Tuesday, May 26, 2020

Virginia Woolf and Wartime Distortions of Natural and Pastoral Imagery in Mrs. Dalloway and Between the Acts - Literature Essay Samples

Alexandra Harris claims in Romantic Moderns that to plant flowers in the middle of a war was to assert one’s firm belief in the future. Virginia Woolf’s Mrs. Dalloway, published in 1925 seven years after the first world war, and her final novel Between the Acts, published in 1941 in the midst of the second, are full of flowers. The pastoral and natural imagery in these novels echo with nostalgia, commemorating happier times past and hoping for their recreation. However, even in their abundance of flowers and birdsong, the images of the pastoral in Woolf’s work do not always look towards a brighter future. The images are distorted and corrupted, resonating with the remaining fears from the previous war and the encroaching fear of the war to come. In Between the Acts, Woolf uses natural imagery as a means to connect the present to the past, reflecting nostalgia as well as the hope that nature provides for continuity. Miss La Trobe flounders at the silence of the stage, but thankfully ‘the cows took up the burden†¦in the very nick of time she lifted her great moon-eyed head and bellowed.’ The pastoral animals fill the silent void, all in unison with the ‘same yearning bellow’ (p. 87). The cows are gentle and ‘great’, with eyes like a ‘moon’, timeless in orbit and with a worldly continuity. The visceral ‘bellow’ joins past and present together: ‘it was the primeval voice sounding loud in the ear of the present moment’ (p. 87). Their ability to cross boundaries of time stretches beyond the context of salvaging the pageant as they ‘annihilated the gap; bridged the distance; filled the emptiness and continued the emotion’ (p. 87). The ‘gap’ and ‘distance’ of time is ‘bridged’ by the cry of nature, one that filled the ‘emptiness’ left by human action, presenting the pastoral as an instrument to con nect with the past and continue to a salvaged future. While the actors are still adorned in their pageant costumes portraying figures from England’s history, ‘each still acted the unacted part conferred on them by their clothes’ (p. 121). Their ‘beauty ’ (p. 121) from the past is ‘revealed’ (p. 121) by the light: ‘the tender, the fading, the uninquisitive but searching light of evening that reveals depths in water and makes even the red brick bungalow radiant’ (p. 121). The natural glow is ‘tender’, enveloping both nature and the industrial ‘red brick bungalow’, joining them under a single place and time to uncover the beauty in each. The idyllic, pastoral setting of the evening creates nostalgia for the beauty that is found in the ‘unacted part conferred on them by their clothes’, a ‘part’ that is rooted in pre-war England.Birds and flowers in particular are remembered in Mrs. Dalloway in conjunction with nostalgic thoughts. The depth of Clarissa Dalloway’s emotion for Peter Walsh as she looks at him ‘passing though all that time’ (p. 37) is likened to a bird that ‘touches a branch and rises and flutters away’ (p. 37). The emotion is fleeting and gentle, remembered in natural terms that remain ‘through all that time’. Clarissa’s happiest memory has flowers scattered in it, reflecting the positive connotations that they can have. This pinnacle, ‘the most exquisite moment of her whole life,’ followed ‘passing a stone urn with flowers in it. Sally stopped; picked a flower; kissed her on the lips’ (p. 30). The flowers are the catalysts and witness, poised in Sally Seton’s hand during Clarissa’s ‘most exquisite moment’. For all the magnitude of this instant, it is the presence of the flowers that take precedence, highlighting their lasting power. Cl arissa in particular loves the flower that is arguably England’s symbol of continuity, establishing its roots slowly and firmly in the ground: the rose. She thinks them ‘absolutely lovely’ (p. 101) and cares about them more than international politics, such as the Armenians in the aftermath of their genocide during the First World War: ‘she cared much more for her roses than for the Armenians’ (p. 102). Nevertheless, they are also strangely ‘the only flowers she could bear to see cut’ (p. 102). This contradicts both her affection for them and their status as symbols of continuity, but hints, rather, at an emerging corruption of traditional natural imagery in face of the horrors of the war. Through likening humans to birds, often in a sinister manner, Woolf begins to corrupt pastoral imagery, tainting it with the actions of humans. In Between the Acts, Isa and Rupert Haines are trapped swans, ‘his snow-white breast circled with a tangle of dirty duckweed; and she too, in her webbed feet was entangled by her husband’ (p. 2). The ‘snow-white’ is polluted, and it is difficult to separate the ‘dirty duckweed’ that imprisons them both with connotations of barbwire, tangling, cutting and trapping those on the war front. People are constantly described negatively as animals, Mrs. Haines with her ‘gooselike eyes, gobbling’ (p. 3), Clarissa with ‘a ridiculous little face, beaked like a bird’s’ (p. 9). The beggar woman in Mrs. Dalloway is a sinister bird, ‘a looming shape, a shadow shape’ (p. 70), steeped in an uncertain darkness, she possessed the ‘bird-like freshness of the very aged, she still twittered’ (p. 70). ‘Bird-like freshness’ is juxtaposed with ‘the very aged’, uniting the two and implying that birds now have ominous echoes of decay and death. The aggressive diction that Lucrezia uses to d escribe her husband Septimus Smith further distorts the bird symbol, drawing them closer to the monstrosities of the war. Her first impression of him was that of a ‘young hawk’ (p. 124), a bird of prey but still not yet aggressive, until Septimus becomes ‘a hawk or crow, being malicious and a great destroyer of crops’ (p. 126). The circling hawk, ‘malicious’ and ‘a great destroyer of crops,’ is not unlike circling military aircrafts, threatening to destroy what feeds and fuels a country. These comparisons of Woolf’s between birds and people corrupt natural imagery on several different levels. Firstly, the actions of humans – that of the war, maybe even of urbanization – have such large repercussions that they affect perceptions of the natural world, that which was meant to remain and continue. Secondly, there could even be suggestions of the transposition of human and animal roles, where humans are now prey on each other and like birds for game, fear being hunted. Moreover, humans are like birds in Woolf’s novels because birds create a birdsong, but through mirroring and merging with humans, it becomes a song of war. The pastoral requires birdsong and there is plenty in Woolf’s novels, but what once was a choir of idyllic chirping is distorted into the sinister, and eventually into a choir of war. Septimus, suffering from shell-shock, hears a sparrow chirping his name ‘four or five times over and went on, drawing its notes out to sing freshly and piercingly in Greek words†¦joined by another sparrow they sang in voices prolonged’ (p. 21). Birds singing with Greek voices were not an unfamiliar notion to Woolf, who in February 1904 suffered her first complete mental breakdown after hearing birds speaking in Greek. The birds’ voices are now an indication of madness, a corruption of nature. The birdsong is tormenting and ‘prolonged’, t he voices are invasive and piercing like the sounds of bombs, drones, gunfire and screams painful memories for a shell-shocked Septimus. However, in Between the Acts, a novel published in 1941, these links to wartime are made even more explicit. The birds are portrayed just as ‘piercingly’, constantly preventing the characters from sleep: ‘she had been waked by the birds. How they sang! Attacking the dawn†¦Ã¢â‚¬â„¢, ‘the random ribbons of birds’ voices woke her’ (p. 127). The diction used begins to resemble that of wartime, ‘attacking’ in the morning and randomly appearing in ‘ribbons’ of sound. Like air raids, the birds are an aerial onslaught, resounding and preventing humans from sleep and peace. The swallows that dance to the music of the pageant are similar, ‘retreating and advancing†¦yes, they barred the music, and massed and hoarded’ (p. 113). The birds ‘retreat and advance’ like soldiers on the field in their multitudes, barring the music of England’s happier past in the play with the song of the present and near future, a song at this point that Woolf knows, is one of war.The distortion of nature, then, signals a loss of the hope and nostalgia found in the pastoral, and indicates the resignation to another world war, the second that Woolf has seen. In Mrs. Dalloway, Woolf and the characters are still recovering from the First World War, but there is the slightest glimmer of hope: ‘the aeroplane soared straight up, curved in a loop, raced, sank, rose, and whatever it did, wherever it went, out fluttered behind it a thick ruffled bar of white smoke’ (p. 17). The plane here is safely for commercial use, ‘writing letters in the sky’ (p. 17), and in its description resembles a swan. The plane ‘raced, sank, rose’ in the same way a swan would in water, and this image is compounded by the ‘thick ruffled bar of white smoke’, like the ruffled white feathers of the bird. In its comparison to a swan, the plane adopts a naturality that reflects the optimism for the positive undercurrents of the pastoral to return. This, however, is contributed to the historical placing and publication of Mrs. Dalloway, nestled seven years after the First World War without the second in sight. In Between the Acts, however, this begins to change. Airplanes are still compared to birds: ‘twelve aeroplanes in perfect formation like a flight of wild duck came overhead’ (p. 119) and the ducks are still thought of in their unison and harmony, ‘perfect formation’. In spite of this, when applied to the planes, the devised aerial arrangement assumes an ominous tinge, indicating that the war is near. Eventually, the inverse comparison of birds as planes is achieved, as starlings become aerial forces attacking a tree, ‘the whole tree hummed with the whizz they made, as if each bir d plucked a wire. A whizz, a buzz rose from the bird-buzzing, bird-vibrant, bird-blackened tree’ (p. 130). The starlings are now mechanical with whizzing sounds and wires, no longer birds but ruthless machines. Conveyed in a tricolon of the birds’ actions, the tree is overwhelmed and helpless as they would not ‘stop devouring the tree’ (p. 130). There is no ‘perfect formation’ but merely a chaos that resonates with mechanical, weapon-like sounds that appear to have seeped into the creatures of nature, Woolf disclosing that war is here. Woolf has shown the state of pastoral and natural imagery to be indicators of historical significance in her novels. These images are connections to a happier past, and as Fussell aptly expresses, recourse to the pastoral is a means of both fully gauging the calamities of The Great War and imaginatively protecting oneself against them. However, their distortion throughout Mrs. Dalloway and more significantly B etween the Acts betrays a disintegration of this hopeful nostalgia. The transformation of the natural world into a world of warfare presents Woolf, who in Mrs. Dalloway was attempting to recover from the First World War, eventually being disillusioned in Between the Acts by the emergence of the second. Between the Acts is appropriately named, after all, set in between two great acts – the two wars. So, flowers and birds for Woolf are no longer, as Harris argues, optimistic symbols of hope. An episode between Woolf and her husband Leonard encapsulates this sentiment, when one afternoon she called him in from the garden to listen to Hitler on the radio, but he preferred to carry on planting irises that would be ‘flowering long after Hitler is dead’. The flowers are Leonard’s optimistic hopes, but Virginia was sitting inside listening to Hitler, dismissing the natural world, hearing and listening instead to the voice of war – a sound that corrupts the pastoral in her novels.

