An Accounting Career Research Paper Example | Topics and Well Written Essays - 750 words

An Accounting Career - Research Paper Example It also looks at the salary scale, with emphasis on the average annual entry level salary as well as the salaries paid to persons who hold the CPA qualification in the state of Mississippi. Introduction Choosing a career is one of the most important decisions that a person will ever make in a lifetime. It is not uncommon for students to start college without any thought or knowledge of what it is that they would like to do as a career. This is so despite the number of career fairs that are held in high school and the resources available on the web and in school libraries. The most important aspects of the accounting profession are the skills required, duties performed and the salary it offers. These represent major considerations when making a decision on career choices. Skills Accounting is a very demanding career. Therefore, in addition to knowledge and qualifications the accountant is required to have a variety of skills. They include but are not limited to communication, presenta tion, information technology, analytical, computation, and critical thinking skills. Good communication skills are very important especially when a job function requires dealing with people at all levels inside and outside the organization. The accountant has to deal with the staff below the position held as well as those in authority. It is a reporting position so at all times reports of one kind or another have to be prepared. These have to be properly communicated both orally and in writing. According to Career Infonet (2011) active listening and speaking skills are required. Active listening involves giving total attention to what others are saying and taking time out to understand what is being said and asking the appropriate questions and interrupting only when appropriate (Career Infonet 2011). Information has to presented properly present so that others can understand. Information technology will also be required to aid in presentations to management as well as to input, pro cessing and summarizing information. In terms of presenting information accountants can use PowerPoint presentation. In terms of summarizing ability to use one or more accounting software packages as well as a spreadsheet is important. Accountants are required to analyze and evaluate accounting and other information. They need to be able to indicate reasons why figures change from one year to the other so that they can make proper recommendations on how to reduce expenses and so increase profitability. The ability to carry out basic computations is very important. All accountant jobs involve figures and there accuracy is key to becoming a good accountant. Critical thinking skills are very important. The accountant is required to use logic and reasoning in identifying the strengths and weakness that may arise from various alternatives relating to the solution of a problem. Duties Accountants perform a wide range of tasks some of which are specific to the profession and some of which are generalized work activities. Completing these tasks play a major role in getting a job done properly. According to Career Infonet (2011) the accounting specific tasks include advising clients in various areas such as compensation, health benefits, design of data processing systems as well as tax planning. They prepare tax computations as well as ensure that organizations that use their services or to which they are employed comply with the requirements of the tax authorities. Additionally, accountants develop, maintain and analyze budgets for clients with the use of information technology. They also prepare financial statements which indicate the financial position and financial performance of organizations including their as well as cash flow statements. Some general duties

Marijuana and students Research Paper Example | Topics and Well Written Essays - 1250 words

Marijuana and students - Research Paper Example My comments are on the use of punctuation and absence of thesis of the paper. A thesis will provide the supporting claims for the paper. I also suggest creating better transition sentences, where it is clear what the claims are. Marijuana is the top illegal drug of choice for students in the United States and other nations, such as Ireland, Belgium, Czech Republic, and the United Kingdom (Duarte, Escario, and Molina 90). Johnston et al. (2005) discover in their 2005 survey that the average incidences of cannabis use in the U.S. â€Å"for eighth, tenth and twelfth graders [were] 16.4%, 34.1% and 44.8%, respectively† (qtd. in Duarte, Escario, and Molina 90). At present, some