, medications, dietary restrictions and adults. But what have been found to be effective in IPAs in children is only one thing. One is psychosocial support which is most effective and other thing which I come to discuss later is the peppermint oil which should be given for almost a period of more than two weeks. It is abdominal migraine which consists of paracysmal episodes of intense acute perium like the pain that lasts for more than one hour. Intervening periods of normal health which can last for weeks to months. The pain interferes with normal activities and it should be associated with two or more of the following. So the child will either have anorexia, nausea, vomiting, headache, photophobia or fallout to a more of them and there will be a positive history of migraine in the family. This is just a brief treatment of abdominal membrane. Usually it is the non-pharmacological therapy which is recommended initially which is explanation and reassurance, avoidance of trigger, modification of diet. Then if there is pharmacotherapy and prophylactic therapy, use the abortive instances of abortive and the prophylactic then there is functional abdominal pain syndrome which is continuous or nearly continuous abdominal pain. It has little or no relationship of pain with eating, deputation or menses. There is some loss of daily functioning that's why these functional disorders are important. The most important thing is the pain is not pain so there is no malingly involved by the child. It will not fit into another function GI disorders and usually there should be symptoms for at least two months, six duration should be two months to six months. So how do we go for it? It's very important for the child or the parent to be told to keep a pain diary to look at the pain, the duration, the location and severity, the possible triggering factors which could be involved, the remedies or interventions that were tried which made the pain better. For adolescent girls, a menstrual history should be obtained in all adults and women. Investigations that should be ordered, we all know that there are basic investigations and then the second line investigation. So whatever is the underlying organic ideology that we are suspect to, based on that we should order the basic blood and the second line investigations. It goes through Apagia endoscopy although it has been documented that it is the second line investigation and before the introduction of esophageal gastroidinoscopy, the majority of recurrent abdominal pain was categorized as functional. However, after the advent in 1970, organic etiologies gradually became more prominent and nowadays it has been found that 10%, less than 10% to as much of 50% pain are because of recurrent abdominal pain. So this is, there has been study done by Genchupi Dal in which they have done upper endoscopy finding in children with recurrent abdominal pain in which 150 degrees were performed in red flat children. So it's very important. We are going to do only endoscopies in which you see evidence of red flat signs in children with recurrent abdominal pain to find out the etiology of their complaints. The, they found that abnormal findings are present in 84% of patients. The most prevalent were esophageitis which was in 40%. Regarding the high prevalence of abdominal pain complaints and increasing the application of EGD in diagnosis of etiology, findings precise indication for performing EGD in children with recurrent abdominal pain seems mandatory. So the popular approach is all the children with recurrent abdominal pain who have red flat signs should undergo upper GA endoscopy. So this was the indication for doing the upper GA endoscopy, the kids with the raised ESR with severe anemia weight loss. So having one or multiple factors, episode of GI feeding or localized tenderness and these were the findings out of which 16% were normal, 20% had creatinine hernia. You see a large young had a 40% have different rates of esophageitis. So I'm just coming to the end of my presentation. This is just a box type lens to manage recurrent abdominal pain. Most important thing is explain and reassure because if you're dealing with functional abdominal pain, this is what is needed. Identification of red flat sign, avoid psychosocial labeling, allow normal activity. It is very, very important to encourage normal activity in kids in between when the child is pain free. Establish regular follow up also make use of judicious second opinion. If you think that you are stuck or you're not able to understand then obviously you should refer to us. Now there have been various therapies which have been tried and according to last again recommendations, we have seen that only two therapies have been beneficial out of which a cognitive behavior therapy has been beneficial in recurrent abdominal pain. There was no use of femuridine or adding dietary fiber or lactose free diet in recurrent abdominal pain. Peppermint oil as I already said is likely to be beneficial in irritable bowel syndrome. There has been no result of any tryptoline or lactobacillus BV in irritable bowel syndrome. To summarize chronic abdominal pain is a common condition in children and adolescents. In most children it is functional that is without any underlying organic disorder. There is evidence that children with functional pain can have symptom clusters that means they may have features of more than one type of pain. The presence of alarm symptoms of signs such as organic disease and may justify the performance of diagnostic test by the treating position. There is inconclusive evidence that a lactose free diet or a diet which in fiber may decrease the frequency of pain. There is inconclusive evidence of benefit of acid suppression with H2 receptor and tokenase to treat with child with dyspensia. Although there is evidence that treatment for two weeks with peppermint oil may provide benefit in children with IVS also similarly cognitive behavior therapy may be useful in improving functional problem pain. Hi, good afternoon. I am Dr. Arvind Sabarala. I am the pediatric surgeon from Manipal Hospital. Now whereas a physician has got a long period of time to decide that which therapy is needed. A surgeon sometimes gets into problems because a surgeon doesn't know exactly where the pain is originating. The child is a poor communicator and it becomes very important for the surgeon to decide whether he should put the knife on the child or not. And normally a surgeon would have a very short time to decide that what should be done. Abdomen was always thought to be a Pandora's box. Over a period of time however we have gained a lot of access into it. We've got now various diagnostic modalities through which we can know what is happening in the abdomen. And today we are in no hurry now to go in and operate in each and every patient. Now abdominal pain in children can be an acute abdomen which normally comes into the domain of the surgeon. The recurrent pains in the pains which are organic or which are psychogenic and non-traumatic, they normally fall into the realm of a medical treatment on which Dr. Supta has already given you a very nice detailed explanation that how we are going to manage these kids with recurrent pains who may have organic causes or psychogenic causes underneath. Now whenever we are talking of abdominal pain in children from a surgeon's point of view, my first question would be that whether this pain is traumatic or non-traumatic. The pain in kids can originate anywhere from the GIT, from the vertebrary tract, from the genital unitary tract and also from the musculoskeletal system. But luckily only less than 5% of all abdominal pains which would come to us less than 5% will need observation or even lesser than that will need an exploration. Most majority of them would have common causes something like gastrointritis or worms or constipation or gastritis or the other factors which Dr. Supta has already so beautifully explained. Now first is the trauma. Most of the time you will get a history. The child will be able to tell that well my friend kicked me in the tummy during the lunch break or there will be history of falling from cycling or the child would have fallen for a swing. So normally in majority of cases you will get a history of trauma and an ultrasound and a CECD abdomen are the two investigations of choice to pinpoint any abdominal injury. At this point however I must share my experience with you that there are a lot of kids who come with a muscle pull of their period abdominal wall. They will come that there is sudden pain and the pain typically comes when you ask the child to sit up or to raise his legs and you will suddenly find that there is pain in the period abdominal wall. The points of