Saturday, May 16, 2020

Essay The Greek Economy - 2993 Words

The Greek economy was a result of the combination of slaves, citizens and Metics. The Metic, however, was the driving and most important force behind the Greek economy. The slave was used only when seen fit. The citizen saw work as below the dignity of a free man. He left to others the labors that he was unwilling to perform himself. Firstly, it must be noted that any prejudice against manual labor among the Greeks was of comparatively late origin. Certainly, in the Homeric age, to labor with one’s hands was no disgrace. The prowess of Odysseus comes to mind, who was a mighty worker and built his own house and even his own bedstead. (Hom. Od.13, 31-34) There was no prejudice against manual labor in the time of Solon either, who decreed†¦show more content†¦This new found standing gave the citizen the view that he was above manual labor. The plunder gained from wars, and after the founding of the Delian League, the riches gained set up new standards of values and condu ct. With the increased wealth, fortunes were made overnight. The citizen enjoyed himself more and saw those who had to work for a living with contempt. Also, with the increased affluence, citizens were able to pay the Metic to carry out trade. Herodotus remarked upon this as something quite new, that the citizens â€Å"practice no trade and only war, which is their hereditary calling. Now, whether this separation, like other customs has come to Greece from Egypt I cannot exactly judge. I know that in Thrace and Scythia and Persia and Lydia and nearly all foreign countries those who learn trades and their descendants are held in less esteem than the rest of the people, and those who have nothing to do with artisan’s work, especially men who are free to practice war, are highly honored.† (Herod. 2, 166-167) This is a testament that the Greek citizen had shifted away from work and had elevated himself upon a pedestal. 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The Minoans adopted almonds, the nuts of the mastic bush, and the yellow pulses that were being refined by more ancient peoples already in Greece, while finding wild grapes. The wild grapes were used to make wine. The people of Greece also foundRead MoreThe Euro in Crisis: Decision Time at the European Central Bank841 Words   |  4 Pagesextraordinary decision-making power, this will in effect have an impact on the financial economy of Greece. From this case analysis, the ECB must decide whether to purchase or to not purchase Greek sovereign debt (Trumbull, Roscini amp; Choi, 2011). The Problem After the sub-prime mortgage burst in the United States, this sent reverberating shock waves throughout world economies. As the US economy tightened, economies around the world were also affected; adversely affected highly leveraged banks in

