Endoscopic Ultrasound Benefits in Gastroenterology

Endoscopic Ultrasound Benefits in Gastroenterology Endoscopy, a big fortune for disease around gastrointestinal tract Gastroenterology, especially the techniques in gastrointestinal (GI) endoscopy, has developed rapidly in the past two decades. The progress made in minimally invasive endoscopic techniques enables more and more gastrointestinal diseases detected and treated. Getting to be mature, the techniques such as the endoscopic ultrasound (EUS), are now applicable to more indications and not that restrained by the condition of GI wall; besides, the techniques are even applied to the organs surrounding the GI tract [1], such as lung, pancreas, gallbladder, liver, adrenal glands, bladder, uterus and etc. EUS EUS is a medical procedure which combines endoscopy with ultrasound to obtain images of the internal organs in the chest and abdomen. During the procedure, a small ultrasound probe is inserted into the GI tract to screening for surrounding lesions. On account of the very close proximity between the probe and the lesion, it is referred to as internal scanning. The high frequency EUS provides very high-resolution images but not leading to vision impairment caused by the air in GI tract. EUS can detect lesions in millimeters by the high-resolution image processed with short wavelength and high frequency sound. And these tiny lesions cannot be detected by CT scan, MRI and other methods, which can only detect lesions of larger volumes, typically measured in centimeters. EUS, recommended by numerous professional guidelines [2-6], have now become an irreplaceable tool in the diagnosis of hepatobilliary malignancies, lung cancer, esophageal cancer, gastric cancer, colon cancer and pancreatic cancer. EUS is also used to identify the tumor staging with invaded adjacent organs due to its accuracy, providing valuable information in selecting treatment protocols and estimating prognosis [7]. Furthermore, the development of linear scanning echo endoscopes has brought a new approach since the 1990s: the ultrasound-guided fine needle puncture. Since then, EUS has evolved from a purely diagnostic imaging modality to an interventional procedure. The devices make it possible to gain access into closed organs through the GI wall and the GI tract; not only the surrounding lesions of the GI tract are detectable, but also the samples can be collected for cytopathological diagnosis; besides, we can drain fluid and inject therapeutic agents to manage the diseases with the devices. EUS-FNA EUS guided fine needle aspiration (EUS-FNA) is currently performed as a routine examination in more and more endoscopic centers. It is extremely important to obtain the malignant samples with EUS-FNA for cytological or histological examinations safely and reliably with notable efficacy [8]; EUS-FNA is also essential in dependably excluding malignancy in indeterminate lesions, particularly for the otherwise inaccessible lesions 9. The GI tract traverses through various anatomical regions with corresponding specialties such as pulmonology, thoracic surgery, internal medicine, oncology, urology, gynecology and endocrinology, so the application of EUS-FNA is not confined to gastroenterology. For experienced practitioners, the sensitivity of this procedure in malignancy is over 90% 10.EUS-FNA is obviously significant in managing malignant tumors. EUS-guided therapy EUS-guided therapy covers immensely, including drainage of pancreatic fluids, gallbladder and other fluids, accessing to pancreatic and biliary systems; celiac plexus neurolysis; vascular interventions and ablative therapies. Being safe and effective, EUS is the first-line therapy for uncomplicated pseudocysts 11. Though there is still controversial, multiple studies have now shown that walled-off pancreatic necrosis (WOPN) can be treated with endoscopy at low morbidity and mortality [12. Limited literature there is, still can EUS guided drainage and debridement be successfully applied to treatment for uncomplicated pseudocysts such as abscesses in the lower and upper abdomen. EUS-guided fine needle therapy is becoming more promising. It is now considered as a cutting edge technique in the rapidly expanding