tenderness normally are just under the rib cage or they may be on the rectus abdominis muscle. Lot of these kids undergo unnecessary investigations and whereas they just have a simple muscle pull of the period abdominal wall because of sudden movement or pain. In cases wherever we are suspecting a gut injury which is not picked up by a CECD we might need to do a peritoneal tap to find the presence of bile. Most of the cases of trauma even a major liver trauma if we look at this film you can see a major liver trauma on the liver can be managed non-operatively. They will need an ICU care but most of them would not require any explanation. Now when we come to a non-traumatic acute pain there are two main categories what we are talking about one is a child who is less than one year of age the first thinking is intersection. Any child who is more than two years of age severe abdominal pain the first thinking is appendicitis. The most important thing is that we need to repeatedly observe these children over a period of time maybe a few minutes a few hours to come to a conclusion. Now even if we operate almost 75 percent of the cases who have a negative exploration in spite of the investigations might have a cause something like a mechal or a small ovarian cyst which has ruptured and in 25 percent of the negative explorations the diagnosis may be made in the post-op period as pylonephritis or a Ajaxal and papula. Medivial diseases such as inflammatory bubble disease or primary peritonitis also can lead on to some negative explorations but the central issue will always remain in kids to be appendicitis. So it is very important to take a history in a kid because it may point you out that what is the probable cause of this pain. Less than one year of age a severe acute pain the cause may be an interception, it may be a malrotation, it might be a hernia which has been overlooked by the parents, there might be heart problems. Generally what we see is that if the sequence comes as that the patient had fever first followed by vomiting and then the pain started the pause most likely is going to be a medical pause whereas if the pain is the first symptom and that is followed by vomiting and then the fever comes it is more towards a surgical problem. A pain which starts with sudden severe onset may be a pain which is due to a torsion or due to a operation or due to an interception. Whereas the slower onset pains are the appendicitis pain which may evolve over a period of time. It may be a pain of pancreatitis or cholecystitis or a urinary tract infection. Most of these pains will take a few hours to gradually increase in intensity. If the patient has got recurrent pain then as Dr. Sopla has told inflammatory rebarber disease, constipation are the common causes. If the pain is cholecystitis it is a rising from a hollow viscous, maybe from the gut, maybe from the urinary tract. If the vomiting is right at the onset, it may be associated with the colic. So any abdominal colic can give vomiting immediately along with the colic. If the appetite of the child has decreased markedly then the pain is most likely to rise from the GIT. Whereas if the appetite is normal the pain is more likely to be from the genital urinary tract. A GI bleed along with the pain could indicate a meccal in HSP or HUS or interception or a marvelous. Past history of any medical problems like nephrotic syndrome or cirrhosis can point out that it might be a primary peritonitis. Whereas any previous surgical history of trauma or previous surgeries could indicate that it might be due to additions. In females it is always important to remember that a follicle cis-structure or a topic pregnancy. Yes even a topic pregnancy because as we are going through this age we are likely to see teenage topic pregnancies to happen and they can mislead us. Then it is very important also in the history to see what is the site of the pain and how it radiates. So the working diagnosis by the site of the pain would be that the right upper quadrant pain is either from the liver, cholera crisis or gallbladder. Whereas an epigastric pain is because of GI, gastritis or a practical disease. Appendicitis, mesoteric adenitis, meccals, ovarian torsion will all give a pain which might start in the mid abdomen but will gradually shift over onto the right side of the abdomen. Pancreatitis pain will be normally in the mid abdomen.  Constipation, UTI and ovarian torsion might give the pain in the left quadrant. Now examination of such a child will show that if the child is restless and rising in pain it is more likely to be a colicky pain and if the child is lying still, still complaining of pain it is more likely a peritoneal pain. That means that it is more likely inflammatory pain and the child does not want to move. Tachycardia, tachypnea and a coated tongue again is normally a sign of an inflammatory pathology. In ways small kids or maybe infants or younger kids we might see a abdominal wall edema, we might see visible loops, we might see some motion of these loops on the abdominal wall. We also try to elicit tenderness, guarding, rigidity and rebound tenderness. The best way to elicit a rebound tenderness is to gently tap on the child's abdomen rather than pushing deeply and leaving the abdomen. We also listen to bowel sounds. Bowel sounds might be indicating few tinkling sounds, they may be something like a water gushing through, the sounds may be like something water is pushing through and various bowel sounds will give us an inkling whether it is an idea or whether it is an obstructive bowel. Again free air or fluid can be judged on percussion. It is very important to examine the lower chest or spectrate the lower chest to find any evidence of pneumonia in that area. Lactal examination though not necessary in all the kids may help and to also look for a pediatrics because a henup shallon can give rise to an abdominal pain. Investigations normally are hemoglobin, PCB, TLC, DLC. A rapidly falling hemoglobin could indicate that it is a volvulus. A raised total leukocyte count with neutrophilia points to an inflammatory bowel disease. Urine analysis, renal function, liver functions, amylase of course will also indicate various diseases of the liver or of the pancreas. One of the important investigations for any abdominal pain may be an x-ray. Now most of the time what I have seen is that an x-ray whenever is ordered is ordered as an erect x-ray. Whereas it is mandatory that before you do an erect x-ray a supine x-ray must also be done. The supine x-ray is a must to find out the level of the bowel obstruction to look for calcifications, to look for any central loops, to find fixed loops from prentin which is seen normally in cases of any ischemia. The presence of any mass in the abdomen because the bowel will split around that mass and to see for the preperitoneal line which will get obliterated in case of there's any inflammation. The investigation of choice in most of the cases would be an ultrasound of the abdomen which is non-invasive, easy to do and does not cause any problem to the child. Followed by an ultrasound the CECT becomes the most important investigation whereas both the solid organs, masses and even cases of intestinal obstruction could be easily diagnosed on a CECT. MRI has got a very limited role and kits for evaluating intestinal pain or evaluating abdominal pain rather because number one it needs a sedation and a GA. It's a long period to do an colageogram and it does not give any additional information to a CECT abdominal. However MRI may be useful when we are doing the colageogram to look for a colidogal cyst or a urogram to look for an amylase in the urinary system or it might be helpful if we are suspecting any spinal cause for the abdominal pain. A diagnostic laparoscopy sometimes might be needed in a tubercular abdominal and in contrast studies such as the varium study might be very useful to make a diagnosis of husband disease. Now always beware of a baby who vomits wide. Abdominal pain the common causes constipation, a history and an examination might reveal that is constipation because of an impacted tooth which is palpable. In acute appendicitis may be diagnosed by history, examination with a pain and reboundedness in the right liposa. Similarly a torsion might get diagnosed by doing a CBC by doing an ultrasound or doing a CT scan. It is very important to always look for an guino-scrotal mass in the kit with abdominal pain because we have seen patients with obstructed hernia being missed as in a abdominal pain. Hennep Schoenland-Parpura again is common in kids and can give rise to abdominal pain. Visitoric lymphatic enactors especially after a viral infection is very common and an ultrasound will most of the time make