Wednesday, May 6, 2020

Childhood Parents And Special Education - 961 Words

Introduction/ Problem Statement As children grow, they are expected to meet milestones along the way to ensure proper development is taking place. When a child fails to meet the developmental milestones for their age, interventions are often put into place in efforts to help the child perform as close to the expectations for his or her age as possible. These early interventions can help rectify the child’s deficiency; but at times, the child may need to receive long- term assistance or accommodation; particularly when entering school. These children can be recommended for special education. Being placed in special education affords children the opportunity to learn at their own pace with all the specific support they need. The children’s needs are met with guidance, patience, and scaffolding. Early childhood parents often have negative perceptions towards special education; resulting in the delay or impediment of their child receiving services. In this author’s experience as a classroom teacher, approximately half of all the parents whose child was identified as special needs resisted or delayed their child’s participation in services or special education because of their perceptions towards special education. It is necessary to understand what contributes to the perceptions in order to provide parents support they need to not only accept, but embrace their child’s needs to ensure the child performs at his or her full potential. Statement of the Problems Impact onShow MoreRelatedChildhood Education : Early Childhood Special Education Essay1266 Words   |  6 Pages Early Childhood Special education Name: Institution: Early Childhood Special education 1-The role of play in learning in early childhood Special Education Play is usually a natural activity in early childhood and has significant importance in early childhood special education. 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Tuesday, May 5, 2020

Financial Information for Decision Making of JB Hi-Fi Limited

Question: Discuss about the Financial Information for Decision Making of JB Hi-Fi Limited. Answer: Introduction The analysis of financial performance and position is essential from the perspectives of the investors. The investors put their money on stake by investing in the companys shares therefore they should have understanding of the companys financial performance and position (Needles, Powers, and Crosson, 2013). In order analyze the companys financial performance, it is essential to assess the business of the company on four core parameters such as profitability, liquidity, efficiency, and gearing. In this context, a report has been presented here that covers the financial analysis of JB Hi-Fi Limited over the period of three financial years commencing from 2014 and ending on 2016. Company Background The JB Hi-Fi Limited, headquartered in Chadstone (Australia), listed on Australian stock exchange, is a retailing company. The company engages in the business of retail sales of home consumer products through two geographical segments such as Australia and New Zealand (JB Hi-Fi, 2016). The company offers a range of products which includes electronic products, telecommunication, and cooking products. The company was incorporated in the year 1974 and since then it has grown manifold to hold presently 194 JB Hi-Fi stores. Presently the company employs 7,814 people, which depicts its growing size. In the year 2016, the company operated with total revenues of $3.95 billion. Further, the EBIT and Operating profit after tax of the company were observed to be $221.2 million and $152.2 million respectively (JB Hi-Fi, 2016). The changes in technology have caused structural changes in the retail industry all over the world in the recent past years. The retail sale through stores is not in fashion now after introduction of sales through online platforms. Further, the competition has got stiff not in Australia but all over the world after introduction of online sales platform. However, JB Hi-Fi is getting into business acquisition strategies to reduce the adverse impact of competition. Recently in 2016, it has acquired one of its competitor in home appliances namely Good Guys (Berry, 2016). Analysis of Financial Performance The financial performance of the company has been observed to be good in the recent years as depicted from the gradual growth in the revenues, profits, and number of stores operated. Further probe into the profitability, liquidity, efficiency, and gearing is carried out as below: Profitability In order to assess the profitability of the company, the prominent ratios namely net profit and return on equity have been analyzed. The net profit ratio shows profits propionate to sales (Tracy, 2012). In regards to JB Hi-Fi, the net profit ratio for the year 2014, 2015, and 2016 have been found to be 3.67%, 3.75%, and 3.84% respectively (Appendix). Thus, it could be observed that the net profit ratio of the company has improved over the years. The increase in net profits ratio is the result of cost cutting. Due to increased competition in the industry, the company is bound to find the cost cutting mechanisms. Further, return on equity shows profits attributable to the equity owners proportionate to the total shareholders equity (Tracy, 2012). The return on equity of JB Hi-Fi has been found to be 43.54%, 39.83%, and 37.62% for the years 2014, 2015, and 2016 (Appendix). The return on equity is showing downward trend. The primary reason for downfall in the return on equity is increase in the shareholders equity over the period. The shareholders equity has increased from $294 million in 2014 to $404 million in 2016. Harvey Norman is the biggest competitor of JB Hi-Fi. Comparing the profitability of JB Hi-Fi with Harvey Norman, it has been observed that net profits ratio of the company is lower than that of competitor. However, the return on equity of the company is better. Harvey Norman has net profit ratio of 12.34% while the return on equity is 13.40% (Morningstar, 2017). Liquidity In order assess liquidity, the primary ratios such as current ratio and quick ratio have been computed and analyzed. The current and quick ratios show companys ability to meet the short term debt obligations. Higher the ratio better will be the liquidity position on the company (Tracy, 2012). In the case of JB Hi-Fi, the current ratio has been found to be 1.64, 1.62, and 1.57 times for the financial years 2014, 2015, and 2016 respectively (Appendix). The current ratio could be observed to be showing the downward trend over the period of time. Further, the quick ratio has been found to be 0.34, 0.36, 0.35 times (Appendix). The decreasing trend in current ratio implies degradation in the liquidity position of the company. However, the current ratio of the company is still better than that of its competitor. Harvey Norman has current ratio of 1.26 times which is lower than the companys current ratio of 1.64 times. Efficiency The measurement of efficiency relates to the assessment of managements efficiency in regards to utilization of assets. The ratios such as receivables days, payable days, and assets turnover have been computed for this purpose (Tracy, 2012). The receivable days have been found to be 7, 8, and 9 days for 2014, 2015, and 2016. The receivable days are showing a little bit increase which is adverse for the company because the funds are being tied for longer time now. The payable days have been found to be 33, 32, and 36. The increase in payable days is favorable for the company because now company is getting more credit period from the suppliers. The asset turnover ratio is also showing downward trend. The ratio fell from 4.05 times in 2014 to 3.99 times in 2016 (Appendix). The decrease in the asset turnover ratio shows degradation in the managements efficiency in regards to utilization of the assets optimally. Gearing/Solvency The gearing or solvency implies the companys ability to meet the long term debt obligations on time. For this purpose, the debt equity ratio and debt to asset ratios are considered to be suitable to evaluate. The debt to equity ratio assesses the debt propionate to equity and debt to asset ratio assesses total assets financed by debt funds (Tracy, 2012). In the case of JB Hi-Fi, the debt to equity ratio has been found to be 1.92, 1.60, and 1.46 times for the financial years 2014, 2015, and 2016 respectively. It could be observed that debt to equity ratio is decreasing over the period which indicates reduction in the risk of solvency. Further, the debt to asset ratio is also observed to be decreasing. In the year 2014, it was 0.66 times and went down to 0.59 times in the year 2016 (appendix). The debt equity ratio of Harvey Norman is 0.08 times which is way lower than that of the company (Morningstar, 2017). Thus, it could be inferred that the company is bearing more solvency risk than the competitor. Conclusion From the discussion in the report, it could be articulated that the financial performance of JB Hi-Fi is moderate. The company is growing at a slow pace. The revenue and net profits are increasing but at slow pace. Further, on certain parameters the company is lagging behind its competitor. The net margin of company is lower than the competitor. Further, the debt to equity ratio of the company is higher than the competitor which depicts high solvency risk for the company. However, the fact that company has acquired one of its competitors namely Good Guys could give a reason to investors to make investment in the companys shares. The acquisition of Good Guys is predicted to have positive impact on the financial performance of the company. Thus, it is recommended to the investors to make investment in the companys shares from the short term perspective. References Berry, P. 2016. JB Hi-Fi takes market lead with Good Guys. [Online]. Available at: https://www.news.com.au/finance/business/breaking-news/jb-hifi-acquires-the-good-guys/news-story/a181998df6d2f1f797fa2f8d28ab3f6d [Accessed on: 17 May 2017]. JB Hi-Fi. 2016. Annual report of JB Hi-Fi Limited for 2016. [Online]. Available at: https://www.jbhifi.com.au/Documents/2016%20JB%20Hi-Fi%20Annual%20Report_ASX.pdf [Accessed on: 17 May 2017]. Morningstar. 2017. Harvey Norman Holdings Ltd. [Online]. Available at: https://financials.morningstar.com/ratios/r.html?t=HVN [Accessed on: 17 May 2017]. Needles, B.E., Powers, M., and Crosson, S.V. 2013. Financial and Managerial Accounting. Cengage Learning. PWC. 2017. 2017 Retail trends. [Online]. Available at: https://www.strategyand.pwc.com/trend/2017-retail-trends [Accessed on: 17 May 2017]. Tracy, A. 2012. Ratio Analysis Fundamentals: How 17 Financial Ratios Can Allow You to Analyse Any Business on the Planet. RatioAnalysis.net.

