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- StarWind.iSCSI.Target.v4.0-NULL Free Download ^NEW^Em Discussões Gerais·10 de março de 2023Black Man And Woman Sex Black Man And Woman Sex ->>->>->> https://urlca.com/2sZ4Sp Large racial and gender wage gaps in the U.S. remain, even as they have narrowed in some cases over the years. Among full- and part-time workers in the U.S., blacks in 2015 earned just 75% as much as whites in median hourly earnings and women earned 83% as much as men. White and Asian women have narrowed the wage gap with white men to a much greater degree than black and Hispanic women. For example, white women narrowed the wage gap in median hourly earnings by 22 cents from 1980 (when they earned, on average, 60 cents for every dollar earned by a white man) to 2015 (when they earned 82 cents). By comparison, black women only narrowed that gap by 9 cents, from earning 56 cents for every dollar earned by a white man in 1980 to 65 cents today. Asian women followed roughly the trajectory of white women (but earned a slightly higher 87 cents per dollar earned by a white man in 2015), whereas Hispanic women fared even worse than black women, narrowing the gap by just 5 cents (earning 58 cents on the dollar in 2015). For example, NBER researchers Francine Blau and Lawerence Kahn found that education and workforce experience accounted for 8% of the total gender wage gap in 2010, while industry and occupation explained 51% of the difference. When it comes to race, sociologists Eric Grodsky and Devah Pager found that education and workforce experience accounted for 52% of the wage gap between black and white men working in the public sector in 1990, and that adding occupational differences explained approximately 20% of the wage gap. And NBER researcher Roland Fryer found that for one group of adults in their 40s, controlling for standardized-test scores reduced the wage gap between black men and white men in 2006 by roughly 70%. When it comes to racial discrimination in the workplace, most Americans (60%) say blacks and whites are treated about equally, but opinions on this vary considerably across racial and ethnic groups. A new Pew Research Center report finds that roughly two-thirds (64%) of blacks say black people in the U.S. are generally treated less fairly than whites in the workplace; just 22% of whites and 38% of Hispanics agree. I know that God is going intervene on his behalf because this is unjust and this man should be set free and DNA testing should have been used to prove his innocence. This has been going on two long , innocence black men convicted of crime that they did not commit, and society going along with killing of black men for no reason. In addition to gender and age, the infidelity rate also differs by a number of other demographic and social factors. For example, cheating is somewhat more common among black adults. Some 22% of ever-married blacks said that they cheated on their spouse, compared with 16% of whites and 13% of Hispanics. And among black men, the rate is highest: 28% reported that they had sex with someone other than their spouse, compared with 20% of white men and 16% of Hispanic men. Sonia Maribel Sontay Herrera is an indigenous woman and human rights defender from Guatemala where systematic discrimination against indigenous women has gone on for decades. Herrera has felt the consequences of these historical injustices since she was a girl. Date Occurred: 02/ 16/198047 0 Flat Shoals Ave SE - Big Buy SupermarketAge:30 Sex: MaleRace: B Report Narrative: On Feb 16, 1980, Officer Alfred Johnson was working an off duty job at the big buy supermarket when two black males came into the store to rob it. One of the males had a shotgun, and the other had a .38 caliber pistol. Officer Johnson confronted the suspects and was shot by both males. He died later that day at Grady Hospital. The robbers fled the scene with cash and food stamps. Date Occurred: 01/29/19782424 Piedmont Rd NEAge:53 Sex:MaleRace:White Report Narrative: On 01/29/78, Louis Zaglin was at a flea market at 2424 Piedmont Rd. when he saw a black male inside of his parked van. When he approached the van, the male shot him and fled the scene. In 1890, the NWSA and AWSA merged into the National American Woman Suffrage Association (NAWSA). It became the largest woman suffrage organization in the country and led much of the struggle for the vote through 1920, when the 19th Amendment was ratified. Stanton became its president; Anthony became its vice president; and Stone became chairman of the executive committee. In 1919, one year before women gained the right to vote with the adoption of the 19th amendment, the NAWSA reorganized into the League of Women Voters. Wealthy white women were not the only supporters of women's suffrage. Frederick Douglass, formerly enslaved and leader of the abolition movement, was also an advocate. He attended the Seneca Falls Convention in 1848. In an editorial published that year in The North Star, the anti-slavery newspaper he published, he wrote, "...in respect to political rights,...there can be no reason in the world for denying to woman the elective franchise,..." By 1877, when he was U.S. marshal for the District of Columbia, Douglass's family was also involved in the movement. His son, Frederick