a diagnosis. In a donor sense appendicitis followed by divertiplitis, pancreatitis, gallbladder stone, and torsion of intra-abdominal structures are the common causes of acute abdominal pain and diagnosis again is through all the means that we have already described. So I will delve a little bit more on appendicitis because that is the normal or a very common condition in kids which need surgical attention. It's always important that a patient of appendicitis must be seen after 2-3 hours again and reassessed to see what is the intensity of pain. In neonatal period the diagnosis is almost never done pre-operative and almost 95% of them will have a perforation by the time they are diagnosed. Even in children the rate of perforations are quite high almost 60% described in literature but the normal perforation rate is somewhere around 30 to 40% and in 15% of them they will perforate in less than 24 hours. So that is why most of the time we recommend early surgery in patients with appendicitis. We can have leukocytosis with a left shift, TLC more than 15,000 with a neutrophilia of more than 80%, a CRP which is raised and a chest on an x-ray of the abdomen showing a frecolate in the right like OSAR are almost diagnostic of an acute appendicitis. On an ultrasound increase of diameter of the appendix more than 7 millimeters in the AP diameter, non-compressible structure has a sensitivity of about 85%. Normally today we are tending to do more and more CCT abdomens because the ultrasound lot of times is inconclusive. But if on an ultrasound a diagnosis is clear cut I don't think that we need to really go in and do a CCT. However if we are suspecting in a particular mass we must do a CCT to look for local collections any other pathologies which might be related in that area. In children chronic and recurrent appendicitis is a definite clinical entity and as I will go to the next slide to tell you the non-operative treatment of appendicitis. We see that in early appendicitis most of the kids will get okay after getting some antibiotics but then they will recur. They will come back, a small percentage will come back and these are the patients who will be diagnosed as recurrent appendicitis. Variable and edema used to be done initially but I think today it has been replaced by doing a CCT The treatment of choice is to do a laparoscopy today. Open surgery is hardly now done in these days and most of the kids we are able to resolve them with the laparoscopy. But sometimes if because of local mass or because of problems we might need to convert these patients into an open surgery. There is lot of talk today of appendicitis non-operative treatment but one should remember that the non-operative treatment requires antibiotics for 7 to 10 days. There are various scores which have been set up such as the pediatric appendicitis score which is based on vomiting, writer-like osapine, tenderness, temperature and these scores are able to predict whether we should operate these kids or not. But normally if an appendix is less than 10 millimeter the leukocytosis is less than 15,000 with a real normal CRP with no petrolate and no pus on either ultrasound or on a CCT and with a pass score of less than 6. These are the patients who can be managed non-operatively. There this non-operative treatment in non-complicated appendicitis may be effective in 71 to 94 percent of cases but almost 30 percent of these cases will return back within six months with a recurrent episode which may need surgical intervention. At any time whenever we are doing a non-operative treatment if the treatment is not giving response within 24 to 48 hours or if there is any deterioration in the condition patient should be immediately taken up for surgery. Interception is another common condition seen in younger children around nine months to one year of age. They normally have had a recent viral illness. They will have intermittent severe miscellaneous pain where the child is cramping and the mother and the parents can visibly see the cramps. The rectal examination or even the per rectal blood will clinch the diagnosis. Eventually they will develop a distal bowel obstruction and behave like an obstructed bowel. This is the typical red current which comes in these kids. Diagnosis is by doing an ultrasound or a valuation of a mass. The treatment is most of the time hydrostatic reduction and surgical reduction is very infrequently done these days. Most of these kids will go well with an hydrostatic reduction. However I must point it out that there is a condition where we have an ideal interception. These are the kids which will not need any surgical treatment immediately. Most of them will reduce by themselves. They may become recurrent, but most of them will not require any self. Then the children could have interstinal obstruction. The differential diagnosis would be a paralytic alias, nitrotizing internal colitis or peritonitis caused mostly man rotation. Could be bands which are not very common. Could be additions due to early surgery. Could be an obstructed hernia. Ultrasound, CCT, abdomen. These are the various causes for obstruction in kids. Important is to find out a mid-gut wall blouse and treat it as the unbiased. Now surgery becomes essential in cases of appendicitis and obstruction, perforations, gonad panes, and wall bladder disease and medicals. It may become essential if there is a primary torsion of the momentum. If there is a perineptic abscess, bladder calculus. If there is a liver abscess or an ectopic pregnancy. Liver and wall bladder disease are not common. We very frequently see liver abscesses giving rise to severe abdominal pain with fever. Majority of them are staff oriented biogenic infections and they may need exploration and drainage. Polycystitis is becoming more and more common in kids. The guidelines are the same as we are calling for adults and a polycystectomy is the routine frequent. A laparoscopic polycystectomy is the standard for treatment and we normally use smaller instruments to take out the gonad. A urinary tract pain is also very commonly seen in kids which might be because of a pilonaphytis or cystitis. There might be urinary calculus. The pain is usually in the flanks and the back and it is superb if the pain is because of cystitis. The pain usually will get referred from the flanks towards the grind or towards the back. There might be pain which gets referred to the tip of the penis and there are tumors like Wilms and neuroplastomas which also can give rise to abdominal pain which might be persistent. Then very important to note that gonadal pain can initially present as a very severe middle abdominal pain. The most important thing is that the time factor is very important. A pain which is arising from a testis and coming to the middle abdomen may be because of a torsion and within six to eight hours this testis will degenerate. So it is very important to keep that in mind. A follicular cyst, monarchy or an ovarian torsion can also give rise to severe abdominal pain and should be diagnosed early if we have to salvage that ovary. Ultrasound is the most important diagnostic tool. So with that I think I wrap up the surgical problems and we are ready to take any questions when the bite comes. So there is a question from Dr Vivek. First he has asked which painkiller do you prefer in abdominal functional pain and its duration and is there a role of lactobacillus re-utri in functional pain? So I will answer them one by one. Dr Vivek, usually in functional abdominal pain there is no role of painkillers unless it's extremely, extremely severe because most of the kids when you see this pain comes and goes off. If there is only in certain conditions like in irritable if we are suspecting an irritable bowel syndrome or if there is a functional constipation then we know the definitive treatment. Other than that we only give them supportive care and behavioral therapy. Probably ask them to keep a painkiller because in most of these cases painkillers are not useful or helpful. The second one, yes, is there a role of lactobacillus re-utri in functional pain? Yes, there has been recent studies which have been done using lactobacillus re-utri and lactobacillus GG and those studies have shown that conditions like functional dyspepsia, functional constipation, there has been some role of using lactobacillus GG but they need to be given for a period of at least two to three weeks or more to have their effect. I hope I have answered your questions, both of them. So with this we end our session. Thank you very much for attending this medical and surgical aspect of abdominal pain which is a common feature or disease that you are seeing in your opening practice. I hope it has been useful. Thank you very much.