people are lobbying to legalize marijuana beyond its medicinal uses. This paper believes that marijuana should not be legalized for all purposes, because of its diverse negative effects on students, especially on their health and academic success. Adolescents are particularly at risk, because cannabis use has been connected to the development of psychotic symptoms (Skinner, Conlon, Gibbons, and McDonald 1). Legalizing marijuana can encourage increased recreational use of marijuana among students, which can have negative effects on their health and academic status. One of the effects of legalizing marijuana is that it can lead to its widespread recreational use, which can result to a greater prevalence of risky behaviors among students. In â€Å"Sending the Wrong Message: Did Medical Marijuana Legalization in California Change Attitudes about and Use of Marijuana?† Khatapoush and Hallfors studied the impact of the legalization of medical marijuana on drug-related attitudes and use among youth in several communities in California and other ten states. They used telephone survey data that included beliefs and experiences related to marijuana use. Findings showed that legalizing marijuana did not encourage more drug use among

Accuracy of Rectal Water Contrast Transvaginal Ultrasound

Accuracy of Rectal Water Contrast Transvaginal Ultrasound Abstract Objectives:  To compare the accuracy of rectal water contrast transvaginal ultrasound (RWC-TVS) and double-contrast barium enema (DCBE) in assessing the presence and extent of bowel endometriosis. Methods:  This prospective study included 198 patients of reproductive age with suspicion of bowel endometriosis. RWC-TVS and DCBE were performed before operative laparoscopy by two groups of physicians specialized in endometriosis, each blinded to the results of the other groups. Findings of RWC-TVS and DCBE were compared with histological results. The severity of pain experienced during RWC-TVS and DCBE was measured by a 10 cm visual analog scale. Results:  In total, 110 of the 198 women had bowel endometriosis nodules confirmed at laparoscopy and histopathology patients. For the diagnosis of bowel endometriosis DCBE and RWC-TVS had a sensitivity of 96.4% and 88.2%, specificity of 100% and 97.3%, positive predictive value of 100% and 98.0%, negative predictive value of 98.0% and 88.0% and accuracy of 98.0% and 92.4% respectively. DCBE was associated with more intense pain than was RWC-TVS. Conclusions: RWC-TVS and DCBE have similar accuracy in the diagnosis of bowel endometriosis, but patients tolerate RWC-TVS better than they do DCBE. Keywords: double-contrast barium enema; rectal water contrast transvaginal ultrasound; bowel endometriosis; diagnosis Introduction Bowel endometriosis affects between 4-37% of patients with endometriosis1. Intestinal endometriosis lesions may have variable size2. Small endometriosis nodules located on the serosal surface of the bowel rarely cause symptoms and, therefore, do not require treatment2. Larger endometriosis nodules infiltrate the bowel wall and may cause various gastrointestinal complaints such as dyschezia, diarrhea, constipation, abdominal bloating and intestinal cramping1, 3. These symptoms may mimic irritable bowel syndrome. Symptoms caused by bowel endometriosis are nonspecific, often resulting in misdiagnosis or delay in diagnosis4. Physical examination may suggest the presence of rectovaginal endometriosis; however, it has poor accuracy in diagnosing rectosigmoid nodules5, 6. Until recently, the ultrasonic diagnosis of endometriosis was limited to patients with ovarian endometriomas and other imaging techniques were used for the assessment of bowel endometriosis including rectal endoscopic ultrasound, transvaginal ultrasound (TVS), double-contrast barium enema (DCBE), magnetic resonance imaging (MRI), multidetector computerized tomography enema (MDCT-e) and virtual colonoscopy7-10. TVS is a reliable non-invasive method to assess the presence and the extent of bowel endometriosis11. Injecting saline through a catheter into the rectum during TVS (rectal-water contrast TVS, RWC-TVS) may facilitate the identification of rectosigmoid nodules, the assessment of the depth of infiltration of endometriosis in the intestinal wall and estimation of the degree of stenosis of the bowel lumen. However, no previous study compared the accuracy of DCBE and RWC-TVS in the diagnosis of rectosigmoid endometriosis4, 12, 13. A preoperative diagnosis of the presence and extent of bowel endometriosis is necessary to determine whether surgery is required and to plan the surgical procedure with the colorectal surgeon14. Knowing before surgery the size and number of intestinal endometriosis