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 .

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.

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

Define the Unique Selling Proposition ( USP) for Nordstrom. Describe a Assignment

Define the Unique Selling Proposition ( USP) for Nordstrom. Describe a USP for each keyroduct and create an Executive Summary - Assignment Example Nordstrom promises that the customer will not only get a product of high quality but also will get the best service from the product and from their staff (Nordstrom). Nordstrom has Jackets that they it calls â€Å"Jacket of all Trades†. The branding of the Jackets is the first unique aspect of the clothing. Secondly the branding proposes that the jackets they sell are for all occasions and third is that the jackets are of high quality at affordable prices and thus gives the customers value for their money and this also has the potential to attract new customers (Nordstrom). Nordstrom has a variety of key products and these include clothing, footwear, bedding, furniture, Jewelry, beauty accessories and house ware. The USP for these products is embedded in the overall companies USP of quality and service. All the products are of high quality and give the customers the service they are intended to give besides the exceptional service that the customers are given at the shops. For example their shops have personal stylists assigned to customers shopping for clothing and this shows how much they care about their customers (Nordstrom). Nordstrom, Inc. is America’s leading fashion specialty retailers. It was founded in 1901 as a shoe shop in Seattle, currently Nordstrom manage 225 stores in 30 states, including 117 full-line stores, 104 Nordstrom Racks, two Jeffrey boutiques, one treasure &bond store and one clearance store (Nordstrom 2). Nordstrom is also available online at  Nordstrom.com  selling on the internet and through its catalogs. Furthermore, the Company operates in the online private sale marketplace through its subsidiary HauteLook. Nordstrom, Inc.s common stock is publicly traded on the NYSE under the symbol JWN. Its mission is to provide the best possible customer service, selection, quality and value and this has made it attract a huge customer base (Nordstrom). The

The School of Athens by Raphael Essay Example for Free

The School of Athens by Raphael Essay The School of Athens by Raphael is a complex painting with a fascinating composition. The subjects, building, composition and his use of color make it a compelling piece. This painting is extremely decorative and complex. With various tools, Raphael was able to emphasize different aspects and pull the viewer into the work. Because of the colors used in the painting, and the setting, this painting seems to be of religious or educated figures. This painting has many subjects, most of which appear to be male. Knowing that most renaissance paintings have both genders, one would conclude that there are a few females. All of the subjects are wearing colorful, flowing robes. The fact that they have colorful clothing on symbolizes a high rank. This rank is either of the church or of land. The highly crafted building the subjects are in leads the viewer to think that the rank is from the church or education. In the middle, the subjects are surrounding two men. Everyone seems to be listening to the men. The men in the bottom left are reading or writing, what could be the primary mens words. The ones in the bottom right are surrounding a board on the floor and could be discussing the words of the men. With all of the conversing going on, and the layout of the people, one would assume that this is a lecture setting. This story is going on in a large, ornate, arched-ceiling building. This building is painted from top to bottom. The main arch in the front has a very geometric pattern on it but the column connecting it to the ground is flowery. There is gold on the ceiling, on the decorative pieces between each painting. The top-left corner has a large rock painted on a background of gold. There is a person standing behind it but the edge of the painting cuts it off at the waist. Under the large rock painting, there is a smaller gold tree on a blue background. These two colors are the epitome or wealth because they are the most costly to buy. In the top right corner, again cut off by the border of the painting, there is a group or what appear to be women. They are focused around some type of animal in the middle. Below this is the same tree as the opposite side. The filling between the two large paintings and the smaller trees is all triangular. It has an ornate pattern in blue and gold, just like the trees. In the bottom left-hand corner, there is a framed square, which looks like it is a mirror. The way there is wood  in it but no other bare wood anywhere in the picture makes it seem to be a reflection. Behind the large arch in the front, there is a hallway type of structure. It has a statue on each side with smaller carved scenes under them. The hallway, which opens up to a ceiling-less patio has statues, similar to the ones on the wall. The archways have geometric carved patterns covering the ceilings. Unlike the foreground arch, the background ones are white stone; there is no paint or gold on them. As the arches become smaller and the sky becomes larger, the pure blue sky with fluffy white clouds begins to show. This painting is very realistic, because of the detail of ornamental pieces and because of the accuracy of the structure. The perspective is precise; larger things are in the foreground and smaller things are in the background. Unlike earlier paintings, the building looks like you could walk through it. The scale of the subjects is also very accurate. Some earlier works had the most important characters larger and in the middle. The values, which differ in the arches, show depth. The arches are darker on the underside and on the right walls, to show a direction of light from the right. The people on the sides are not exact copies but the fact that they are on both sides makes the painting approximately symmetrical. The evenness of the arches also emphasizes the symmetrical characteristic. The composition of the image is made interesting by the complexity of the people. The empty building without the individuals in it would be an architectural study. The colors in this painting pull the viewer in. The use of gold in modesty, compared to many other paintings, makes the whole painting brighten. The colors on the robes are impressive. The subjects closer to the two in the middle have more primary and secondary colored gowns while the perimeter has primarily tertiary colored clothing. This may have to do with class or emphasis. As concluded earlier, the middle subjects are significant so to make them stand out, the robes are more vibrant. The archway in the front is much more decorative and frames the subjects underneath. With the arches in the back being less showy, the foreground with the people stands out more. In conclusion, this painting has many facets and details, which could go unnoticed. Raphael stressed certain parts by using color and framing. The context leads one to believe that the subjects are knowledgeable. With the color, composition and subjects combined, this painting is a significant piece. The School of Athens is an elaborate painting with a multifaceted story.