Is Christianity a relationship or religion? It's both. Sometimes we get in the habit of just saying things because it sounds good, it feels good, maybe even makes sense. One of the things that we hear often is that Christianity is a relationship, but not a religion. Well, is that true? Well, we need to figure out what a religion is. The Bible actually tells us that we ought to have a religion. James was at this way in James chapter 1 verse 26. He says, if anyone thinks he is religious and does not bridle his tongue but deceives his heart, this person's religion is worthless. Religion that is pure and undefiled before God, the Father, is this, to visit orphans and widows in their afflictions and to keep oneself unstained from the world. So we're told to have a religion. As a matter of fact, we want to have a pure, undefiled religion. The problem is religion has gotten a dirty word, but it would help to see what religion is. Now, before we go there, obviously we know that we are to have a relationship with Christ. It is about a relationship with him and us. Jesus stated that the people that don't go to heaven in Matthew 7, though they do all these different things, which is religious, their issue is they don't know him or he had no them. And so it is important first of all that we have a relationship with our Savior. However, we also ought to have this religion. Well, the question then begs is what does the word religion mean? So let's go back to the word, to the passage and let's see what the word religion is. The word religion in the Greek is the word threskeia. Threskeia simply means an expression of that faith or that worship. How we show our worship, what we do, it's the things that we do, which is why we say sometimes we do things religiously. We are just doing this, doing this, doing this. Now, we don't want to just do it mindlessly. We want to do it for a particular reason. As a matter of fact, sometimes, as a matter of fact, many times we don't feel like doing things that we know we ought to do. Sometimes we might get in the habit of doing things religiously, and the question is, does God have any sort of preference? Well, God obviously knows that sometimes we are going to do things for him or that we should do just because we love him. We feel a desire we want to, but then there are sometimes we do it not because we want to, because I got to, because I have to, and God honors that as well because you are doing what you're supposed to do because it's pleasing to him, even though at that moment it may not be pleasing to you. Let's be honest, if that happens sometimes, sometimes I just don't feel like going to church, sometimes I just don't feel like sharing the gospel, sometimes I just don't feel like showing love and appreciation towards my fellow man. That's how it is sometimes, but I do it anyway. As a matter of fact, it's part of us disciplining ourselves. Paul even put it this way, that we do it sometimes also to benefit ourselves. He says every athlete in 1 Corinthians 9-25, he says every athlete exercises self-control in all things. They do it to receive a perishable wreath, but we an imperishable one. So I do not run aimlessly. I do not box as one beating the air, but I discipline. There's the issue. I discipline my body and keep it under control, lest after preaching to others, I myself should be disqualified. And so I want to make sure that when there are times I don't feel like I have to be disciplined enough. I need to have enough self-control to where I just have to just have myself do it. And I do it obviously out of a love for him. It's his love that compels us, as Paul tells us also. It's his love that compels us to share the gospel. And I mean, I feel like it. And so yes, our faith that we had that we hold to this Christianity, that we're part of this us being Christians, it's not just a relationship, but it's also religion. The both go hand in hand. You know my relationship with him by my expression, which is my religion. And you know what my religion is. After doing so, then I can even tell you about my relationship with him. They work hand in hand. Amen.


Zero Accounting Software 2023 Enter Transaction for the Purchase of Inventory Using Bank Feeds Overview Get ready to become an Accountant Hero with Zero 2023 Here we are in our Custom Zero home page going into the company file we set up in a prior presentation The Bank Feed File We're going to be duplicating some tabs to put reports in like we do every time Right clicking on the tab up top so we can duplicate it And then we're going to right click on the tab up top again and duplicate it again Back to the tab to the middle Accounting drop down, we want to open up the major financial statement report of the balance sheet And then we'll tab to the right as the balance sheet is thinking Accounting drop down, this time the income statement, the other financial statement report Let's go back to the balance sheet The date looks good for us because the data I am uploading will be in 2022 for the...


And Moldova I wouldn't go to because Moldova is probably the most hostile place I've ever been I've been there three times and was attacked twice. Why is that? because they are super right-wing nationalists and You know, what's crazy even though they attacked me. I respect them for it So me and my brother were walking down Kishinaw, Moldova. It's two in the morning. We had these three girls with us We're walking we're talking to the girls in English and this guy goes. Oh American I go, hi, he goes.   Why else am I there? Why else would I be in Kishinaw, Moldova is not for all the beautiful girls They know exactly why I was there.   Why would we? They're super super nationalistic super super right-wing and that's happened to me twice They came they punched me. I took it. I punched my brother. We got them all on one side because we had him surrounded We're like, okay, we're leaving leave. Sorry We're leaving we're leaving my brother speaks Romanian. They speak Romanian and Russian my brother said we're not tourists We're not tourists in Romanian which took threw him off a little bit and we got in the taxi We said to the girls come get in the taxi the girls still came with us We got in the taxi Tristan's lips bleeding a little bit nothing too big We go back to the hotel and went to went to the hotel the girls started telling the hotel receptionist What happened and then what was scary is the hotel receptionist started to panic We're like cuz it was a woman. She's like, oh, what car were they in and I was like a BMW She was up cuz over there the average wage in Moldova's like 200 dollars a month having a BMW is a big deal, right? Like I did a BMW all the they might be mafia guys.  I'm here by myself. I'm here by myself Well, and she started really having a panic attack. I'll so we'll call the police then she goes no No, she didn't want to call the police don't know why so now me interesting or scared the whole interaction We were only it was just reaction, right? We weren't really scared and once were the taxi or like whatever but now we're scared because the receptionist is panicking It was a four in the morning on a Saturday morning and we're sitting there We looked on the thing and there was a flight back to Romania, which is generally safe at 6 a.m So we just packed and bailed. It's like, all right, let's get out of here And that twice similar stories has happened to me in Moldova. So Moldovans are super super protective of their people and their culture


I'm Alan Davis and we're located on a farm here about five miles south of Paragal, Arkansas. We're on the Crowley's Ridge, a beautiful location that we feel like, I think Green County is probably one of the best places in the world to live and raise your kids and that's one reason I've stayed here. I worked 38 years for the Cooperative Extension Service and 36 of those years were right here in Green County. We were blessed to be able to to purchase some land back years ago. My wife Karen and I in 1980 bought our first piece of land 13 acres which is on the south end of this property. Now we have about 250 acres that we own here in Green County and then our sons and family they have another 70 acres that add to that operation. My kids have four children that Karen and I raised here on this farm. Actually two of them were born when we lived at Finch on our first other farm over there but then the other two were born when we lived here and we raised all four of them on this this farm right here. I'm a registered nurse so I might not have worked like maybe one day a week and I continued to work with them. I may work a night a week or something like that and Alan would take care of them but also the times I always continue my nursing degree. But our goal when we got married was we talked we were married seven years before we started having kids but we wanted to raise them on a farm some kind of farm and that's that's why we did what we did. I am with in partners kind of with my mom and dad on the cattle operation and then and then I also do a row crop. I farm a little over 400 acres total. We're in about 350 and I own about about 60 or so and that just that that's all just right down the road. I live about two two and a half miles from here and it's all in between here and there pretty well that we row crop and then I also have a crop consulting business here in Green County that I do as well. My name is Jordan Leatherman my wife Katie and our son Colin and daughter Elliot we own and operate final drive genetics. We would have built this farm the final drive genetics the show pig portion of the farm here on the father-in-law's place home place here back in 2018. We run about 60 head of show pigs house and that's what we do full time is we sell raise and sell baby show pigs all across the country. Basically do it year round we're breeding and farrowing and then selling selling baby pigs you know from coast to coast California to Florida to Texas and large portion of what we do is here in Arkansas and then we sell a lot there Louisiana Texas Oklahoma is a big big area for us and you know raising the show pigs up and selling them to the 4-H and FFA kids and raising for projects. It's a great opportunity to be able to work with your family and and it's even a greater opportunity or blessing that Karen and I was able to put this farm together over the last 40 years to where we can share it with them and give them an opportunity to conduct their hog operation and their cattle and row crop operation. Otherwise it would be very tough to go out and buy or rent land to to do that so we were blessed to be able to do this.