nodules, the depth of infiltration of the nodules in the intestinal wall and the degree of stenosis of the bowel lumen allows determining whether surgery is required and may allow the surgeons to choose between nodulectomy and bowel segmental resection15, 16. In addition, determining before surgery the extent of bowel endometriosis allows the surgeon to inform the patient about the potential benefits and complications of the surgical procedure that will be performed. In fact, postoperative complications and evolution of digestive symptoms after surgery may differ between patients undergoing nodulectomy and those undergoing segmental resection, with a higher incidence of bladder-voiding dysfunction and postoperative constipation in patients undergoing the latter procedure. In this study, we compared the accuracy of DCBE and RWC-TVS in assessing the presence and extent of bowel endometriosis. Methods Study population This prospective study was performed between May 2012 and Aug 2016. Participants were recruited among patients of reproductive age scheduled for laparoscopy with strong suspicion of intestinal endometriosis based on symptoms and clinical examination. During this period, the imaging workup required that both DCBE and RWC-TVS were performed in patients with suspicion of bowel endometriosis. Institutional review board approval was obtained before initiating the study. Patients participating in the study signed a written consent form. Inclusion criteria for the study were: reproductive age and suspicion of deep pelvic endometriosis; presence of gastrointestinal symptoms that might be caused by bowel endometriosis; and desire to undergo complete surgical excision of the endometriosis. Patients were excluded from the study if they had previous bilateral ovariectomy; previous barium radiological examination or radiological diagnosis of bowel endometriosis; previous colorectal surgery; previ ous episodes suggestive of intolerance to iodinated contrast medium; renal or hepatic failure; refusal to undergo DCBE and psychiatric disorders. Symptoms were systematically investigated during the study period and they were recorded in a database. The presence of dysmenorrheal, deep dyspareunia, non-menstrual pelvic pain and dyschezia was investigated and the intensity of their symptoms was assessed in all patients on a 10 cm visual analog scale (VAS), on which the left extremity represented absence of pain and the right extremity indicated maximum intensity of pain. The presence of the following gastrointestinal symptoms was assessed: diarrhea-predominant irritable bowel syndrome; constipation-predominant irritable bowel syndrome; passage of mucus in the stools; rectal bleeding; intestinal cramping; and abdominal bloating. A symptom analogue scale questionnaire was used to estimate the severity of each gastrointestinal symptom. DCBE and RWC-TVS results were compared with surgical and pathologic findings. The radiologists performing DCBE and the gynecologists performing TVS were each blinded to the others results. They were blinded to the clinical data and knew only that the presence of intestinal endometriosis was suspected. All patients underwent laparoscopy within 1 month from the completion of the diagnostic investigations. Intestinal endometriosis was defined as the disease infiltrating at least the muscularis propria. Endometriosis foci located on the bowel serosa were considered peritoneal and not bowel endometriosis. The present study determined the accuracy of DCBE and RWC-TVS in assessing the presence of bowel endometriosis, estimating the size and the number of bowel endometriosis nodules and determining the presence of peritoneal endometriosis infiltrating only the intestinal serosa. Rectal water contrast transvaginal ultrasound technique Two physicians performed all the examinations according to a standardized procedure. RWC-TVS was performed by using a Voluson E6 machine connected to a transvaginal transducer. After the transducer had been introduced into the vagina, an assistant inserted a 6-mm flexible catheter through the anus into the rectal lumen up to a 15 cm distance from the anus. A gel infused with lidocaine was used to facilitate passage of the catheter. A 50 mL syringe was connected to the catheter and warm sterile saline solution was injected inside the rectum and the sigmoid under ultrasonic control. The amount of saline solution needed to show the rectosigmoid ranged between 100 and 350 mL, depending on the distensibility of the intestinal wall. One hundred milliliters of saline solution were continuously and slowly infused at the beginning of the procedure; the rest of the solution was infused when requested by the ultrasound. During