field of therapy for pancreatic cancerà ¦Ã‚ ­Ã‚ ¤Ãƒ ¥Ã‚ ¤Ã¢â‚¬Å¾Ãƒ ¨Ã‚ ¡Ã‚ ¥Ãƒ ¥Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ãƒ ¦Ã‹Å" ¯Ãƒ ¥Ã‚ Ã‚ ¦Ãƒ ¦Ã‚ ­Ã‚ £Ãƒ §Ã‚ ¡Ã‚ ®, especially in an era when so many ablation therapies are confirmed with palliative effect for advanced pancreatic cancer. Pancreatic cancer is a significant cause of morbidity and mortality, the current therapies, however,benefit little to most patients. Recently, initial success is reported in many studies that medication injection and intra-pancreatic tumor therapy under the EUS guidance [13, including EUS-guided radiofrequency ablation, EUS-guided alcoholic ablation, EUS-guided gene therapy and EUS guided interstitial brachytherapy. These techniques enable us to manage pancreatic cancer in a relatively minimally invasive manner with low incidence of procedure-related complications. These latest cutting-edge techniques may give hope in treating pancreatic cancer, the deadly disease in the near future. Natural Orifice Transluminal Endoscopic Surgery (NOTES) More vigorous endoscopic therapies emerge as the development of flexible endoscopic technology, such as endoscopic necrosectomy, full thickness resection and endoscopic submucosal dissection. So more and more diseases are now treated with endoscopy. NOTES, another up-to-date technique as a promising alternative to conventional surgery, is of great concern recently. In NOTS, an endoscope passes through the natural orifice such as mouth, urethra and anus, and then it goes through an internal incision in the stomach, vagina or colon, thus external incisions and incision-related complications would be avoidable. The NOTES is improving as the GI closure instrument develops, and it is studied not only in animal models but also in humans [14, involving abdominal cavity exploration and biopsy, transvaginal cholecystectomy, transgastric appendectomy, transvaginal appendectomy, transvesical peritoneoscopy and so forth. According to literature, EUS is essential for its value in evaluating and performing NOTES [15-18. There is a promising platform for EUS-based NOTES in the future 15. Jeong et al has shown the feasibility of NOTES interventions through a forward-viewing endoscopic ultrasound 15. Currently, the following mentioned EUS-based procedures are performed: EUS evaluation and endoscopic biopsy of intraperitoneal organs, EUS-guided radiofrequency ablation (EUS-RFA), EUS-guided fine needle aspiration (EUS-FNA) and argon plasma coagulation (APC) for hemostatic control. Not only can EUS detect the lesions surrounding the GI tract, but also can locate for the NOTES procedure. EUS guided drainage for pseudocyst and EUS guided transluminal retroperitoneal endoscopic necrosectomy of walled-off necrosis have now proved to be safe and effective in clinical setting 15, 19. This is the real day for NOTES technique. Studies on NOTES are encouraging, but still there is a long way to go. More sophisticated NOTES technique is to be explored to guarantee the safety of the procedure. To summarize, more and more diseases surrounding the GI tract can be diagnosed and treated as the big fortune of endoscopic technique develops, such as the EUS and NOTES, and the GI tract will become the service tunnel of human body. References Mekky MA, Abbas WA. Endoscopic ultrasound in gastroenterology: From diagnosis to therapeutic implications. World J Gastroenterol. 2014 Jun 28;20(24):7801-7807. Ajani JA, Barthel JS, Bentrem DJ, DAmico TA, Das P, Denlinger CS, et al. Esophageal and esophagogastric junction cancers. J Natl Compr Canc Netw. 2011 Aug 1;9(8):830-87. Ajani JA, Bentrem DJ, Besh S, D’Amico TA, Das P, Denlinger C, et al. Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw. 2013 May 1;11(5):531-46. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Pancreatic Adenocarcinoma. Version 1.2013. Accessed September 24, 2013. Kalemkerian GP, Akerley W, Bogner P, Borghaei H, Chow L, Downey RJ, et al. Smallcelllungcancer. J Natl Compr Canc Netw. 2011 Oct;9(10):1086-113. Ettinger DS1, Akerley W, Borghaei H, Chang AC, Cheney RT, Chirieac LR, et al. Non-small cell lung cancer.J Natl Compr Canc Netw. 2012 Oct 1;10(10):1236-71. D’Journo XB, Thomas PA. Current management of esophageal cancer. J Thorac Dis 2014;6(S2):S253-S264. Leong S, Shaipanich T, Lam S, Yasufuku K. Diagnostic bronchoscopycurrent and future perspectives. J Thorac Dis 2013;5(S5):S498-S510. Costache MI, Iordache S, Karstensen JG, Saftoiu A, Vilmann P. Endoscopic ultrasound-guided fine needle aspiration: From the past to the future. Endosc Ultrasound 2013;2:77-85. Sahai AV. Endoscopic ultrasound-guided fine-needle aspiration: Getting to the point. Endosc Ultrasound 2014;3:1-2. Ng PY, Rasmussen DN, Vilmann P, et al. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts: Medium-term assessment of outcomes and complications. Endosc Ultrasound 2013;2:199-203. Kawakami H, Itoi T, Sakamoto N. Endoscopic Ultrasound-Guided Transluminal Drainage for Peripancreatic Fluid Collections: Where Are We Now? Gut Liver. 2014 Jul;8(4):341-355. Epub 2014 Jul 1. Carrara S, Petrone MC, Testoni PA, Arcidiacono PG.Tumors and new endoscopic ultrasound-guided therapies.World J Gastrointest Endosc. 2013 Apr 16;5(4):141-7. Chen Huang, Ren-Xiang Huang, Zheng-Jun Qiu.Natural orifice transluminal endoscopic surgery: New minimally invasive surgery come of age. World J Gastroenterol. Oct 21, 2011; 17(39): 4382-4388. Jeong SU, Aizan H, Song TJ, Seo DW, Kim SH, Park do H, et al. Forward-viewing endoscopic ultrasound-guided NOTES interventions: a study on peritoneoscopic potential. World J Gastroenterol. 2013 Nov 7;19(41):7160-7. Donatsky AM1, Andersen L, Nielsen OL, Holzknecht BJ, Vilmann P, et al. Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study. SurgEndosc. 2012 Jul;26(7):1952-62. Matthes K1, Thakkar SJ, Lee SH, Gromski MA, Lim RB, Janschek J, et al. Development of a pancreatic tumor animal model and evaluation of NOTES tumor enucleation. SurgEndosc. 2011 Oct;25(10):3191-7. Saftoiu A1, Vilmann P, Bhutani MS. Feasibility study of EUS-NOTES as a novel approach for peroralcholecysto-gastrostomy. Chirurgia (Bucur). 2013 Jan-Feb;108(1):62-9. Abdelhafez M1, Elnegouly M, Hasab Allah MS, Elshazli M, Mikhail HM, Yosry A. Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surg Endosc. 2013 Oct;27(10):3911-20.

The Transformation of George in John Steinbecks Of Mice and Men :: Steinbeck Of Mice and Men Essays

The Transformation of George in Of Mice and Men Of Mice and Men, by John Steinbeck, is a dramatic novel that depicts how different groups of people were treated and how hard life was during the Great Depression. Lennie and George were the main characters along with Curley and his wife, Candy, Slim, and Crooks. Lennie, a big guy and mentally slow, is George's friend and doesn't really change throughout the novel. George, on the other hand, is a small man and changes from a daydreamer to a more down-to-earth, logical person. In the beginning of the novel George daydreams of the future and tells Lennie stories about how they are going to have a farm someday with rabbits. George never really has any set plans on how he will get the farm with Lennie. At about the same time George is telling tales of the future, Lennie is petting mice and killing them. George knows that killing the mice is an accident and doesn't think Lennie would hurt any people. George and Lennie keep drifting and land a job in Soledad, California. Upon arriving in Soledad, George and Lennie meet Candy, an old man with a gimp hand who shows an interest in the farm. Candy offers to throw in $350 if he can be a part of their "dream farm". Suddenly, Georges dreams of the future start to seem more like a reality when they hear of a small plot of land for sale. When everything seems to be going right, a freak accident occurs. Lennie is invited by Curley's wife to pet her hair. He starts to pet her hair when she quickly wants him to let go and screams. Lennie panics and accidentally kills her because he hasn't learned from his mistakes. When Curley, the boss' son, hears of what happened he starts to look for Lennie who is hiding. Curley says that when he finds Lennie he will shoot him in the gut. George knows that him and Lennie couldn't run from this mistake, and Lennie will be hunted and killed painfully. To spare him the pain George kills Lennie quickly. Even though going on with the dream farm would be possible, George knows it wouldn't be the same without Lennie.