Welcome, everyone, think Tech Hawaii time for responsible change, and we're here to celebrate Juneteenth just signed into law by President Biden, with also proclamations from Governor EG, and from city and county of Honolulu, and Mayor Blanjari, and we have with us today. Just a wonderful diverse group of people. We have retired judge Sandra Sims from Hawaii, who survived a number of years of law practice and state court. And we can see how incredibly intact and lovely she has emerged from all of that. That makes one of us. We have Louisiana one of our leading women's rights lawyers and civil litigators a partner at Dentons. We have David Larson from the Mitchell Hamlin School of Law in St. Paul, David is among many other things, as well as a law professor did the incoming chair of the American Bar Association section of dispute resolution. And brings to it, a wonderful expertise in both conflict resolution and technology and having engineered New York's online court dispute resolution system for a number of years and Tina Patterson mediator arbitrator. So, folks, Juneteenth cause for celebration. Now that it's nationally recognized. Where did it come from? You know, Oh Chuck, I'm going to be your outlier so the history of Juneteenth goes back to Lincoln signing the Emancipation Proclamation and soldiers entering Texas there were a number of states that post Emancipation Proclamation that were unwilling to give up their enslaved people and Texas was one of the last. So Juneteenth is a celebration regarding those individuals being informed that they had been emancipated by the president of the United States. Having said that. Juneteenth is not my thing. And I'm glad to see that the president has made it a national holiday. But I'll be transparent. I've been saying this since I was 13 years old I wrote an essay about this. The day that I look toward is June, July 2, the signing of the Civil Rights Act. To me, that is my true emancipation day. No tolls, no polls, no test at the voting. We are talking about Juneteenth and I think it's wonderful, but we have, we have a struggle on our hands right now we've got educational institutions, saying that they can't be being told they can't talk about critical race theory. There are people who literally are fighting for their voting rights. I can appreciate the holiday and for those who want to celebrate. I'm all for it. I think there's another element that I think will need to be explored more, which is, will it be much like Dr. King's holiday. It's a federal holiday, but private sector can make an optional holiday. Are we going to see the same thing with Juneteenth. So, I probably not the best person to start off discussing because I think others will be much more excited but for me. I've struggled with this Juneteenth and I, you know, for those who celebrate, I encourage them to do so. For me, it brings up the discussion of what happened after Juneteenth and the reconstruction period in the United States. So, you know, I hate to sound like negative Nancy, and for anybody named Nancy, no disrespect. But it just brings up. I'd rather see the focus on July 2nd personally, but it, you know, what's done is done and we move forward a friend text me this afternoon and said, I've got Friday off now. This was a complete surprise. It will be interesting to see what the United States does in terms of an actual celebration and talking about the truth of what happened. This is a fantastic place to start. Yes, it is. If anyone thought for a second that we are any place in terms of racial disparities and treatment that is caused for celebration. They must be in some other country, not this one. Yes. In night in 2020. There were 40 bills introduced in right wing legislatures to restrict voting act in less than half of 2021. There are 389 in 48 different states. Thankfully Hawaii is not one of them. This is not a time for celebration of racial equity. Or equity in any of the other categories. Yeah, the Supreme Court just today issued a decision 90. They tried to narrow it but basically they said to Catholic social services. It's okay for you to refuse. We are a long way from where we need to be. Your point team is absolutely well taken. I saw it more about an opportunity for educating people as to why we are in the situation that we are in. The notion of Juneteenth is if you look at what really happened. We are talking about Texas again, Texas, simply refusing to allow the 250,000 enslaved people to be informed of their freedom and kept them enslaved years after the emancipation proclamation had been signed. And kept them enslaved continue to build their wealth based on the backs of these folks of our basically my ancestors and so what I see it as in I'm glad you brought that perspective up Tina because I've always wrestled with the notion of celebrating not even celebrating July 4 and I have a whole story about celebrating July 4. But is an option to really now look at this juxtaposition of racial equity and looking at these laws against what actually happened with Juneteenth. It was just a blatant exercise of racism, pure and simple to simply tell these to not tell folks and they toy old and toy old and continue to toil. Now I never heard I didn't know about Juneteenth, Juneteenth until actually I moved here to Hawaii and was like in the 80s late 80s. When there was one. I don't know if you remember her Mary Wagner she was real active with the Democratic Party at that time she moved to Maui and she since moves to the mainland but she brought the notion of Juneteenth I she had this picnic to explain to people. What this is all about I I was embarrassed at how little I knew about it I grew up in in Chicago in the north and that's just not something that what our education system is is its own issue. But when I learned of it. Yeah, we shared it with my kids with the family so we've always known about it. But the the the thing that was shocking was that here was these people were just simply not told they were free and they toiled as slaves for an additional two and a half years. Hey, and we have a question from a viewer, which is, can children who haven't been educated about critical critical race theory, still appreciate these values and these disparities. What needs to happen in education. Critical race theory, are we teaching kids critical to race theory or we just don't be teaching a mystery. And if we just simply teach some history we don't have to get into the notion of critical race theory you recognize Juneteenth standing on his own is like, hey, we didn't tell the people, what does that mean, what will be trying to do. I mean critical race theory I don't know is that something you take an elementary school that's a, you know that's a, that's a. That's a subject for, I don't even, I don't even want to get into a debate about critical race theory because that's, let's just teach the history let's just tell the truth. Okay, and the truth that you just said, is that even two and a half years after the emancipation population. It took military intervention. Yes, to theoretically liberate 250,000 enslaved black people, and who knows how long it really took after that. Exactly. For any of those people to obtain anything approaching freedom. I'm just, I just wanted to answer the viewers question since I'm the one that brought up critical race theory, their critical race theory debate is actually taking place in higher education institutions it's happening in colleges and universities it's not happening in elementary schools, junior high schools, and high schools. At that level, as the viewer asked children need to know what actually happened we have school systems that don't want to talk about slavery, and it's removed from the books or talked There were people and I used to live in Texas so I remember this debate regarding, should we talk about enslaved persons and at one point the conversation was, no, let the, let the history books show in the schools that these were people who enjoyed working hard and and and earning a living well fact the matter was they weren't working and earning a living, it was they were enslaved they were chattel. The same we've had conversations about talking about the internment of people in the United States. Yeah, and talking about the trail of tears and always, you know, First Nation people gladly moved to the West know that's not actually what happened so we have to really talk about what happened even going as far back as when the first individuals came to Jamestown, when they showed up at Plymouth Rock, and what happened to the people who were there. And after the first year. No, it's not pretty but I think it's it's a reality of what what we see later with Andrew Jackson and manifest destiny that this has been a thought process that goes back to 1619. I'll be quiet I know that Louise and David had had an opportunity to speak but I hope I answered the viewers question, because I brought up critical race theory. No but that's important too because, as someone said about the subject of taking children away from their families dividing families at the southern border. Don't be surprised. This is not new. This is part of our history. We've done it to blacks we have done it to indigenous people for hundreds of years. So the question is, where do we go from here what what do we need to understand and what do we need to do about it. I was just thinking that I mean it's great that Hawaii and the US have recognized this as an official holiday. Our firm had already done that, but I see this really as an opportunity. It's not really just a holiday. I would be an opportunity to learn and educate and to connect all those dots that you've been talking about. And just I wanted to let people speak but then of course, your it is get articulated cycle. Well, they'll call it later on. But I think there's some value making a national holiday because now people can ask about it and she'll they're going to ask about it. It's like, what is this thing. And I was talking with a black friend of mine in New York today, who emigrated. Didn't come from after her family. But, you know, she's saying I didn't get any of this stuff in school. And it's all, you know, it was all new to me. And the idea that the fact that it's now a national holidays, there will be questions asked about it. And the hope is that more information will be learned. Now, I'm thinking about this year I'm thinking about, you know, the information I'm reporting about the Tulsa NASA here which was never talked about in school. And finally it's getting talked about this year. And I feel that that there is at least a kind of a recognition that we need to look back and think a little harder about where we came from and what happened previously. I was thinking, for example, I've been thinking today a lot about the idea of white privilege. And I don't love that term, because I think that term anger some people they resent it they don't respond to it. I don't even think it's accurate I mean I think there is white privilege. But really I think a better term is is is white indebtedness. I mean there's really, there's really a debt. When we talk about slavery and