ultrasound, when saline solution was not being infused, backflow through the catheter was prevented by placing a Klemmer forceps on the catheter. There w as no significant leakage of saline solution into the space between the catheter and the anus. Images were obtained before, during and after saline injection. Bowel endometriosis appears ultrasonographically as a nodular, solid, hypoechoic lesion, adjacent to and/or penetrating the intestinal wall. Hyperechoic foci may sometimes be present within the lesion. Intestinal distension allows defining the limits of the intestinal nodules and in particular the various layers of the rectal wall in order to estimate the depth of infiltration. The intestinal serosa is hyperechoic; the two layers of the muscularis propria appear as hypoechoic strips separated by a fine hyperechoic line; the submucosa is hyperechoic; the muscularis mucosa is hypoechoic and the interface between the lumen and the mucosal layer is hyperechoic. Rectal endometriosis infiltration is demonstrated by the fact that the hypoechoic nodule penetrates the intestinal wall and, in general, it thickens the muscularis mucosa. Two different ultrasonic signs are commonly used to describe this condition. Double-contrast barium enema All DCBE procedures were carried out using a motorized tilting table for fluoroscopic and radiological examination. In preparation, patients maintained a low-residue diet for 1 day prior to the examination in order to keep the enteric content fluid. The examination was performed after intramuscular administration of 20 mg (1 ampoule) Scopolamine in order to induce colonic hypotonia. The presence of bowel endometriosis was diagnosed on DCBE when the bowel lumen was narrowed at any level from the sigmoid to the anus in association with crenulation of the mucosa and/or speculation of contour. Tolerability of the examinations Immediately after each examination patients were asked to rate the discomfort encountered during DCBE and RWC-TVS by means of a 10 cm visual analogue scale (VAS), mild pain was defined as a VAS score of 5. Surgery and histological evaluation The surgeons examined the reports and the images of DCBE and RWC-TVS prior to laparoscopy. Although the diagnosis of recto-sigmoid endometriosis and its treatment were based on laparoscopic findings. All surgical procedures were performed laparoscope by a team of gynecological and colorectal surgeons with extensive experience in the treatment of pelvic and bowel endometriosis. In all cases, after adequate adhesiolysis, the sigmoid colon and rectum were systematically examined to verify the presence of endometriosis lesions. Bowel endometriosis lesions were removed by intestinal resection in cases of a single lesion >3 cm in diameter, a single lesion infiltrating at least 50% of the circumference of the intestinal wall or three or more lesions infiltrating the muscular layer. In all other cases of bowel endometriosis partial- or full-thickness disk resection was performed. Intestinal lesions infiltrating only the serosal layer of the bowel wall were excised by shaving. All visible les ions suspected to be endometriosis were excised and sent for histological examination in agreement with our clinical protocol. The surgical specimens were evaluated by histological; the depth of infiltration of the endometriosis nodules in the bowel wall was assessed. In cases of nodulectomy the specimens were macroscopically oriented along the intestinal wall (from the serosa towards the mucosa) and cut into macro sections of 2 mm thickness. From each macrosection tissue blocks of 1.5 cm length were obtained in variable numbers according to the size of the lesion, and from each tissue block a 5  µm section was obtained for microscopically evaluation. In cases of bowel resection the specimen was opened longitudinally through its entire length and 2mm longitudinal bands of bowel wall, reaching the two resection margins and passing through all macroscopically visible lesions, were cut. These bands were sampled in tissue blocks and 5  µm sections were obtained for microscopic evaluation. Statistical analysis Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for both DCBE and RWC-TVS. The diagnostic value of each test was also assessed using positive likelihood ratio (LR+) and negative likelihood ratio (LR-). Efficacy parameters were calculated with 95% confidence intervals (CIs). McNemars test with the Yates continuity correction was used to compare the accuracy of DCBE and RWC-TVS in the diagnosis of intestinal endometriosis. McNemars test was used to compare the number of patients in which the number of rectosigmoid nodules was correctly identified by DCBE and RWC-TVS. The accuracy