Douglass, Jr.; daughter, Mrs. Nathan Sprague; and son-in-law, Nathan Sprague, all signed a petition to Congress for woman suffrage "...to prohibit the several States from Disfranchising United States Citizens on account of Sex." Many of the women who had been active in the suffrage movement in the 1860s and 1870s continued their involvement over 50 years later. In 1917, Mary O. Stevens, secretary and press correspondent of the Association of Army Nurses of the Civil War, asked the chairman of the House Judiciary Committee to help the cause of woman suffrage by explaining: "My father trained me in my childhood days to expect this right. I have given my help to the agitation, and work[ed] for its coming a good many years." When New York adopted woman suffrage in 1917 and President Woodrow Wilson changed his position to support an amendment in 1918, the political balance began to shift in favor of the vote for women. There was still strong opposition to enfranchising women, however, as illustrated by petitions from anti-suffrage groups. As a result of falling age-specific mortality, life expectancy rose dramatically in the United States over the past century. Final data for 2003 (the most recent available) show that life expectancy at birth for the total population has reached an all-time American high level, 77.5 years, up from 49.2 years at the turn of the 20th century. Record-high life expectancies were found for white females (80.5 years) and black females (76.1 years), as well as for white males (75.3 years) and black males (69.0 years). Life expectancy gaps between males and females and between whites and blacks persisted. It has long been argued that hormones play a role in longevity. As described by Desjardins,40 the female hormone estrogen helps to eliminate "bad" cholesterol (LDL) and thus may offer some protection against heart disease.41 In contrast, some say, testosterone, found in greater amounts in males, may make men more likely to engage in violence and risk-taking behavior, especially if reinforced by cultural influences.42 Women may also gain an additional biological advantage because of their two X chromosomes. If a gene mutation occurs on one X, a woman's second X chromosome may be able to compensate. In comparison, genes on men's sole X chromosome may be expressed, even if they are deleterious without compensation. Life expectancy at birth for whites significantly exceeded that for blacks at the turn of the 20th century (see Figure 2 and Appendix B Table B-1). At that time, the expected longevity of a white newborn girl exceeded that of a black newborn girl by about 16.0 years (with longevity measured at 51.1 years vs. 35.0 years, respectively). For newborn boys, the white advantage was 15.7 years (48.2 years vs. 32.5 years). What accounts for the higher mortality, and subsequent lower life expectancy for blacks, and especially for black men in the United States? This has been a subject of research by medical and social scientists for at least a century, and the issue stands at the heart of the current public health agenda in the United States.55 One of the two primary goals of Healthy People 2010 is to eliminate health disparities. Mortality from most, but not all, causes of death are higher for blacks, and a number of researchers have investigated which specific diseases contribute most to life expectancy differences between the races. Wong and colleagues,56 for instance, recently calculated potential years of life lost related to specific causes of deaths for blacks and whites in the United States (Table 5). Notes: Calculations adjust for differences between races in age, sex, and level of education; numbers in parentheses show causes-of-death for which blacks fare better than whites; and these estimates are for persons dying before the age of 75 years though the authors state that all results were similar when potential life-years lost before the age of 85 years were examined. Note that trends and racial differentials at the oldest ages (85 and older) differ as black mortality rates are lower than those of whites for both men and women in official mortality data from NCHS. See Appendix B Table B-2. 2b1af7f3a8006
- According To The Declaration Of Independence What Is The Primary Purpose Of GovernmentEm Discussões Gerais·23 de março de 2023According To The Declaration Of Independence What Is The Primary Purpose Of Government CLICK HERE ->>> https://urlin.us/2t7zxJ In fact, the very distance of the colonies from the Mother Country hadalready altered those rights, as well as the perceptions of the colonistsregarding rights of the individual in general. The frontier society ofthe American colonies had fostered a greater sense of individual autonomy,a sense that government should not interfere in the daily lives of itscitizens, and that the purpose of government is to secure and protect theliberty and property of its citizens. The seeds of these ideas clearlycould be found in English thought, but British government and law in theeighteenth century were slowly changing to give the King, and especiallyParliament, greater authority. Law, according to Sir William Blackstone,was the command of the sovereign. After its petitions failed to secure redress, the Second ContinentalCongress voted to declare independence from England, and named John