Thursday, April 16, 2020

The Spaces between Stars by Geeta Kothari An interpretation based on Hindusism Essay Example

The Spaces between Stars by Geeta Kothari: An interpretation based on Hindusism Essay Hinduism is one of the oldest religions of the world. It evolved in the Indian subcontinent over 5000 years ago and has a rich body of literature. Unlike monotheistic religions such as Christianity or Islam, Hinduism is polytheistic, with thousands of deities and gods being worshipped. Even in terms of ethnography and culture there is a rich diversity of Hindu expression. The sacred rituals and beliefs related to Hinduism vary across ethnic communities in India. The Hindu scriptures explain morality in the form of legends and myths. More than a religion per se, Hinduism can be looked at as a philosophical system. The key themes of this system are that of the interconnectedness of life, repercussions of good and bad deeds (karma), the temporariness of earthly existence and the aspiration toward liberation from it (moksha). Texts such as the Upanishads and epics such as Ramayana and Mahabaratha serve as mediums of this philosophic discourse. In Geeta Kothari’s short story the major theme is one of entrapment. She regrets the condition of her married life with Evan. She wonders morosely if she had erred by agreeing to marriage in the name of security and conformity. There are parallels to it in the Hindu conception of life, whereby, our present life carries forward and expiates the Karma accumulate from our previous life. In this cycle of birth and rebirth thus continues the one constant reality is that of suffering. Certainly Maya has a legitimate feeling of betrayal in her marriage, and she wonders why things had turned out this way. Hinduism’s answer to her pondering would be that she is presently suffering on account of the bad Karma she had acquired in previous incarnations. We will write a custom essay sample on The Spaces between Stars by Geeta Kothari: An interpretation based on Hindusism specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on The Spaces between Stars by Geeta Kothari: An interpretation based on Hindusism specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on The Spaces between Stars by Geeta Kothari: An interpretation based on Hindusism specifically for you FOR ONLY $16.38 $13.9/page Hire Writer While the Hindu idea of karma is deterministic, it does not promote fatalistic attitude. While the circumstances we find ourselves in are somewhat arbitrary, there is much we can alter about our future through the exercise of free will. Towards the end of the story Maya seems to realize this truth. She is seen to slowly make a resolution that she will henceforth be more faithful to her feelings and no more live in denial. Hindu spiritual practices in the form of yoga, dhyana and yagnya are deviced to alleviate our suffering by altering our natural state of ego-consciousness. By subjugating the impulses of the ego and attuning our senses toward cosmic consciousness we reach a state where suffering ceases. It is called in Sanskrit as mukthi. Maya’s project of self-actualization is not articulated in such esoteric Hindu philosophic terms. But hers is a project of great import in the context of the constricting and adversarial reality her marriage has turned out to be. In my own experience I’ve faced issues of melancholy in the past. In the early days, I used to feel very let down and feel victimized. But slowly I realized that remorse and helplessness lead us nowhere. I then started undergoing an attitudinal change in two aspects. First I trained myself to accept difficulties as part of life. Second I trained myself to proactively mitigate adversities. As a result I can claim that I am a much happier person now than I was a few years back. The important thing is that my circumstances have not drastically changed but my outlook and behaviour has changed. And it has made a world of difference. In this regard I share the same spirit of Maya. Between me and her, we share the Hindu philosophic outlook to addressing problems, although it took us both some time to make this transition. Hinduism is one of the oldest religions of the world. It evolved in the Indian subcontinent over 5000 years ago and has a rich body of literature. Unlike monotheistic religions such as Christianity or Islam, Hinduism is polytheistic, with thousands of deities and gods being worshipped. Even in terms of ethnography and culture there is a rich diversity of Hindu expression. The sacred rituals and beliefs related to Hinduism vary across ethnic communities in India. The Hindu scriptures explain morality in the form of legends and myths. More than a religion per se, Hinduism can be looked at as a philosophical system. The key themes of this system are that of the interconnectedness of life, repercussions of good and bad deeds (karma), the temporariness of earthly existence and the aspiration toward liberation from it (moksha). Texts such as the Upanishads and epics such as Ramayana and Mahabaratha serve as mediums of this philosophic discourse. In Geeta Kothari’s short story the .