the history of slavery and the fact that wealth was built upon a population that didn't participate in that wealth building. And there's a, you know, so it's privilege I don't think is the right word I think indebtedness is a better word. And, and I don't know if I'm right or wrong. I just thought about this today. But, you know, but the fact that it's, we've got this holiday has me thinking about it it's got to have other people thinking about it. And I think that's positive. Yeah. Yeah, I think today but I think it is raised a really important point which is children may come young people may come to see things without some of the lenses without some of the biases. If the learning is opened up. And if it's okay to talk about it it's okay. What Sandra mentioned before what Tina mentioned before, there is a concerted effort to prevent that kind of learning from opening. Hey, and all of you folks are or have been involved in education personally for your children through your families. What needs to happen in our learning system, different from what has been happening. I think we need to simply tell the truth. Tell the truth. You know, slavery wasn't in order to perpetuate slavery, we had to tell, we had to diminish the humanity of, of Blacks were born from Africa we had to decide, and in turn, and document that they were not people so we could justify it. I think also. Oh, sorry Sandra. No go ahead. Oh, my thinking on how do we teach history differently is I would just remember the way I was taught it, which was really from the dominant colonizing populations perspective. And so I identify to with our founding fathers of that history but I think what's important is that even more and more we need to learn it from the perspective of all the different groups that have enriched our history and our culture. That's starting I think that in some many ways this you know we haven't everybody calls it an inflection point we have a point, maybe because of the pandemic, where people are much more aware of these issues. This is a point at which we can hopefully treat ethnic studies is just not ethnic studies but really it's part of the fabric of our history. I agree with that that's absolutely it it shouldn't just be marginalized as to some, you know, ancillary of the history, it's a part of how we became, we look at when you look at things like the arts, and, and the creativity of people who came out of those systems and what they had to do to spiritually strengthen themselves to endure it's not just, you know, an Africa for African Americans for Native Hawaiians I mean you took the whole, you had to build that whole thing of your sense of who you are, based on your language culture that you struggled to preserve in some place the instance struggle to define and find it, and then be able to build that to build that up and that's, and we made that part of American culture but we got to understand the pain that that culture came out of to be as important as it is. I think you need to be, you know, as an educator I think we need to be proactive. So at my law school, Mitchell Hamlin School of Law, we are, we've changed our mission statement and we're going to identify ourselves as an unbiased anti racist school. So, so, but what does that mean? It's got to mean something it's got to, it's got to, it's got to result in some kind of action. And we're spending a lot of time talking about okay, what does that mean and what does it mean to be anti racist. Does it mean just not to be overtly racist that can't be it. It's got to be something more active than that. So then the question becomes okay, what kinds of actions, should we be engaging and what kinds of actions are necessary. I think that's, that's really productive and that's part of my responsibility as an educator to think about where are we today and what can I do as an educator to make things better and that may require some, some action, some act, some activist. And all of you have touched deeply upon a critical convergence of what Sandra, David, the two of you put so well. It's a cultural indebtedness. There is a cultural debt that is owed to people who have been undervalued, dishonored, disserved. There are cultural reparations as well as others that need to be sincerely understood and undertaken. And that's kind of why I was thinking about that term indebtedness today. So when people talk about privilege. It just doesn't connect with reparations it's just like, I don't see the connection that is connected to reparations. That's a better term. And if you understand how the founding fathers became so wealthy at relatively young ages of life, it's because they had slaves. So wealth was built upon people's shoulders who didn't participate in the accumulation of that wealth. And I think that if we frame it that way, I think it's much more understandable. We see that in Hawaii, in native Hawaiian history is the whole concept of overthrowing the kingdom had to be crushed and made to look like something else that was necessary.  And then you look at like now, I think you're, you're absolutely right. You know, Davis, we've got to, you know, look internally and see what it is that we need to look at and decide what needs to be told and how it needs to be shared and that story needs to be told. I mean, when I teach my classes in criminal justice about the master case here in Hawaii, students who are young, they're 1819 20 year old students, they are simply appalled they had no they have no that's not taught to them. The notion that you know someone who's native Hawaiian would just be hauled away and and killed and there be no consequence. And it's, you know, those kinds of things have shaped how is as Louise has pointed out how we have that colonial perspective even here. They're still lingers it's why you have so many more native native native Hawaiians and and people of color incarcerated in our the incarceration rates are so high for those groups. Um, that's, that's a piece of it. I was talking about thing, you know, that's one thing to say your any racist and what are you going to do about it. One thing our school is doing about it, we have a truth and action project. And, you know, the premises that you can't really have any reform without understanding the truth can have any reconciliation reform unless you understand the truth first. So the first phase of the project is to go out in the community and basically collect stories of people who believe they've in particular focusing on the criminal justice system, who have victims of systemic bias and criminal justice system and begin to collect those stories. And there's a large advisory group that's very cross occupational prosecutors defenders, judges, you know, trying to get as wide of breadth as possible people participate in this project. But the goal is to try and accumulate these stories and identify common themes and begin to quantify things in terms of is a particular kind of thing happening in a particular step in the process and be bargaining.  Can we actually identify problem points in this process, empirically, so it's not just anecdotal, and then maybe we can begin to begin to create some reform. David, is that having other law schools to I know that various professors have looked at aspects of truth and reconciliation and reparations but you know how widespread is it. Yeah, I think, I think we're at a, you know, at the emerging stage where people are beginning to do that kind of thing. Yeah, I think there's probably been isolated cases where people have actually tried to do that. But I think it's been pretty isolated in terms of a particular study in a particular jurisdiction wrote an article about it and maybe that's where it ended. And the hope is that, you know, hope with our project is that, okay, we'll start in kind of the same Paul Minneapolis. Let's build it out then the surrounding metro area, then let's take it out to the whole entire state and keep expand keep just keep expanding it. I was just curious, I mean it kind of ties in with something I think it was Tina who forwarded about some well Providence Rhode Island maybe there's other cities to are starting their own truth and reconciliation, reparation. You know, is that a one offer are you seeing that in other municipalities to I am seeing it in other municipalities, a friend of mine, a childhood friend actually her mother is a descendant of a First Nation community in Rhode Island and a tooth and reconciliation. I don't know what I call it it's beyond a committee but they formed so that they could talk about the truth of, of what it was like for in this case we're we're talking about the first settlers English settlers white settlers coming to Rhode Island and what the, what the interface was with the peoples on those lands that initially there's been a lot of misinformation, a lot of things that have been left out, and we're starting to see this elsewhere.  I'm participating in a project where about facilitating racially just spaces, and each session we have to start by talking about whose land are we on, and I know I'm on the land of the Piscataway and a Manahoa. Okay, but it's enlightening because you can literally see, as you mentioned before, Louise, this mosaic. I think about the area Louisiana where I was born, and I always knew that my great grandmother was one of her descendants is First Nation, but I never knew and when I typed in the area where I was born. It suddenly popped up and I thought, well, that makes sense. It's chalk top. I never knew it, but it makes when I go back and look at the records and I see the naming conventions and see some of the pictures. It definitely ties in so yes, I think we're starting to see more of this where where it's the opportunity to talk about where is like you said, where is that inflection point, but you know, you have parallel activity happening so it also makes me think about the stories that we hear in the south where you have outlier communities of Chinese in the south and people ask, well, how did that happen I thought the Chinese were only on the West Coast. No man. And again, it's that parallel that mosaic the same thing in Minnesota when we talk about First Nation people, the people who came from Scandinavia nations but also those who were traveling from the east, heading west and that influx in terms of ideology, culture, food, way of life, you know it's a mosaic. And while we're out of time for today. Maybe that's a good place for us to stop with that thought that maybe clearly with Juneteenth, we've moved toward some concept of restorative truth that is part of a cultural debt to those who have been deprived of it. And a cultural obligation of those who have misused it or abused it for advantage. Maybe truth that seeks balance is where we might need to go. Thank you all. Come back and join us in two weeks. Thanks for coming to think tech Hawaii and thanks David Sandra Dana Louise. Who's land are you on I like that. It's a good place to start a discussion who's land and I think that applies to all of us. In all of the places that we are certainly Hawaii and Minnesota and the East Coast and everywhere. Yeah. I like it. Thank you.