of the measurement of nodule size by imaging techniques was estimated by subtracting the size of the nodule as measured by the techniques from the size of the nodules measured at histology. The nonparametric Mann-Whitney test was used to compare the intensity of pain experienced by patients during DCBE and RWC-TVS, the chi-square test was used to co mpare the type of pain (mild, moderate or severe) and Spearmans rank correlation coefficient was used to determine whether there was a correlation between the intensity of pain experienced by patients during the two techniques. Data were analyzed using the SPSS software. p Results Study population A total of 198 patients were enrolled in the study and all underwent surgery were included in this study (Figure 1). The main demographic characteristics of the study are demonstrated in Table 1. The intensity of pain and gastrointestinal symptoms are presented in Table 2. Surgery and histology demonstrated that 110 patients (55.6%) had bowel endometriosis nodules. The endometriosis lesions infiltrating the intestinal serosa in 28 patients. The remaining 82 patients had only pelvic endometriosis with no evidence of intestinal lesions. The largest intestinal endometriosis nodule was found locate on the sigmoid colon in 53 patients, on the rectum in 30 patients, at the rectosigmoid junction in 20 patients, on the ileum in 5 patients and on the caecum in 2 patients. The endometriosis lesions infiltrating only the intestinal serosa were located on the sigmoid colon in 15 cases, on the rectum in 5cases and at the rectosigmoid junction in 3 cases. The mean ( ±SD) length of the resected bowel segment was 12.2  ± 3.6 cm. The diagnosis of endometriosis was confirmed in all the excised nodules by histological exam. Furthermore, it demonstrated that the deepest endometriosis nodule infiltrated the muscularis propria in 62 patients (56.4 %), the submucosa in 3 1 patients (28.2%) and the mucosa in 17 patients (15.5%). Accuracy of RWC-TVS and DCBE in the diagnosis of bowel endometriosis The accuracy, sensitivity, specificity, PPV, NPV, LR+ and LR- of DCBE and RWC-TVS in the diagnosis of bowel endometriosis are described in Table 3. DCBE identified 106 of 110 patients with bowel endometriosis (96.4%). In 4 patients endometriosis nodules infiltrating the muscularis propria of the rectum were not identified, which were excised by partial-thickness nodulectomy. RWC-TVS identified 97 of 110 patients with intestinal endometriosis (88.2%). RWC-TVS did not identify 4 ileal lesions, 2 cecal lesions, 4 sigmoid nodules and 3 rectal nodules infiltrating the muscularis propria. Furthermore, we identified 4 of these patients had large bilateral endometriosis ovarian cysts, which may have hampered the identification of intestinal nodules. There was 2 false positive on RWC-TVS-a rectovaginal endometriosis nodule that was judged to infiltrate the muscularis of the rectum. Surgery confirmed the presence of the rectovaginal nodule but did not reveal infiltration of the rectal muscularis. The sensitivity, specificity, PPV, NPV, LR+, LR- and accuracy of the two techniques in the diagnosis of intestinal endometriosis were shown in Table 3. McNemars test showed that there was no significant difference in the accuracy of the two techniques in the diagnosis of bowel endometriosis (P=0.109). Histology examination demonstrated that endometriosis infiltrated the submucosa or mucosa of the rectosigmoid colon in 53 patients. DCBE correctly identified the depth of infiltration in 27 of these patients (50.9%), while RWC-TVS correctly identified the depth of infiltration in 20 of them (37.7%) (P=0.126). All the other nodules that were seen to infiltrate the submucosa or mucosa at histology were judged to reach only the muscularis at DCBE and RWC-TVS. Both techniques had no cases of false-positive diagnosis of submucosal or mucosal infiltration. Both DCBE and RWC-TVS underestimated the size of the endometriosis nodules; however, the underestimation was greater for RWC-TVS than for DCBE (Table 4). In addition, in both imaging techniques the underestimation was greater for nodules with diameter≠¥30 mm. Tolerability of DCBE and RWC-TVS DCBE was safely performed in all the patients. During both the examinations all patients tolerated intestinal distension and in no patient was it necessary to interrupt the procedure. However, the intensity of pain experienced during DCBE was significantly higher than the intensity of pain experienced during RWC-TVS (Table 5). A positive correlation was observed between the intensity of pain experienced by the patients during the two examinations (Spearman correlation coefficient=0.575; p Discussion To the best of our knowledge, this