Eco- Resort

Hotel and Resort Management Assignment Diploma Fall 2012 Title:Growing trend: Eco-resorts Tutor:Mr. Hailstones From:Katy Hui Man Ying Course:Diploma 2 Submission Date:Week 15 Word count:1,553 Table of Contents Introduction3 Criteria of Eco-resorts4 – 6 Benefits of Eco-resorts6 – 7 Considerations on Eco-resorts7 – 8 Conclusion8 References9 – 10 Introduction There are researches done by the United Nations Environment Program (UNEP, 2005) indicate that, from 1994 to 2004, the international economic sector of tourism industry has grown by 25%, contributing to 10. % of the world’s total GDP. To aid the growth of tourism, the UNEP, connected with the World Tourism Organisation, has released the report titled Making Tourism More Sustainable: A Guide for Policy Makers. The report emphasizes the importance of tourism hoteliers to make efficient effort to maintain the environmental sustainability. According to World Wildlife Fund (2010), eco-resorts are †Å"types of resorts in which eco-efficiency measures are adopted throughout the lifecycle of the building, ranging from orientation, design, operation and maintenance†.Dowling (2000) also defines the eco-resort, quoted as followings: â€Å"An eco-resort is a self-contained, upmarket, nature-based accommodation facility. It is characterised by environmentally sensitive design, development and management which minimizes its adverse impact on the environment, particularly in the areas of energy and waste management, water conservation and purchasing. † (Dowling 2000: 165). To summarise the above, eco-resorts are not just focusing on the operation process, but from the concept design until the sustainability of the on-going policies.This paper is going to explore the principles of eco-resorts, also analysing the benefits and the disadvantages of eco-resorts. Criteria of eco-resorts The Sharetime Magazine (2011) suggests that eco-resorts include the theme of re-use, re-cycle and reduce. As mentioned before, in order to claim that is an eco-resort, there are several criteria to be covered. Environmental factors should be considered during the design stages of the resort. Murphy (2008) suggested that the landscape features need to be appealing to guests and efficient to operate.Bohdanowicz (2003) pointed out that resorts are built â€Å"to provide comfort and services twenty-four hours a day, year round†. This shows that the consumption of the resorts is massive and non-stop. Green-orientated landscape features can be added during the design stages in order to carry out the green policies in the operations. One of the most significant examples of green-orientated landscape is the green roof. According to the EPA, the United States Environmental Protection Agency (2012), a green roof is a ‘vegetative layer grown on a rooftop’.The green roof helps cool down the temperature in the area through evapotranspiration. During the process of eva potranspiration, water from the rooftop soil is absorbed and enters the plants in the transpiration process. The water is then evaporated by the sun through evaporation (Wark, 2010). The other main benefit from implementing a green roof is that the air quality will be improved by a green roof (Martin, 2008). It works as a natural air-cleaner as green plants absorb carbon dioxide, the most common automobile emission, and release oxygen.In addition, as resorts are massive in energy consumption, it is efficient and beneficial to design a building-integrated photovoltaic. The building-integrated photovoltaic is solar electricity systems which are built into a building, instead of added on a building later (Gold Coast Energy, 2012). Solar energy is known as one of the most effective renewable energy source. The research carried out by Roisin (2012) points out that the amount of incident solar energy on earth each year equals to 1500 times the world’s annual energy use.Apart from t he green-orientated landscape features, there are small designs that can input in the design of the resorts. For example, the resorts can design to use energy saving light bulbs such as LED light bulbs to minimise the energy consumption (Eartheasy. com, 2012). Another idea is to create policies that aim at being eco-friendly. In the aspect of transportation, electric cars can be used within the resort area, to minimise the exhaust emission (Dissabandara, 2010). In the aspect of technology, nowadays the Key Activated system is common in most of the resorts (Entergize, 2012).The system is designed to reduce the energy consumption to minimum level in the resorts while the room is unoccupied. It automatically detects the room status and switches the energy on and off. This reduces the unnecessary waste of energy cost by the guests. In the aspect of daily operations, there are several ways to be ‘green’. The re-use towels policy based on guest request helps save energy and w ater for washing laundry. According to the Pacific Institute (2011), toilet flush volumes in the resort have declined significantly in the past 25 years, decreasing from 6 gallon per flush in 1980s to the new volume 1. gallon per flush in 2001. In addition to that, the older showerheads have flow rates of an average rate of 5 gallon per minute and 3. 