The straw hats are back and and more of them fake fake ones. It's really something else The ladies and gentlemen welcome back to the channel, and we have had a two-year time skip. The straw hats are reuniting on Saba Odi very slowly We've gotten a little bit of a look of them all except for Frankie who looks to be the most different at this point I mean there's like entire mechanical parts on him. I have no idea choppers under the assumption that he's actually with Zoro and Sanji which is definitely not rook is a famous musician There's a lot going on if you knew the channel. Don't forget to drop us up and let's hop into it That's my mom. Well, is that purple jacket? Oh, she's gonna see Frankie Frankie's on Sony She says vibrant his ever It's all coated and ready for him, too There is oh Is that him playing?    It's time freeze Romantic masculinity Oh my god, is that all mechanical or his arms in there? Oh my gosh, he's Why wait, how am I supposed to tell me he's got juice? Dude, he's enormous. He's a whole unit. Oh my gosh wait. He actually Button chops now or his arms are in there.  I still drink and cola at least Oh He's actually enormous now. Oh my gosh. He used to be like a regular sized guy I see all the stitches. Did he just add on to his body? Oh my gosh. I'm like awestruck Oh, I missed him so much man Dude, it's cool these additions of Frankie, but I kind of miss his hair True actually alone for 50 years to the spotlight the guy kept the glasses at least two and his Hawaiian first This better not be some early foreshadowing that Brooke stays here as a musician He's only just begun his journey with us.  I mean Frankie did but So who is that who's voice is Zorro So Lou via Zorro, yeah, definitely was a trick for sure I like how they call them by the like their fake names, too. I think completely adopted these identities Oh The music going back that's Zorro for Sanji Cocoa is Robin's real name. I guess he's not me is Robin Robin is not me Come on chopper the real movie would never abandon a friend Even if it's a joke Oh my gosh move your late a hand on chopper Yeah, what a hundred people do they recruit are they all just foot soldiers? Oh I have an idea that those these hundred people are gonna be how the straw has like show off their new abilities It's fighting through all of them guarantee it Yes, so Frankie is Brooke Oh no, Nami is chopper That's Frankie. Oh my gosh That's such a good bit This isn't them He's so confused Toys today It's like you guys change don't chop. I need somebody to find my boy and reassure him. This breaks my heart The straw hats Oh What are the odds that these fake straw hats assemble here the same day or the same time that the real straw hats are supposed to come back Oh Here's a navy part of it of sub-Odi who's here is the question. Are there any big hitters here? Look like it.  Oh Shoot oh Oh Freakin, what's his name? So tomorrow it is kumas. Oh my god He's five seven. Oh my god. So tomorrow just stayed here No, so tomorrow doesn't look like he's changed too much Oh, they still been figured out what he did that feels like a lifetime ago, dude But they still haven't really figured out what kumo was up to that he was helping them I guess I don't know so where is the original original kuma now?  Oh my gosh Put it on the straw hat Her hair looks so good.  Oh no and they're split up again Oh no, is it a woman? Oh Well Did this harassment Riz Sanji stop I mean, where did he go?  So that eye is like done done. He's not opening it at all For chopper His buddy's like freaking out his upper. He has this nice chill time on the island Oh his outfit whatever he's in this form too. He keeps his little shirt on They've all changed.    There you go.  I mean nobody was really recognizing him to begin with Happy old man No way. He thinks that's them. Please tell me he doesn't think that's them It's his brain. There's no way. There's no way Of course leave it's a luffy and chopper man. Anybody else would just realize it instantly. Good god Stray moss Number seven I was like, yeah, wouldn't zoro be number two. I'm very proud of him for getting there first number seven Oh Brothers in zoro actually land on fire I'd believe it for sanji. It makes sense zoro not so much Meeting spot for the straw hats. Oh no. Oh wait. This. Oh, this is all the hundred. I see. Okay My boy, you're in danger. You better go 92 million. Oh my gosh gashed albion lip service dowdy. Oh, yeah, then those two that they already mentioned The two caribous And blood spatter 190 that's that's nothing to scoff at man. Yeah, his eyes are creepy All right, so like I said, I think it's setting up all of this Both the navy officers and these captains and whatnot for a sort of battle for all the straw hats to show off the new powers It would only be apropos We've gotten a little bit of a tease with some of them, especially zoro But dude, can we talk about frankie man? Like out of all the straw hats in terms of their their character design changes His is by far the most drastic brother grew in like three times his size episode 520 Let's go I think my prediction about brook is right too in terms of why why the manager called himself is because he Brook knows this is the day that he's supposed to be like back with them The board is world famous got all the women fainting. Oh my gosh But he needs a refill with some milk, I'm guessing Yes, sir.   He wants the battle Koraboo Those are both koraboo. Oh that one is like bids to this one's will I was like, does he look with the lizard on his on his shoulder the navy soldier killer? Darn his laugh God damn, I thought this guy was gonna be something of a joke What is with this one though? Oh no way I'm like koraboo will see through this No, I guess they're all here to like join the crew.  I don't know Even they haven't put two and two together that he is luffy. It's just my god intellectual titans here But he has to be insanely rich from this tour Brooks return is kind of just oh wait the navy is here for him Oh shoot, I mean they know he's a member of the straw hats. He's ripped out man the pants The sort of scarf Oh, he's gonna say like this is his final performance Oh the navy Guys during the show really Acting captain of the rhombarb pirates feels good. Oh, yeah, I guess they don't have hard evidence that he's him It's just like hey, you kind of look like him. I guess he didn't change his name.  Come on. He makes good music Oh my gosh his manager told on him Yes, I was on the money. Let's go You've already made plenty brother. He's like, oh well, you're leaving.  We're gonna need some backup man. I really like this eye catcher now, man It's like I said it's like a lot of them coming back together. It even has Frankie back there. I just saw Yeah, I was gonna say they're all gonna freak out about Frankie Like dude, it's so much. He's like a kuma. I know He is really glorious He's like an action hero. Yeah god his arms So, yeah, is it is he oh my god, I knew chopper would fanboy at the very least Yeah, true. That's a good point Okay, so his hands aren't actually in there like he's straight up replace his arms and his shoulders The girls are back, baby.  