Adams,Benjamin Franklin and Thomas Jefferson to draft a declaration. All threemen were familiar with English tradition, and each had thought at lengthabout the problems of government. But of the three, Jefferson was acknowledgedto possess the most facile pen, and his words caught the hopes and idealsof the American experiment. The long list of grievances Jefferson marshalled to support his chargethat the king had violated his obligations to the people is hardly convincingto a modern reader, and like all good propagandists, Jefferson distortedhistory to serve his purposes. But if one reads the grievances carefully,they contain notions that are basic to American democracy: government isa compact among the people, and can be overthrown when it fails to fulfillits obligations; government exists to protect the rights and property ofits citizens; every person accused of a crime is entitled to trial by ajury of peers; the state cannot search the homes of its citizens withouta warrant; and taxes cannot be levied without the consent of the people. From a constitutional point of view, the Declaration served severalpurposes. It enshrined the compact theory as the heart of the Americanphilosophy of government, not only for the revolutionary generation butfor succeeding ones as well. Long after the particular grievances againstGeorge III have been forgotten, the belief that government exists to preservethe rights of the people, and can be dissolved if it fails to do so, remainsa prime article of faith for Americans. But even though the Declaration built upon generations of American andBritish experience, it went far beyond those ideas, and, in fact, as manymodern writers have noted, it is a radical statement in its view of thepurposes of government. As nation-states began emerging in Europe in thelate middle ages, the common assumption had been that governments existedto ensure order and protect the stability of society. But the Declarationof Independence, while not denying the need for order, asserts that theprime purpose of government is to protect the rights of the individual.For the first time, it is the individual and not the society that is paramount,and the success of government is to be measured not by how well societyis regulated, but by how free the individual is from government. The development of American democracy has been, in many ways, an elucidationof the premises outlined in the Declaration of Independence: that certaintruths are self-evident, that people are created equal, that they are endowedwith inalienable rights, that governments derive their power from the consentof the governed and that the purpose of government is to protect theserights. Such sentiments have not lost their power to inspire men and womento this day. They are the mark of the successes of American democracy,as well as of its failures. This clause of the Declaration is the link between the Declaration and the preamble to the United States Constitution. Justice, domestic tranquility, common defense, the general welfare, and securing the blessings of liberty are all elements of our safety and happiness as an independent, self-governing people. The Constitution lays out exactly the form or structure of the government designed to achieve those purposes, replacing the Articles of Confederation, which had not achieved them, which in turn had replaced the regime of the British empire, which had violated them. Soon after Jefferson arrived in Philadelphia, Congress assigned him to draft a document explaining why the colonists had taken up arms against England. Even at this late date, the Congress still blamed only Parliament and the king's government ministers, not King George himself, for the growing conflict. Jefferson's Declaration of the Causes and Necessity for Taking Up Arms stopped short of declaring independence, but pointed out the folly of governing the American colonies from England. Neither Parliament nor King George, however, were interested in negotiations to prevent all-out war. In August 1775, King George issued a proclamation charging that the Americans "had proceeded to open and avowed rebellion." A few months later, Parliament passed a significant act that placed the American colonies outside the king's protection. This act allowed the seizing of American ships, justified the burning of colonial towns, and led to sending war ships and troops, including foreign mercenaries, to put down the rebellion. Meanwhile, the royal governor of Virginia offered freedom to slaves who joined the British cause. These actions by the British king and government inflamed Americans who were undecided about independence and made war with England all but certain. In May 1776, the Continental Congress took a fateful step and passed a resolution that attacked King George himself. This was not the first time in English history that such a thing had occurred. In 1688, Parliament had similarly denounced King James II. This led to the so-called Glorious Revolution, which drove James off the throne. Now, almost 100 years later, a formal declaration of independence by the Continental Congress was the only thing standing in the way of a complete break with King George. Even before the Continental Congress declared independence, most colonies along with some towns, counties, and even private organizations