The Turkish Pogrom of 1955 and the Elimination of the Greek Minority of

With an official statement, issued on 7 September 1955, the Menderes government expressed its deepest sorrow for the losses suffered by Greek minority in Istanbul. The Turkish Prime Minister blamed the riots on communists, underlining its commitment to the exemplary punishment of the perpetrators (Xristidis 2000). The interpretation of the pogrom as a conspiracy of international communism was repeated during the extraordinary meeting of the Grand National Assembly, which took place on September 12, 1955. However, under the force of circumstances, Adnan Menderes admitted that the government knew about the demonstration on September 6th, in advance. Also, the Turkish Prime Minister argued that, the riot was a spontaneous expression of national sentiment of the Turkish people who was stimulated by the news about the imminent massacre of Turkish Cypriots on 28 August. Moreover, he stated that the hysteria that gripped the crowd was so strong that immobilized the police forces, which foun d themselves between their quest to restore order and their commitment to the homeland, thus leaving full freedom of movement to the protesters. The claim of the Turkish government that the country suffered a severe blow because of the Communists was met with scepticism by foreign observers (Guven 2006). First of all, the number of Communists in Turkey was small and secondly, their activities were under the watchful eyes of the Turkish Intelligence Services (MIT). It seems that, only a small percentage of people who were arrested immediately after the episodes were communists. The arrest of those who had communist beliefs, such as the well-known Turkish writer Aziz Nessin, was totally unjustified, since there was no evidence for their participation i... ...itly the Christian Orthodox and Jews, which were the largest minority groups from Turkey. In addition, according to nationalist elites, these minorities were assimilable thus, were not capable of becoming part of the Turkish nation. Also, they stated that, the Non-Muslim minorities, mainly the Greek, were not composed of loyal citizens but possible traitors to the Turkish state (Guven 2006). Adnan Menderes believed that was national and extremely important responsibility of every Turk to implement the Turkification, in an attempt to establish an independent Turkish state. A corollary of this concept was the effort of assimilation of the Greek minority by force, exercising a policy of discrimination and restrictions against it. In this context, the language, culture and desires of Non-Muslim minorities had to be connected with the history and dignity of Turks.

Mount Everest and Peak Climb Mt

The book I chose for my independent reading project was Peak by Roland Smith. My favorite character in this book is Peak Marcello. Peak is my favorite character because he is smart, caring, and brave. I can’t believe that he climbed a skyscraper! I wish that I had the climbing skills that he has. It seems like Peak has been climbing his whole life, probably because his father, Josh Wood, is a professional climber and he taught him how to climb. Since Peak’s mother, Teri Marcello, fell of a 30 ft. wall when she was free-climbing and broke her back and shattered her hip, I agree with her that climbing is very dangerous.I think the relationship between Peak and his father is interesting because Peak’s father hasn’t been around much in his life, but when Peak got in trouble he was there. I also think that the relationship is interesting because Peak doesn’t call his father â€Å"dad,† he calls him by his first name. Because Peak got in a lot of t rouble and had to leave the U. S. and live with his father in Thailand, I felt sad when Peak’s two younger twin sisters started to cry because they knew that they wouldn't be seeing their role model for a long time.I think that Josh only let Peak live with him because he was 14, and if he reached the summit of Mt. Everest before his next birthday, he would be the youngest person to ever climb it. I want to know more about Zopa, the man who is helping Peak climb Mt. Everest. I know that he was a Sherpa, which are mountain people who live on the slopes of the Himalayas. He is also a Buddhist monk but has gotten permission to put aside his vows for a couple of weeks to help Peak.I like the way that the author wrote the book because it is very easy to understand what is going on. If I were Peak right now I would be so confused because so much is happening in such a small amount of time, and I’d be scared because I am afraid of heights and I don’t know if I would wan t to climb Mt. Everest. I can’t believe that Peak is so calm during this time and isn’t freaking out like I would be. I predict in the future that Peak will have a closer relationship with his dad and will be the youngest person to climb Mt. Everest.