is the first study demonstrated that DCBE and RWC-TVS have similar accuracy in the diagnosis of bowel endometriosis. Both RWC-TVS and DCBE underestimated the size of bowel endometriosis nodules, but under estimation was greater for RWC-TVS than for DCBE, particularly when the nodules had largest diameter ≠¥ 30 mm (Table 4). The choice of the ultrasonic technique is often based on the experience of the ultrasonographers rather than on evidence of superiority of one technique compared to the others. In fact, TVS must be performed by highly skilled, it has been recently estimated that the learning curve for an accurate diagnosis of deep pelvic endometriosis by TVS requires performing about 40 cases17. Therefore, it may be difficult to achieve such experience for ultrasonographers working in small hospital. The main advantage of DCBE could be that, with a retrograde distension of the entire colon, this technique may provide a complete overview of t he whole colon18. In the current study, the distension was targeted to the rectosigmoid because the aim of the study was the comparison with RWC-TVS and endometriosis lesions of the right colon are beyond the field of view of a transvaginal approach. Furthermore, we did not compare the accuracy of RWC-TVS with TVS alone, which was the objective of a previous study. RWC-TVS was chosen for the comparison with DCBE because of the personal experience of the authors and of the common criterion of bowel distension with fluid. The usefulness of this technique was subsequently confirmed by the same authors in larger series. Furthermore, other authors confirmed that intestinal distension and opacification using ultrasound gel helps to visualize rectosigmoid endometriosis nodules19, 20. Previous studies have suggested that TVS could reliably diagnose rectosigmoid endometriosis. The sensitivity of TVS for detecting rectosigmoid endometriosis is between 91 and 98%, the specificity between 97 and 100%, the PPV between 97 and 100% and the NPV between 87 and 98%21-24. Recently, RWC-TVS has been developed to facilitate identification of intestinal lesions in patients with rectovaginal endometriosis and to determine the depth of infiltration of endometriosis in the intestinal wall25. TVS has been extensively used in patients with bowel endometriosis; while only little data is available on the use of DCBE in these patients. This study demonstrated that DCBE and RWC-TVS have similar accuracy in the diagnosis of bowel endometriosis. Both techniques precisely estimated the length of the rectosigmoid nodules, but DCBE was more precise than RWC-TVS in assessing the distance between the endometriosis nodule and the anal verge9. Obviously, the extensive experience of the radiologi st and the gynecologist in DCBE and RWCTVS, respectively, may have influenced the accuracy of these techniques in diagnosing bowel endometriosis24, 26. The findings may be explained by the fact that when performing imaging techniques, particularly RWC-TVS, it might be difficult to choose the plane in which the irregular endometriosis nodule has the largest diameter. However, the difference between the estimated size of the nodule and the largest diameter as measured on histopathology was quite small and, in most cases, it seems unlikely that this difference would affect the choice of nodulectomy or bowel resection as treatment27. Importantly, patients tolerated RWC-TVS better than they did DCBE. These findings are in line with those of previous studies demonstrating the accuracy of TVS in the diagnosis of bowel endometriosis and comparing TVS with other techniques such as MRI and rectal endoscopic ultrasound11, 28-30. The potential benefits of introducing aqueous contrast medium into the rectum during TVS have been questioned. TVS is an operator-dependent procedure and it is possible that the differences observed in the accuracy of this technique are determined by the experience of the ultrasonographer carrying out the procedure31. However, adding intestinal aqueous contrast to TVS may facilitate the identification of rectosigmoid lesions. Other techniques have been proposed for improving the accuracy of TVS in the detection of deep endometriosis, such as sonovaginography or the use of large quantities of ultrasound transmission gel (12 mL) in the probe cover32. Up to now, no study has established whether any one of these ultrasonic techniques is superior to the others in the diagnosis of deep endometriosis. TVS should be considered the first-line investigation in patients with deep endometriosis, and allows the diagnosis of intestinal lesions24. Other investigations such as RWC-TVS, MDCT-e, MRI, rectal endoscopic ultrasound and DCBE may be used to determine