had issued their own declarations. In most cases, these statements detailed British abuses of power and demanded the right of self-government. On June 8, 1776, the Continental Congress voted to write a declaration of independence and quickly appointed a committee to draft a formal document. But the job of actually writing the draft fell to Thomas Jefferson, mainly because John Adams and other committee members were busy trying to manage the rapidly escalating war with England. Working off and on while attending to other duties, Jefferson completed his draft of the declaration in a few days. He argued in his opening two paragraphs that a people had the right to overthrow their government when it abused their fundamental natural rights over a long period of time. Then in a direct attack on King George, Jefferson listed 20 instances when the king violated the rights of the American colonists. Having thoroughly laid out his proof that the king was a "tyrant" who was "unfit to be the ruler of a people," Jefferson continued on to condemn the British people. "These unfeeling brethren," he wrote, had reelected members of Parliament who had conspired with the king to destroy the rights of the colonists. Jefferson ended his draft by stating, "we do assert and declare these colonies to be free and independent states. . . ." As a man of the Enlightenment, Jefferson was well acquainted with British history and political philosophy. He also had read the statements of independence drafted by Virginia and other colonies as well as the writings of fellow revolutionaries like Tom Paine and George Mason. In composing the declaration, Jefferson followed the format of the English Declaration of Rights, written after the Glorious Revolution of 1689. The purpose of government, Locke wrote, is to secure and protect the God-given inalienable natural rights of the people. For their part, the people must obey the laws of their rulers. Thus, a sort of contract exists between the rulers and the ruled. But, Locke concluded, if a government persecutes its people with "a long train of abuses" over an extended period, the people have the right to resist that government, alter or abolish it, and create a new political system. 1 Pub. L. 104-191.2 65 FR 82462.3 67 FR 53182.4 45 C.F.R. §§ 160.102, 160.103.5 Even if an entity, such as a community health center, does not meet the definition of a health plan, it may, nonetheless, meet the definition of a health care provider, and, if it transmits health information in electronic form in connection with the transactions for which the Secretary of HHS has adopted standards under HIPAA, may still be a covered entity.6 45 C.F.R. §§ 160.102, 160.103; see Social Security Act § 1172(a)(3), 42 U.S.C. § 1320d-1(a)(3).The transaction standards are established by the HIPAA Transactions Rule at 45 C.F.R. Part 162.7 45 C.F.R. § 160.103.8 45 C.F.R. § 164.500(b).9 45 C.F.R. § 160.103.10 45 C.F.R. §§ 164.502(e), 164.504(e).11 45 C.F.R. § 164.53212 45 C.F.R. § 160.103.13 45 C.F.R. § 160.10314 45 C.F.R. §§ 164.502(d)(2), 164.514(a) and (b).15 The following identifiers of the individual or of relatives, employers, or household members of the individual must be removed to achieve the "safe harbor" method of de-identification: (A) Names; (B) All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of Census (1) the geographic units formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) the initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000; (C) All elements of dates (except year) for dates directly related to the individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; (D) Telephone numbers; (E) Fax numbers; (F) Electronic mail addresses: (G) Social security numbers; (H) Medical record numbers; (I) Health plan beneficiary numbers; (J) Account numbers; (K) Certificate/license numbers; (L) Vehicle identifiers and serial numbers, including license plate numbers; (M) Device identifiers and serial numbers; (N) Web Universal Resource Locators (URLs); (O) Internet Protocol (IP) address numbers; (P) Biometric identifiers, including finger and voice prints; (Q) Full face photographic images and any comparable images; and ® any other unique identifying number, characteristic, or code, except as permitted for re-identification purposes provided certain conditions are met. In addition to the removal of the above-stated identifiers, the covered entity may not have actual knowledge that the remaining information could be used alone or in combination with any other information to identify an individual who is subject of the information. 