Friday, March 13, 2020

Acute Cholecystitis Essay Example

Acute Cholecystitis Essay Example Acute Cholecystitis Essay Acute Cholecystitis Essay kulasekar Definition Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone blocking the cystic duct. Gallbladder inflammation usually results from a gallstone blocking the flow of bile. Typically, people have abdominal pain that lasts more than 6 hours, fever, and nausea. Ultrasonography can usually detect signs of gallbladder inflammation. The gallbladder is removed, often using a laparoscope. Cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the gallbladder Causes In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Severe illness, alcohol abuse and, rarely, tumors of the gallbladder may also cause cholecystitis. Acute cholecystitis causes bile to become trapped in the gallbladder. The build up of bile causes irritation and pressure in the gallbladder. This can lead to bacterial infection and perforation of the organ. Gallstones occur more frequently in women than men. Gallstones become more common with age in both sexes. Native Americans have a higher rate of gallstones. Symptoms The main symptom is abdominal pain particularly after a fatty meal that is located on the upper right side of the abdomen. Occasionally, nausea and vomiting or fever may occur. Exams and Tests A doctors examination of the abdomen by touch (palpation) may reveal tenderness. Tests that detect the presence of gallstones or inflammation include: Abdominal ultrasound Abdominal CT scan Abdominal x-ray Oral cholecystogram Gallbladder radionuclide scan A CBC shows infection by an elevated white blood cell count [pic] Outlook (Prognosis) Patients who have cholecystectomy usually do very well. Possible Complications Empyema (pus in the gallbladder) Peritonitis (inflammation of the lining of the abdomen) Gangrene (tissue death) of the gallbladder Injury to the bile ducts draining the liver (a rare complication of cholecystectomy) Cholecystitis is classified as acute or chronic. Acute Cholecystitis: Acute cholecystitis begins suddenly, resulting in severe, steady pain in the upper abdo men. At least 95% of people with acute cholecystitis have gallstones. The inflammation almost always begins without infection, although infection may follow later. Inflammation may cause the gallbladder to fill with fluid and its walls to thicken. Rarely, a form of acute cholecystitis without gallstones (acalculous cholecystitis) occurs. Acalculous cholecystitis is more serious than other types of cholecystitis. It tends to occur after the following: Major surgery Critical illnesses such as serious injuries, major burns, and bodywide infections (sepsis) Intravenous feedings for a long time Fasting for a prolonged time A deficiency in the immune system It can occur in young children, perhaps developing from a viral or another infection. Chronic Cholecystitis: Chronic cholecystitis is gallbladder inflammation that has lasted a long time. It almost always results from gallstones. It is characterized by repeated attacks of pain (biliary colic). In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually due to gallstones, and may become thick-walled, scarred, and small. The gallbladder usually contains sludge (microscopic particles of materials similar to those in gallstones), or gallstones that either block its opening into the cystic duct or reside in the cystic duct itself. A gallbladder attack, whether in acute or chronic cholecystitis, begins as pain. The pain of cholecystitis is similar to that caused by gallstones (biliary colic) but is more severe and lasts longer- more than 6 hours and often more than 12 hours. The pain peaks after 15 to 60 minutes and remains constant. It usually occurs in the upper right part of the abdomen. The pain may become excruciating. Most people feel a sharp pain when a doctor presses on the upper right part of the abdomen. Breathing deeply may worsen the pain. The pain often extends to the lower part of the right shoulder blade or to the back. Nausea and vomiting are common. Within a few hours, the abdominal muscles on the right side may become rigid. Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100. 4 ° F (38 ° C) and may be accompanied by chills. Fever rarely occurs in people with chronic cholecystitis. In older people, the first or only symptoms of cholecystitis may be rather general. For example, older people may lose their appetite, feel tired or weak, or vomit. They may not develop a fever. Typically, an attack subsides in 2 to 3 days and completely resolves in a week. If the acute episode persists, it may signal a serious complication. A high fever, chills, a marked increase in the white blood cell count, and essation of the normal rhythmic contractions of the intestine (ileus- see Gastrointestinal Emergencies: Appendicitis) suggest pockets of pus (abscesses) in the abdomen near the gallbladder from gangrene (which develops when tissue dies) or a perforated gallbladder. If people develop jaundice (see Manifestations of Liver Disease: Jaundice) or pass dar k urine and light-colored stools, the common bile duct is probably blocked by a stone, causing a backup of bile in the liver (cholestasis). Inflammation of the pancreas (pancreatitis) can develop. It is caused by a stone blocking the ampulla of Vater, near the exit of the pancreatic duct. Acalculous cholecystitis typically causes sudden, excruciating pain in the upper abdomen in people with no previous symptoms or other evidence of a gallbladder disorder. The inflammation is often very severe and can lead to gangrene or rupture of the gallbladder. In people with other severe problems (including people in the intensive care unit for another reason), acalculous cholecystitis may be overlooked at first. The only symptoms may be a swollen (distended), tender abdomen or a fever with no known cause. If untreated, acalculous cholecystitis results in death for 65% of people. Diagnosis Doctors diagnose cholecystitis based mainly on symptoms and results of imaging tests. Ultrasonography is the best way to detect gallstones in the gallbladder. Ultrasonography can also detect fluid around the gallbladder or thickening of its wall, which are typical of acute cholecystitis. Often, when the ultrasound probe is moved across the upper abdomen above the gallbladder, people report tenderness. Cholescintigraphy, another imaging test, is useful when acute cholecystitis is difficult to diagnose. For this test, a radioactive substance (radionuclide) is injected intravenously. A gamma camera detects the radioactivity given off, and a computer is used to produce an image. Thus, movement of the radionuclide from the liver through the biliary tract can be followed. Images of the liver, bile ducts, gallbladder, and upper part of the small intestine are taken. If the radionuclide does not fill the gallbladder, the cystic duct is probably blocked by a gallstone. Liver blood tests are often normal unless the person has an obstructed bile duct. Other blood tests can detect some complications such as a high level of a pancreatic enzyme (lipase or amylase) in pancreatitis. A high white blood cell count suggests inflammation, an abscess, gangrene, or a perforated gallbladder. Treatment People with acute or chronic cholecystitis need to be hospitalized. They are not allowed to eat or drink and are given fluids and electrolytes intravenously. A doctor may pass a tube through the nose and into the stomach, so that suctioning can be used to keep the stomach empty and reduce fluid accumulating in the intestine if the intestine is not contracting normally. Usually, antibiotics are given intravenously, and pain relievers are given. If acute cholecystitis is confirmed and the risk of surgery is small, the gallbladder is usually removed within 24 to 48 hours after symptoms start. If necessary, surgery can be delayed for 6 weeks or more while the attack subsides. Delay is often necessary for people with a disorder that makes surgery too risky (such as a heart, lung, or kidney disorder). If a complication such as an abscess, gangrene, or perforated gallbladder is suspected, immediate surgery is necessary. In chronic cholecystitis, the gallbladder is usually removed after the acute episode subsides. In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder. Surgical removal of the gallbladder (cholecystectomy) is usually done using a flexible viewing tube called a laparoscope. After small incisions are made in the abdomen, the laparoscope and other tubes are inserted, and surgical tools are passed through the incisions and used to remove the gallbladder. [pic] Pain After Surgery: A few people have new or recurring episodes of pain that feel like gallbladder attacks even though the gallbladder (and the stones) have been removed. The cause is not known, but it may be malfunction of the sphincter of Oddi, the muscles that control the release of bile and pancreatic secretions through the opening of the bile and pancreatic ducts into the small intestine. Pain may occur because pressure in the ducts is increased by sphincter spasms, which hinders the flow of bile and pancreatic secretions. Pain also may result from small gallstones that remain in the ducts after the gallbladder is removed. More commonly, the cause is another problem, such as irritable bowel syndrome or even peptic ulcer disease. Endoscopic retrograde cholangiopancreatography (ERCP) may be necessary to determine if the cause of pain is increased pressure. For this procedure, a flexible viewing tube (endoscope) is inserted through the mouth and into the intestine, and a device to measure pressure is inserted through the tube. If pressure is increased, surgical instruments are inserted into the tube and used to cut and thus widen the sphincter of Oddi. This procedure (called endoscopic sphincterotomy) can relieve symptoms in people who have an abnormality of the sphincter. Background Acute cholecystitis (AC) occurs as a result of inflammation of the gallbladder (GB) wall usually secondary to cystic duct obstruction. In 90% of patients, AC is initiated by impaction of a calculus in the neck of the GB or in the cystic duct. 22 Acute acalculous cholecystitis (AAC) represents inflammation of the GB in the absence of GB calculi. AAC occurs more commonly in children and adults who are critically ill or in those who have recently undergone stress in the form of severe trauma, burns, or major surgery. Acute emphysematous cholecystitis is characterized by the presence of gas within the wall and/or lumen of the GB. It occurs more commonly in diabetic men and less frequently in association with cholelithiasis. Emphysematous cholecystitis is considered either a complication of AC or a separate entity. For excellent patient education resources, see eMedicines Liver, Gallbladder, and Pancreas Center. Also, visit eMedicines patient education article Gallstones. Pathophysiology AC represents an acute inflammation of the GB caused in most instances by obstruction of the cystic duct, usually by a gallstone and resulting in acute inflammation of the GB wall. AC is one of the major complications of cholelithiasis. The inflammatory process begins with a calculous obstruction of the cystic duct or GB neck. The exact mechanism by which GB inflammation is initiated is unknown. Microorganisms can be identified in 80% of cases early in the disease onset; such organisms include primarily  Escherichia coli, other gram-negative aerobic rods, enterococci, and a number of anaerobes. The bacterial invasion is not considered  to be  a primary event, because in 20% of patients, no bacterial growth  occurs in  surgical specimens. 