5 gallon per minute average flow for the new ones (Vickers, 2001). The above changes in the resort accommodation greatly help minimising the consumption level of water within a resort. Recycle of wastes can also be carried out to ensure the environmental footprint of the resorts to be minimised. In order to help the customers define the eco-resorts, there is a third-party certification program, which is known as LEED, Leadership in Energy and Environmental Design.According to LEED official website (2012), it is a nationally accepted organisation for design, operation and construction of high performance green buildings. With the LEED ce rtification, the resorts can thus claim themselves an ‘eco-resort’. Benefits of eco-resort To introduce, the sustainability of both the business and the neighbourhood environment has become two important focuses in the recent years. Firstly, in the point of view of the resort owners, the eco-friendly concept can attract target market group which has awareness to the environment aspect.Eco-resorts provide a positive impression to the public, which is also a major selling point for marketing. LEED certified resorts can request a higher rental rates than the non-certified resorts (LEED, 2012). Secondly, standing in the position of a consumer, eco-resorts can be attractive to who is paying attention to environmental protection. They can enjoy themselves in the resorts without worrying about massive damages to the environment. Thirdly, looking on the environmental side, eco-resorts, for sure, is an absolute benefit to the environmental protection.It is not just about the pre sent effort, but also raising public awareness to environmental protection (Eco Green Hotel, 2008). Considerations in eco-resorts It is no doubt that going green for a resort is a contemporary develop trend and an absolute benefit to resort management. However, there are some constraints that needed to take in consideration during planning. First of all, focusing on the staff management, for sure that the staffs working in a green resort should maintain the green policies carried out. The staffs need to be well-trained and willing to input effort into helping the resort to be ‘green’ (Townsend, 2011).Individuals that are believed in environmental protection will be willing to do more work for the environment. This is one of the motivations to the organisation as keeping the resort ‘green’ is a complex responsibility. Another point is at the financial side, the construction cost and maintenance fee of the building-integrated photovoltaic is higher than tradi tional electricity system (Sutherland, 2008). The hoteliers need to consider whether the cost is worth spending to operate an eco-resort. In addition to that, consumer behaviour is one factor which is not controllable.Even if the resort is encouraging customers to save energy and reduce wastes, they may still produce a lot of wastage throughout their stay. For example they may flush the toilet a few more times due to the fact that the decrease in the volume per flush. Therefore, it is an uncertain input to the resort. The resort can encourage the customers to be environmental friendly through marketing campaigns. Conclusion To summarise the above, it is a win-win strategy for both the business and the neighbourhood environment to go ‘green’ as long as they are able to set up an effective plan successfully.It is not just about recycling, but a complex concept with different considerations. Designs, operation policies, financial aspect, human resources and customersâ€⠄¢ behaviour are the major elements that are included in an eco-resort. They need to be linked and corporate with each other in order to set up a successful eco-resort. People nowadays pay more and more attention in environmental protection, sustainability is a growing concern to all industries. It is a trend for the hospitality to go green, as a small step of the resort can bring huge improvement to the environment.According to Murphy (2008), the resort should have a long-term vision and goals that matches sustainable objectives development strategy. Resorts should try to minimise the ecological footprint, which has been proposed to be ‘accounting tool that enables us to estimate the resource consumption and waste assimilation requirements of a defined human population (resort) in terms of a corresponding productive land area’ (Wackernagel and Rees, 1996). References