the characteristics of intestinal endometriosis, such as the size and number of nodules, the depth of infiltration of the nodules in the intestinal wall and the degree of stenosis of the bowel lumen33-35. RWC-TVS has several advantages over the other techniques. It is less expensive than MDCT-e and MRI and the equipment required to perform the procedure is commonly available to gynecologists, who are usually involved in the management of patients with endometriosis. A recent study has shown that RWC-TVS allows estimation of the degree of stenosis of the intestinal lumen caused by endometriosis36. Unfortunately, this parameter was not examined in the current study- the major limitation of our investigation. Theoretically, RWC-TVS may also allow determination of the extent of the disease along the longitudinal intestinal axis. Obviously, RWC-TVS cannot determine the presence of intestinal nodules located proximally to the sigmoid because these lesions are beyond the field of TVS. This study had several limitations. First, the experience of the ultrasonographer in RWC-TVS may influence the accuracy of these techniques in diagnosing bowel endometriosis. Second, the surgeons were aware of the findings of DCBE and RWC-TVS. Although in an ideal prospective study the surgeons should be blinded to the findings of the preoperative investigations, this theoretical study design appears unethical in clinical practice because diagnostic imaging may facilitate the identification of intestinal endometriosis nodules during surgery. Furthermore, the knowledge of the findings of the preoperative investigations may only help the surgeons in identifying endometriosis nodules that were actually present. Third, RWC-TVS and DCBE did not estimate the percentage of the circumference of the intestinal wall infiltrated by endometriosis, a criterion used to choose between nodulectomy and bowel resection. Therefore, patients scheduled for nodulectomy on the basis of DCBE and RWC-TVS fin dings should be informed that bowel resection might be required for the complete excision of intestinal endometriosis. Future studies should examine whether DCBE and RWC-TVS can reliably estimate what percentage of intestinal circumference is infiltrated by endometriosis. DCBE may still have a role in the diagnostic workup of patients with suspected bowel endometriosis. When TVS or RWC-TVS demonstrates large intestinal nodules infiltrating the bowel muscularis, bowel resection can probably be performed without further investigation unless the surgeon wants to exclude intestinal lesions located proximally to the sigmoid. In contrast, when ultrasound demonstrates a single bowel nodule that may be excised by nodulectomy, DCBE should be used to exclude the presence of other intestinal nodules and, thus, to adequately plan the surgical procedure with the colorectal surgeon and the patient. Conclusions This study showed that RWC-TVS is a reliable technique for determining the presence and extent of bowel endometriosis and that it has an accuracy similar to that of DCBE. However, RWC-TVS may sometimes underestimate the presence of multiple bowel nodules and can be performed easily in an ambulatory setting and it is better tolerated by patients. It may be hypothesized to combine TVS and DCBE to achieve a complete preoperative assessment of the bowel in order to offer to the patients an adequate counseling and the most appropriate one-step surgical treatment.

Chinese Shih Poetry And Philosophy Essay -- essays research papers

Since the beginning of time, man has sought to explain the world around him. This is called philosophy, a Greek word which means "love of wisdom." However, over the millennia it has come to mean much more. The philosophies of the ancient Chinese people, whether they explain nature or present ways to live a just life, became so complex that simple prose could not suitably express their meaning. Yet paradoxically, the simpler, less exact form of poetry does put forth the ideas. Nowhere is this more exemplified than in the literature pertaining to the two major schools of ancient Chinese thought; Taoism and Confucianism. Poets such as Tu Fu and Po Chà ¼-i expressed the ideas of Taoism and Confucianism, respectively, while their fellow poet T’ao Ch’ien expressed both, through their poetry. Confucianism is based on the ideas of Confucius, the man who gave the school of thought its name. The main goal of Confucianists was to return a gentlemanly society to China. The core of Confucianism concerned social structure. Confucius taught that a man should respect and obey those of higher rank than himself, whether they be the father of a family, or the emperor of a nation. But even with absolute