It's so sweet. It's like a dad Is he gonna fill them in on what's happening? Oh, I guess yeah, they gotta go save brook too And luffy is kind of in the thick of things and then saji and zoro are question mark Play me off one more time My music is power You think a bullet's gonna take him down after all this Is this how he freed those people he just took these guys along as his managers He's admitting to it right now Luffy See this is cool, but is this a good idea right now we got to get off the island first No, this is sick. This is worth it. True. It wouldn't be right if it was a quiet departure See Yeah, dude, who cares if he's a pirate.   Maybe as quickly as he arrived Oh my god, he's out of the room. Let's go Okay, so brook made it out. Okay, at least they're all being filled in Ah, that's who called I see Thanks, Rayleigh. Yeah, how do you like send it down into the ocean god, dude They're all jigga chats now every single one of them.  Oh my gosh like I didn't realize how How good it felt to have all of the straw hats together until they're apart for over a hundred episodes Was it over a hundred? I mean they were split up at the end of Saba Odie and were gone for all of impel down And all of marine forward and all of everything after marine forward like we checked in on themselves I think it was over a hundred episodes. So to have them back now It's like an overwhelming happiness and Luffy is even there with them So Zoro Sanji aren't even there with them yet Brook isn't there with them yet But to see all their interactions again It's just it's perfect and they interact like a day has gone by because they all have that bond already Nothing has changed and again. I can't get over Frankie's change I'm so glad that his hair can come back out because that was my only problem Like I think it's sick how much they've added to his character and whatnot But the hair is just iconic and while the clean cut does kind of fit his new look like his new More mechanic look less rugged look the hair. I get it's iconic man Especially since it's tied to how much energy he has but now Luffy is about to beat fake Luffy I think things are really gonna pop off as we try to leave Saba Odie And I really did enjoy Brook's little song about Luffy and uh the new world Like I said, it has to be optimistic when they were all separated all that time ago It was just the most dire situation of all time They have to step foot into the new world with this newfound confidence because they are all way stronger now I'm guessing most of them. We've already gotten a little bit of a tease, but I'm sure we'll see more But guys that's been it from this 5 19 and 5 20 of our one bees watch dude Do drop a sub to the channel if you're new and I catch you in the next one. Peace base


The study investigates how the surface roughness, Ra, in overhang regions of laser powder bed fusion, LPBF, printed parts is affected by the overhang angle, theta, which results from a combination of border-track contour, powder adhesion, warp deformation, and dross formation. When 0° less than or equal to theta less than or equal to 15°, Ra is not significantly affected since only a small area of the melt-pull boundaries contacts the powder bed resulting in slight powder adhesion. When 15° theta less than or equal to 50°, powder adhesion is enhanced by the melt-pull sinking and increased contact area between the melt-pull boundary and powder bed, leading to a sharp increase in Ra. When theta greater than 50°, large waviness of the overhang contour, adhesion of powder clusters, severe warp deformation, and dross formation further increase sharply. This article was authored by Xiaotuan Feng, Amar M. Comet, Sohil Sabuni and others. We are article.tv, links in the description below.


Hey, how you doing? That's good. How your mom and them doing too? That's good to hear too. Your sister alright? I was just checking on everybody just to see if everybody was good enough to make it to the show May 12th at the Good Year Theater in Akron, Ohio. You already said everybody was okay to do it, so why don't you grab those tickets and meet me there. I'm not gonna wear this. I got a whole outfit already laid out on the bed. I know, but I'm leaving it there until it's time to go to Akron. That was May 12th at the Good Year Theater at the end of the day tour. It's gonna be me, and you know I'm good.   Because you guarantee to laugh. I'm talking about laugh so hard if you don't be by the end of the show, you'll have to. I put that on me. Cut it off. That's enough. If they don't believe me by now, I don't want them there anyway. I don't want people coming there to see if I'm funny. I want people that who already know it.


Hello and welcome to the coaches corner. I'm Joe Wamba. I'm joined now with cross-country head coach Dave Burdan and coach Over the weekend. He had the Shannon Henredi Invitational a big event that we have on campus and memory of a real close friend On the cross-country women's team Can you talk a little bit about how that event went for us? We had some good finishes and some really tough Tough conditions. Yes, definitely The man actually won the race and the women's team got second The conditions were definitely very difficult So I had to have a little meeting before the race and tell them that I really wanted them to go out conservative that first Two or three miles and then work their way up and they all did a really good job of following the race plan And it paid off and Kelly finishes first and Langston on the men's side Talk a little bit about their performances throughout that meet. Yeah, so I was really pleased It was the first time this year that we raced the full distance with the 8k for men and 6k for woman and it was kind of just to see to see where they were and Due to the conditions we really can't look at the times because of how hot it was and how humid it was but They followed the game plan and were patient and both were not leading halfway through the race and ended up winning Right and then this weekend You head out to Rowan and a larger set meet. There's gonna be a lot more competition there And totally different weather conditions Can you talk a little bit about what you may expect into this meet coming up this weekend? Yeah, so I'd say this weekend's our first time that we're really gonna test ourselves and see See how good everybody really is and and how far everyone's come along It's not gonna be as hot and I'm not gonna hold them back as much as I have in the past two meets early on in the race So it's the first opportunity that they're gonna really be able to to race the full distance great and Just revisiting back to this The Shannon-Henredi imitation. Oh, can you talk a lot about? What that may mean to the the members on the team to be running into an event? about such a close friend on on our campus in the nursing department and in the cross-country team just talk about How that affected the the runners. Yeah, so a lot of the runners is especially the upperclassmen They just I mean never remember Shannon some of the runners that were able to come back alumni and speak at the race Got to tell give everybody kind of a little bit more insight as to who Shannon was But she was an athlete on our team graduating 2014 and then she was actually a volunteer assistant coach for us in the fall of 2014 so she was here all the time just a Great positive presence at all times and just really I mean it's so they knew what they were right and and they They they met maybe expectations, you know You want to perform the way we performed in in a meet of that magnitude? Definitely, they definitely had that in the back of the mind wonderful and thank you coach again for your time He's Dave Burdan. I'm Joe Wamba and this has been the coaches corner