Dissabandara, R. (2010). International Conference on Sustainable Built Environment. Eco Friendly Resort For Tourism: A Case Study at Ulagalla Resort.Dowling, R. K (2000). Ecoresort. In  Jafari, J. (editor). Encyclopedia of tourism. Routledge,  London; 2000. pp. 165. Eco green Hotel. com. (2012). Benefits of Environmentally Friendly Hotel. Available from: http://www. ecogreenhotel. com [Accessed 20 November 2012] Entergize. (2012). Patented Entergize Key Card Technology. Available from: http://www. entergize. com [Accessed 17 November 2012] EPA. (2012). United States Environmental Protection Agency: Green roofs. Available from: http://www. epa. gov [Accessed 15 November 2012] Gold Coast Energy. (2012). What is Building Integrated Photovoltaics.Available from: http://www. goldcoastenergy. com. au [Accessed 19 November 2012] LEED. (2012). Leadership in Energy and Environmental Design: What is LEED. Available from: http://www. leed. net [Accessed 12 November 2012] Murphy,P. (2008). The Business of Resort Management. New York: Routledge. Pacific Institute. (2011). Hidden Oasis: Water Conservation and Efficiency in Las Vegas. Calculation of Potential Water Savings at Resorts and Casinos. Radcliff, M. (2012). Ways to stop pollution. Available from: http://greenliving. lovetoknow. com [Accessed 11 November 2012] Roisin, B. (2012). Sustainable Design: Solar energy.Available from: http://engineering . dartmouth. edu [Accessed 17 November 2012] Sutherland, L. J. (2008). Solar Energy Advantages Disadvantages: Solar Energy Problem Solved. Available from: http://ezinearticles. com [Accessed 20 November 2012] TATOC. (2011). Sharetime: Green resorts – how TATOC resorts are tackling environmental issues, 5. Available from: http://www. sharetimemagazine. com/ [Accessed 11 November 2012] Townsend, A. (2011). Malta Green Hotels Guide. Available from: http://www. projectgaia. org [Accessed 20 November 2012] UNESCAP. (2012). Fact sheet: Eco-resorts and hotels.Available from: http://www. unescap. org [Accessed 13 November 2012] United Nations Environment Program and World Tourism Organization. (2005). Making tourism more sustainable: a guide for policy makers. Madrid: UNEP and WTO. Vickers, A. (2001). Handbook of Water Use and Conservation. Waterplow Press: Amherst, Massachusetts. Wackernagel, M. and Rees, W. E. (1997). Resort Development Handbook. Washington D. C. : Urban Land Institute. Wark, C. (2010). Cooler than Cool Roofs: How Heat Doesn’t move through a Green Roof, Part 2 Evapotranspiration. Available from: http://www. greenroofs. com [Accessed 19 November 2012]

D.H. Lawrences use of Language in Odour of Chrysanthemums...

Write a study of the opening of D.H. Lawrence’s short story Odour of Chrysanthemums. Comment in detail on the way in which Lawrence’s use of language creates a particular atmosphere and raises certain expectations. The opening of ‘Odour of Chrysanthemums’ tells us about the domination of industry over nature. It presents nature at its worst and the dominance of technology, symbolized by the engine. The focus of the story is on the engine, the people, nature and its description and the mood of the story is gloomy, despondent. The struggle of the people parallels that of nature, which highlights the story. The themes revolving around the story are tension, struggles, dominance, disappointment and loss. At first glance, the†¦show more content†¦There is a description of a woman â€Å"trapped between the jolting black wagons and the hedge† which gives the impression that mankind is standing in between the struggle of industry and mature. The woman is unnamed to represent mankind and she cannot do anything to stop it. Industry maybe slow and ‘outdistanced’ by nature but it still keeps going and we stand between the battle of these two ‘insignificantly’ and little. There is also another unnamed woman in the story which will refer to as Elizabeth to avoid confusion along with a little boy whom is said to be his son. Elizabeth is pictured in the story as a hard-working, disciplined woman. She is portrayed as a strong and â€Å"handsome† woman rather attractive than beautiful. â€Å"Her smooth, black hair was parted exactly† shows that she is aware of her appearance. The story gives us the idea that she is without hopes or dreams, being let down so many times. â€Å"Her mouth closed with disillusionment† tell us that she has given up, but someone who had once hoped and dreamed and her smelling the flowers is an act of remembrance; contemplating and reliving the happier times and she puts them in her apron as a charm and talisman. And her son, whom is quite an emotional character, is shown as someone with a temper, having replied his â€Å"stern† mother with a â€Å"sulky voice†. â€Å"He stood quite still, defiantly† shows that he is not the type of person to follow orders and is uncommunicative, being