1 The general consensus is that bacterial infection is a secondary event,  not an initiating one. Spontaneous resolution of AC may occur within 5-7 days after onset of symptoms,  because of reestablishment of cystic duct patency. In the majority of such cases, fibrotic wall thickening of the GB occurs, which  is characteristic of chronic cholecystitis. In more than 90% of cholecystectomy specimens, the histologic pattern is  AC superimposed on chronic cholecystitis. If the cystic duct patency is not reestablished, inflammatory cell infiltration of the GB wall follows,  with the occurrence of  mural and mucosal hemorrhagic necrosis. Gangrenous cholecystitis may  be seen  in as many as 21% of AC patients. Acalculous cholecystitis occurs in a different clinical setting, occurring  more often in males, usually children and in those older than 65 years. The pathophysiology of acalculous cholecystitis is  not well  understood but is probably multifactorial. Systemic mediators of inflammation, localized or generalized tissue ischemia, and bile stasis probably work to gether. The population at risk for acalculous AC often has predisposing factors for bile stasis; such  populations include patients with  starvation, on parenteral nutrition, using narcotic analgesics, and  lacking mobility in postoperative states. Hypovolemia and shock also predispose such patients to tissue ischemia, although ischemia may be a primary event causing acalculous AC,  such as  small-vessel vasculitis,  or may be  a complication of hepatic chemoembolization. Often, functional cystic duct obstruction is present and is related to inflammation and viscous bile. Extrinsic compression may also play a role in the development of bile stasis. The majority of patients with acalculous AC disease have secondary infection with gram-negative enteric flora3; however, in patients with typhoid fever, infection as a primary event has been  identified with  Salmonella organisms. AIDS-related cholecystitis and cholangiopathy may be secondary to cytomegalovirus (CMV) infection  and infections with Cryptosporidium organisms. In patients who have  emphysematous cholecystitis,  ischemia of the GB wall is followed by infection with gas-forming organisms that produce gas in the GB lumen, in the GB  wall, or both. In 30-50% of patients, preexisting diabetes mellitus is present,  and the  male-to-female ratio  is 5:1. 22 Gas may be confined to the GB; however, in 20% of cases, gas is also seen in the rest of biliary tree. Gallstones are not present in 30-50% of cases, and the mortality rate is 15%. 2  There is a predisposition  for gangrene formation and perforation, but clinical symptoms are mild, which can be deceptive. Emphysematous cholecystitis  may occur after  chemoembolization  as palliation  for hepatocellular carcinoma,  following atheromatous embolism during aortography, and after GB hypoperfusion during cardiorespiratory resusc itation. The following factors have been  associated with acalculous cholecystitis4: Surgery, particularly abdominal Severe burns Gastroenteritis Severe trauma Total parenteral nutrition (TPN) Mechanical ventilation Blood transfusion reactions Dehydration Narcotic analgesia Diabetes mellitus Antibiotics, particularly broad spectrum Hepatic arterial embolization (islet cell tumors and hepatocellular carcinoma) Postpartum complications Vascular insufficiency and vasculitis such as systemic lupus erythematosus (SLE) and Sjogren syndrome Arteriostenosis/hypertension AIDS, CMV, Cryptosporidium infections Typhoid Empyema of the GB may develop as a complication of AC. In AC, the GB is usually distended  as a result of  inflammatory cells mixed with bile and calculi. The bile becomes infected as the disease progresses. In 85% of patients, the cystic duct disimpacts, and  the inflammation in the GB settles. If the cystic duct remains obstructed, the inflammatory process may progress to a GB empyema and  eventually  result in  perforation. Frequency United States Because of the close relationship between gallstones and AC, the distribution and the incidence of AC follow that of cholelithiasis. Gallstones may be present in more than 20 million  persons in the United States,  resulting in 500,000 cholecystectomies annually. In 10-20% of patients, AC complicates the course of symptomatic gallstones. 2   AAC accounts for 5-15% of cases of AC,22 with the  incidence  being higher in ICU patients, particularly  those with burns and trauma. Most cases of AC in the ICU are acalculous, but in this setting, the overall incidence of acalculous AC is only 0. 2%. In the majority of postoperative cases (90%), AC is acalculous. 5 Mortality/Morbidity The AC mortality of 5-10% is  mostly confined to patients older than 60 years. AC may be complicated by empyema, gangrenous cholecystitis, GB perforation, pericholecystic abscess, and bilioenteric fistula. Gangrenous cholecystitis is a frequent cause of GB perforation. Suppurative complications are more frequent in the elderly. Most localized perforations can be satisfactorily treated by means of surgery. Although free intraperitoneal perforation is  rare, it is associated with a mortality of 25%. Necrosis of the GB wall occurs in about 60% of cases of acalculous cholecystitis because gangrene and perforation are frequent. Mortality can be as high as 9-66%. 6 The higher mortality in AAC  has been  attributed to delayed diagnosis and comorbidities. The morbidity associated with emphysematous cholecystitis is also higher, because  GB wall gangrene and perforation. Recurrent symptoms are common in patients with AC who are treated expectantly, and most patients need elective cholecystectomy. Race Because of the close relationship between gallstones and AC, the incidence of  AC is expected to be higher in races with a higher incidence of gallstones. Such populations include Native Americans and persons of Chinese or Japanese descent. Sex The male-to-female ratio of AC is 1:3. AAC is more common in men than in women; the male-to-female ratio in AAC is 2-3:1. Acute emphysematous cholecystitis is also more common in men than in women. Age AC affects all age groups, but the peak incidence is in  persons aged 40-60 years. Approximately 50% of cases of AC in children are acalculous. Anatomy The GB stores and concentrates bile,  and the ducts function as a bile drainage system. The flow of bile through the bile ducts is affected by several factors, including hepatic secretory pressure, tone in the sphincter of Oddi, the rate of GB fluid absorption, and GB contraction. Anatomically, the GB is a pear-shaped musculomembranous reservoir lying in the GB fossa on the inferior aspect of the liver. The fundus of the GB lies close to the nterior abdominal wall and near the hepatic flexure of the colon. The surface marking of the GB fundus is in the region of the costal cartilage. At this point, it is covered by peritoneum, and its proximity to the hepatic flexure of the colon may obscure it. The body of the GB is adjacent to the duodenum, which indents and produces a frequent ultrasonographic artifact that mimics gallstones or a mass in the GB. An inflamed GB may perforate into the colon or duodenum because of the close proximity of the GB to these structures. The mucosa of the GB neck is thrown into folds, giving an echogenic appearance that may also mimic gallstones. A small pouch, known as the Hartmann pouch, projects from the right side of the GB neck. When visible, this finding is frequently associated with pathology, particularly dilatation. The GB fundus is often folded over, and the GB then assumes a double-barrel appearance. Pseudoseptation of the GB fundus  caused by  kinking or, occasionally, a true septum called the phrygian cap is seen in 2-6% of GBs. The phrygian cap is of no pathologic significance. A cystic artery supplies the GB, and it is usually a branch of the right hepatic artery. The artery lies in the triangle made by the liver, the cystic duct, and the common hepatic duct (CHD). Other, smaller tributaries supply the GB  through the right hepatic artery via the GB bed through the liver. Usually, the right hepatic artery passes behind the CHD and the cystic artery crosses behind the cystic duct. In 25% of cases, the common hepatic artery passes in front of the CHD and the cystic artery in front of the cystic duct. Recognition of GB blood supply is gaining increased importance because of vascular intervention in the liver, particularly chemoembolization. Catheters should be placed distal to the cystic artery to prevent embolic material from entering the cystic artery and causing GB ischemia. Ultrasonographic anatomy The GB is a pear-shaped anechoic structure indenting the inferomedial aspect of the right lobe of the liver. A linear echogenic line representing fat in the main interlobar fissure is interposed between the GB and the right main portal vein. The GB mucosa is hyperechoic, the submucosa and the muscle layer are hypoechoic, and the serosal surface fatty layer is hyperechoic. A linear fold is present on the posterior GB wall at the junction of the body and neck. Called the junctional fold, this structure is of no pathologic significance. Sound waves from the spiral valve of the neck may cast an acoustic shadow and mimic a gallstone. The normal thickness of the GB wall is usually less than 3 mm. Provided that the patient has been fasting for 8-12 hours, visualization of the normal GB should be nearly complete. In a truly fasting patient, nonvisualization of the GB is a pathologic finding in 96% of patients. GB dimensions The normal GB usually measures 7-10 X 2-3. 