45 C.F.R. § 164.514(b).16 45 C.F.R. § 164.502(a).17 45 C.F.R. § 164.502(a)(2).18 45 C.F.R. § 164.502(a)(1).19 45 C.F.R. § 164.506(c).20 45 C.F.R. § 164.501.21 45 C.F.R. § 164.501.22 45 C.F.R. § 164.501.23 45 C.F.R. § 164.508(a)(2)24 45 C.F.R. § 164.506(b).25 45 C.F.R. § 164.510(a).26 45 C.F.R. § 164.510(b).27 45 C.F.R. §§ 164.502(a)(1)(iii).28 See 45 C.F.R. § 164.512.29 45 C.F.R. § 164.512(a).30 45 C.F.R. § 164.512(b).31 45 C.F.R. § 164.512(a), (c).32 45 C.F.R. § 164.512(d).33 45 C.F.R. § 164.512(e).34 45 C.F.R. § 164.512(f).35 45 C.F.R. § 164.512(g).36 45 C.F.R. § 164.512(h).37 The Privacy Rule defines research as, "a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge." 45 C.F.R. § 164.501.38 45 C.F.R. § 164.512(i).39 45 CFR § 164.514(e).40 45 C.F.R. § 164.512(j).41 45 C.F.R. § 164.512(k).42 45 C.F.R. § 164.512(l).43 45 C.F.R. § 164.514(e). A limited data set is protected health information that excludes thefollowing direct identifiers of the individual or of relatives, employers, or household members ofthe individual: (i) Names; (ii) Postal address information, other than town or city, State and zipcode; (iii) Telephone numbers; (iv) Fax numbers; (v) Electronic mail addresses: (vi) Socialsecurity numbers; (vii) Medical record numbers; (viii) Health plan beneficiary numbers; (ix)Account numbers; (x) Certificate/license numbers; (xi) Vehicle identifiers and serial numbers,including license plate numbers; (xii) Device identifiers and serial numbers; (xiii) Web UniversalResource Locators (URLs); (xiv) Internet Protocol (IP) address numbers; (xv) Biometricidentifiers, including finger and voice prints; (xvi) Full face photographic images and anycomparable images. 45 C.F.R. § 164.514(e)(2).44 45 C.F.R. § 164.508.45 A covered entity may condition the provision of health care solely to generate protected health information for disclosure to a third party on the individual giving authorization to disclose the information to the third party. For example, a covered entity physician may condition the provision of a physical examination to be paid for by a life insurance issuer on an individual's authorization to disclose the results of that examination to the life insurance issuer. A health plan may condition enrollment or benefits eligibility on the individual giving authorization, requested before the individual's enrollment, to obtain protected health information (other than psychotherapy notes) to determine the individual's eligibility or enrollment or for underwriting or risk rating. A covered health care provider may condition treatment related to research (e.g., clinical trials) on the individual giving authorization to use or disclose the individual's protected health information for the research. 45 C.F.R. 508(b)(4).46 45 CFR § 164.532.47 "Psychotherapy notes" means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.45 C.F.R. § 164.501.48 45 C.F.R. § 164.508(a)(2).49 45 C.F.R. §§ 164.501 and 164.508(a)(3).50 45 C.F.R. §§ 164.502(b) and 164.514 (d).51 45 C.F.R. §§ 164.520(a) and (b). A group health plan, or a health insurer or HMO with respect to the group health plan, that intends to disclose protected health information (including enrollment data or summary health information) to the plan sponsor, must state that fact in the notice. Special statements are also required in the notice if a covered entity intends to contact individuals about health-related benefits or services, treatment alternatives, or appointment reminders, or for the covered entity's own fundraising.52 45 C.F.R. § 164.520(c).53 45 C.F.R. § 164.520(d).54 45 C.F.R. § 164.520(c).55 45 C.F.R. § 164.524.56 45 C.F.R. § 164.501.57 A covered entity may deny an individual access, provided that the individual is given a right to have such denials reviewed by a licensed health care professional (who is designated by the covered entity and who did not participate in the original decision to deny), when a licensed health care professional has determined, in the exercise of professional judgment, that: (a) the access requested is reasonably likely to endanger the life or physical safety of the individual or another person; (b) the protected health information makes reference to another person (unless such other person is a health care provider) and the access requested is reasonably likely to cause substantial harm to such other person; or (c) the request for access is made by the individual's personal representative and the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person. 2b1af7f3a8001
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- Pthc Collection 2013 PreviewEm Discussões Gerais·23 de março de 2023Pthc Collection 2013 Preview Download https://blltly.com/2t7Rtz The Depthcore Collective is thrilled to release it's 45th Chapter of work "Primal". Consisting of over sixty original works of art, photography and music the collective used this Chapter as a launching pad to explore concepts of nature, beast, instincts and primal origin. Whilst all of our artists rose admirably to the challenge, Ari Wenkle delivered an especially powerful collection of work, exploring various aspects of the core themes and bringing them to life with in boldly intricate executions. I had the pleasure of interviewing Ari to learn more about him and his artistic life - be sure to check out the transcript here. Methods: PubMed, Google Scholar, and the Cochrane database were searched to 31 December 2013. Main outcome measurements were therapeutic success rate, 30-day mortality rate, overall complications, cholangitis, and pancreatitis. Biliary leaks and fistulas are also a common complication after liver and biliary surgery. Leaks and fistulas may take origin from various procedures like bilio-digestive anastomoses, bile or cystic duct stumps or other intraoperative bile duct injury [9, 10]. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. Most bile leaks from the intra-hepatic biliary tree are transient and managed conservatively by drainage alone or by endoscopic biliary decompression. Minimally invasive percutaneous techniques for the management of biliary leaks and fistulas include percutaneous bile collection drainage, percutaneous trans-hepatic biliary drainage, biliary leak site embolisation sclerosis, ablation of a leaking biliary segment and treatment with a covered stent. Biliary leaks are an abnormal passage or communication from the biliary system to another location, intra- or extra-hepatic, and most commonly follow gallbladder surgery but can result from ductal injury related to blunt or sharp trauma or iatrogenic injury (e.g. liver biopsy) [15]. The most commonly accepted definition of a bile leak requires the presence of bile discharge from an abdominal wound and/or drain, with a total bilirubin level of >5 mg/ml or three-times the serum level, intra-abdominal collections of bile confirmed by percutaneous aspiration or cholangiographic evidence of dye leaking from the opacified bile ducts [16]. Surgery for hydatid disease may also lead to internal biliary leaks, with a frequency between 4 % and 28 %, mainly when deeply located cysts and right lobe cysts are excised [17]. In the case of bile leaks and fistulas, ultrasound and CT may help in the detection of the localised collections of bile or bile lying free in the peritoneal cavity. CT scanning may be used in conjunction with intravenous cholangiography (CT-IVC) to produce axial and three-dimensional images [22]. This technique is very useful in the detection of stones and in the creation of virtual cholangiographic pictures and may be very valuable in defining sites of leaks as it has the functional dimension that conventional MRCP does not. a Laceration and obstruction of common hepatic duct post laparoscopic cholecystectomy that led to biloma formation. b Percutaneous CT-guided drainage of the biloma. c Cholangiographic picture that confirms the communication of the collection with the biliary system. Surgical repair of the bile ducts followed The laparoscopic cholecystectomy has become one of the most common operations for treatment of symptomatic gallbladder disease. However significant postoperative biliary duct injuries can occur, leading to biliary leaks. Here we present a case where multiple abdominal collections are detected in a 64-year-old male patient who underwent laparoscopic cholecystectomy due to gallbladder stones two weeks prior. Percutaneous drainage under computed tomography guidance is implemented to treat the collections which result to be bilomas. After controlling the leak, an endoscopic retrograde cholangiopancreatography with papillotomy and stent placement is performed believing that the problem was settled in the cystic duct. But after observing that the leak increased with this treatment, an anatomical variation is suspected. A percutaneous transhepatic cholangiography is performed which confirm the diagnosis. In case of any deviation of a normal surgical post operatory, a biliary leak must be suspected. Surgeons nowadays must be trained in different diagnosis and treatment methods. Abdominal ultrasound (US) is performed as first approach, showing intrahepatic and extrahepatic ducts with normal size and without any sign of biliary stones. A fluid collection of 160 mL is detected in the anterior subphrenic space, and free fluid on the right flank and right lower quadrant (Fig. 1, 2). Due to the relative well clinical status of the patient, it is decided to perform a computed tomography (CT)-scan with percutaneous drainage of the collection. In the CT-scan more collections are detected in the subhepatic space and de Douglas pouch (Fig. 3). The US is often the initial imaging modality due to the lack of invasion, the cheap cost, and being accessible. It can show from anechoic, well-circumscribed collections to complex fluid with multiple fine internal septa.7 Although the US is useful, further imaging is often necessary to confirm the diagnosis. The MRI, besides of diagnose the possible free fluid and the collections, can detect the site of the leak and show us the biliary anatomy with the magnetic resonance cholangiopancreatography (MRCP). Specifically, thin-slab MRCP sequences may show the point of communication between the fluid collection and bile ducts. Thin-slab MRCP sequences are also helpful in depicting the detailed anatomy of the biliary tree and in detecting accessory biliary ducts, which could potentially be the source of the bile leak.8,9 Once the diagnosis is done, the surgeon has three main minimal invasive tools to treat the leak: image guided drainage of fluid and collections, PTHC with percutaneous biliary drainage and ERCP with papillotomy or stent placement. The image guided drainage is usually performed utilizing a 16- to 22-gauge needle with Seldinger technique, under CT or US guidance. Given the lack of radiation exposure, portability, flexibility to angle the probe and real time imaging capability, US is considered the preferred modality to guide diagnostic aspiration and drain placement. Although some collections due to localization or bone or air interposition may require CT guidance. Even though the precise position of the catheter in an isolated biloma is crucial, in an active bile leak, the catheter should be placed in close proximity to the site of the leak.10,11 2b1af7f3a800312
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