5 cm. In the fasting patient, the normal dimensions of the GB seldom exceed 4 X 10 cm. The size of the GB generally increases with age, but the GB wall thickness is unaffected by age. The normal wall thickness is 2-3 mm. Neonatal GB dimensions are 0. 5-1. 6 cm (mean, 0. 9 cm) X 2. 5 cm. The wall thickness is usually 1 mm. GB anomalies Many anatomic anomalies affect the GB. The recognition of these anomalies is important in the context of GB disease. Errors in GB surgery are frequently a result of the failure to appreciate variations in the anatomy of the biliary system. Anomalous positioning or orientation of the GB includes situs inversus when the GB is in the left upper quadrant. A GB  in the left lobe of the liver without situs inversus is rare. Heterotaxia, which represents an intermediate situs with GB in the midline, may be associated with asplenia, polysplenia, pulmonary isomerism, and congenital heart disease. An anomalous orientation may be present when the GB is vertical or horizontal. It may descend into the right iliac fossa, particularly in the presence of the Riedel lobe. Unusual locations include intrahepatic, suprahepatic, lateral, anterior abdominal wall, and retrorenal sites. The GB may also be present in the thorax, in the falciform ligament and/or interlobular fissure, and in the transverse mesocolon. A wandering GB results when the GB is suspended on its own mesentery. Recognition of this anomaly is important because  such a GB is  prone to torsion. Agenesis is a rare anomaly found in 0. 04-0. 07% of autopsies. Agenesis may be associated with biliary atresia, imperforate anus, CHD, and common bile duct (CBD) anomalies. Rarely, the GB opens separately into the duodenum. The most common anomalous shape is due to the phrygian cap, in which the fundus of the GB is folded back on itself, producing a kink in the fundus. The GB may rarely appear as a diverticulum with no cystic duct. Other anomalies include fishhook, a siphon, and an hourglass configuration. A diverticulum of the GB is extremely rare and usually located at the neck of the GB. This is rarely symptomatic unless it is complicated by calculus disease. Regarding GB duplication, true duplication is rare, but it has been reported in as many as 1 in 3000-4000 people, with a male-to-female ratio of 2:1. Triplication is even rarer, and it may be an incidental finding at autopsy. In duplication, each GB may have a separate cystic duct or there may be 1 shared cystic duct. A septate GB may have an isolated transverse septum. True duplication has a longitudinal septum. A multiseptate GB is extremely rare, with multiple loculi connected by small pores; patients with this condition are particularly prone to bile stasis and calculus formation. With an anomalous cystic duct insertion, the cystic duct may insert into the CBD or CHD high or low. The cystic duct is often intramural, running for some distance in the wall of the CBD within a common sheath. Congenital stenosis of the cystic duct is extremely rare, and it may be complicated by calculus disease. Heterotopic tissue may be present within the GB, where gastric or pancreatic tissue has been described within the GB wall. This tissue may mimic tumors. Clinical findings AC usually occurs with right upper quadrant pain and tenderness. The abdominal pain increases with time. The site of pain is usually the right subcostal region, although the pain may begin in the epigastrium or the left upper quadrant and then shift to the right subcostal region to the area of the GB inflammation. Referred pain to the right shoulder or the interscapular region may be experienced. Approximately 70% of patients have had previous attacks of similar pain that spontaneously resolved. Anorexia, nausea, and vomiting may occur, but vomiting is seldom severe. Most patients are afebrile and have no leukocytosis. When fever occurs, the patients temperature is seldom  higher than 38 °C. Chills are unusual, and their presence suggests a complicated cholecystitis (abscess or associated cholangitis). Palpation of the right subcostal area reveals muscle spasm. During deep inspiration, the tenderness becomes suddenly worse and produces an inspiratory arrest called the Murphy sign. The Murphy sign  cab be elicited with an ultrasound probe. In approximately 35% of patients, a distended, tender GB may be palpable as a distinct mass. This is an important clinical finding and may confirm the diagnosis. Approximately 20% patients with AC may have mild jaundice, which may be related to common hepatic and/or bile duct edema or to the presence of calculi within the CBD. 22 Most patients improve within 24 hours after hospitalization, and signs and symptoms gradually subside. However, persistent pain, fever and leukocytosis, chills, and more severe localized or generalized tenderness may indicate complicated disease such as abscess formation or GB perforation. The development of empyema of the GB can produce systemic toxicity, and it may be a predictor of GB perforation. Leukocytosis is pronounced with empyema and is usually in the range of 10,000-15,000/? L. The clinical differential diagnosis includes acute pancreatitis, perforated peptic ulcer, gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome) in women, acute hepatitis, pneumonitis, pyelonephritis, cardiac disease, sickle cell crises, and leptospirosis. AAC is difficult to diagnose clinically. It occurs often in children (50%) and in patients who are critically ill or who have recently undergone stress from severe trauma, burns, or surgery. Predisposing factors include prolonged fasting, immobility, and hemodynamic instability. Often, these patients cannot express pain; however, fever, jaundice, vomiting, abdominal tenderness, leukocytosis, and hyperbilirubinemia should lead to a high index of clinical suspicion. Children with AAC more often present in the outpatient setting than in other settings, and they usually present with  right upper quadrant  pain in the absence of gallstones. These patients are usually treated by means of cholecystectomy. Some elderly patients have few signs during their initial presentation with AC. A minority of adult patients, mostly elderly patients with AAC, also present in the outpatient setting. These cases are diagnosed and treated early and are associated with a good prognosis. Causes Hemolytic o Hemolytic anemias such as congenital spherocytosis (43-85%), sickle cell disease (7-37%), and thalassemia o Cardiac causes such as mitral valve stenosis and prosthetic heart valves o Pernicious anemia o Aortic aneurysm o Hypersplenism Metabolic o Overweight, female sex, fair complexion, fertile, and age of 40 years or older o Diabetes mellitus o Obesity o Hemosiderosis o Pregnancy o Prolonged use of estrogen/progesterone o Hyperparathyroidism o Cystic fibrosis o Pancreatitis o Hypothyroidism Muscular dystrophy o Crohn disease o Ileal resection and intestinal malabsorption o Type IV hyperlipidemia o Surgical bypass for obesity o Cholestasis Miscellaneous o Chronic hepatitis o Cirrhosis o Congenital biliary malformation (eg, Caroli disease) o Parasites (eg, ascariasis, liver flukes), which form a nidus for development of calculi o Drugs such as methadone o Biliary strictures ( eg, oriental cholangiohepatitis [bile stasis]) Genetic o Genetic predisposition in populations such as Native Americans o Higher incidence of intrahepatic gallstones in Chinese and Japanese populations Preferred Examination Clinically, few signs differentiate uncomplicated AC from complicated AC. Complications of AC may have serious clinical implications. These complications include perforation, pericholecystic abscess, and development of empyema and bilioenteric fistula. Therefore, radiologic imaging makes a substantial contribution to the differential diagnosis. Ultrasonography significantly aids  in the diagnosis of AC, although most ultrasonographic signs are not typical but suggestive of AC. Inflammatory pericholecystic reaction in the GB fossa is better depicted with CT than with other techniques. Also, CT is useful in making the differential diagnosis when obesity or gaseous distention limits the use of ultrasonography. MRI can demonstrate the same morphologic changes as CT, displaying inflammatory changes in the GB wall, pericholecystic fat, and intrahepatic periportal tissues. Plain radiography greatly contributes to the diagnosis of emphysematous pyelonephritis, and ultrasonographic and CT scan results can further confirm the diagnosis (although  CT scanning is  not strictly needed  to make  the diagnosis). Cholescintigraphy is an extremely sensitive diagnostic modality in diagnosing AC, although the findings are nonspecific. Oral cholecystography is of historical interest and has no role in the diagnosis of AC. Arteriography is seldom required for AC. Limitations of Techniques Plain radiographic findings may be entirely normal. Radiolucent calculi are visible. Opaque calculi in the  right upper quadrant  on plain abdominal radiographs may be an incidental finding and is not necessarily related to AC. Oral cholecystography is of historical interest and has a low sensitivity and specificity in the diagnosis of AC. The main features of AC on ultrasonography are all nonspecific findings. Examples include GB thickening, calculi in the GB, a positive ultrasonographic Murphy sign, and pericholecystic fluid. The sonographic Murphy sign is negative in as many as 70% of patients with AC. In a perforated GB, the wall of the GB is not well delineated, and a localized interruption of the wall may not be noted at the site of perforation. Ultrasonography has problems in making the diagnosis in obese patients and in patients with gaseous distention. The technique remains operator dependent. CT exposes the patient to a radiation burden, which may not be necessary. Arteriography is invasive and is seldom indicated. MRI has a limited availability; it is expensive; and it has problems in making the diagnosis in patients with certain prosthetics, surgical clips, cardiac pacemakers, or claustrophobia. Although cholescintigraphy is  sensitive, it has a low specificity and involves the use of ionizing radiation.

Tuesday, February 25, 2020

Social implications of IT Essay Example | Topics and Well Written Essays - 2500 words - 2

Social implications of IT - Essay Example It is the fastest growing branch of electronics and computer technology. The distinguishing feature of VR is that its users feel that they are living in the computer – generated scene. VR games and other accessories are generally available with Incredible Universe and CompUSA chain stores. The present estimation regarding sales in the virtual reality market is approximately ninety million dollars per annum; and this is expected to increase to nearly six billion dollars in the future1. Virtual reality can be attributed to Sutherland who performed several pioneering works to develop the concept of virtual reality in the 1960’s. However the phrase virtual reality was coined for the first time in the late 1980’s. Some historians claim that the VR industry emerged during the 1990’s. VR gained popularity due to the extraordinary efforts of the early pioneers in this field2. Virtual reality is a computer – simulated world with which users can interact. These simulations, generally have some common characteristics, such as shared workspaces for the interaction of people with the programme, graphical user interface, real – time action, interactivity and persistence. Almost all simulations can be accessed over the internet. In those simulated worlds, there will be changes to the themes and landscapes, irrespective of the users who access the site. Online real time games come under this category of VR. For instance, Massively – multiplayer online role – playing games or MMORPGS are played in the virtual worlds. These are video games, which allow players to choose the persona of the characters in the play, and these persona are termed as avatars. MMORPGs and other virtual worlds are considered to be social networking programmes. Moreover, players can interact, form clubs, groups and chat with each other3. The availability of personal computers increased in the