obedience, Confucianists believed that men should practice restraint and benevolence in those inferior to them. At the same time, those in high status were expected to lead virtuous lives, and to set examples for those that followed them. Confucianists believed that the moral code of man was set down by heaven, and if those in positions of authority did not set good examples, then they would deposed by the forces of heaven. One of the first great Chinese poets to write of Confucianism was T’ao Ch’ien. T’ao Ch’ien’s poem Substance, Shadow, and Spirit shows a comparison between Confucianism, Buddhism, Taoism, and the views on life and death of each. A clear example of Confucian beliefs can be taken from this poem. He states, "Let us strive and labor while yet we may / To do some deed that men will praise." This clearly demonstrates the fact that Confucianists do not believe in reincarnation. Also, in his Poem on Returning to Dwell in the Country, T’ao Ch’ien writes, "In the same world men lead different lives; / Some at the court, some in the marketplace." These lines illustrate that for every man there is a place in an ... ...orld around him, which was full of chaos and turmoil. In the final section of the poem Substance, Shadow, and Spirit he discusses the Taoist view, which is that one should not worry about death, but should "go where Fate leads – Drift on the Stream of Infinite Flux" and "make as little fuss as you can," when death finally comes. His Poem on Returning to Dwell in the County also shows Taoist ideas on simplicity, and following the way of nature. Passages such as "Long I have loved to stroll among the hills and marshes, / And take my pleasure roaming the woods and fields," demonstrate the Taoist love for nature. Poets such as Po Chà ¼-i presented the ideas of in a form that better impacted the common man, and carried their ideas crystal clear to the intellectuals. His fellow poets, T’ao Ch’ien and Tu Fu presented images of nature so intense, that the reader could gain a sense of calm from reading their poems. These poems have passed the test of time, and have not weathered the slightest. The followers of these schools were gifted enough to state their beliefs in poetry so vivid that they still enlighten lovers of wisdom today.

Anecdote: the Curious Incident of the Dog in the Night-Time Essay

â€Å"The Curious Incident of the Dog in the Night-Time† essay was the only thing I was concerned with that night. Finishing it, handing it in, and voila, I’m done. But for me, it was always more complicated than that. Procrastination is practically my middle name. After what seemed like an eternity of blankly staring at the computer screen, the phone rang. All of my limbs felt unnaturally stiff as I went to retrieve the phone. â€Å"Hello?† I said. â€Å"Hi, it’s Sarah.† My best friend, Sarah, who was usually loud, hysterical, and had an exciting voice, now spoke in a distant mumble, as if it wasn’t really her. â€Å"Dude, I don’t have time to talk I have to finish this†¦Ã¢â‚¬  I said. â€Å"Pedro Gurrola is dead† she said as if she herself were dead, too. â€Å"Huh?† I was sure I hadn’t heard correctly. â€Å"Alex’s dad? Pedro Gurrola? He was killed this morning in his garage,† she explained. â€Å"Jeez, that sucks.† I said, trying to focus on my paper. â€Å"I’d says it more than sucks. Anyway, all of the youth group is meeting at the church to comfort Alex. I’m really worried about her.† It took me a minute to realize she was suggesting I join too. Still subconsciously stressing about my paper, I excused myself. â€Å"Ah†¦I would go but I really have to finish this paper. I’m not even half way done. â€Å" â€Å"Are you serious right now?† She sounded sarcastic as usual, but I took it the wrong way. â€Å"I know right!† â€Å"No, not that you idiot. Just come to the church.† She sounded frustrated, so I gave in. â€Å"I’ll ask my mom.† â€Å"Okay, you better be there.† As I walked into the living room, the too familiar sound of my parent’s favorite show, Jeopardy, filled my ears. I looked at my parents, whose eyes were glued to the screen. â€Å"Hey Mom, can I go to the church?† She didn’t take her eyes off the screen. â€Å"What for?† â€Å"Pedro Gurrola is dead-â€Å" â€Å"30 seconds, contestants. Good luck!† interrupted Alex Trebek on the TV. â€Å"Pedro Gurrola, Alex’s dad, is dead.†I repeated. After I said it, it felt like I was hearing it for the first time as well. My parents glared at me like I was as entertaining as the TV show. Before they even had a chance to respond, I started for the front door. I knew what I had to do.

How Customer Service is provoded in business Essay

Costumer service is the ability of an organisation to recognise and consistently meet the costumers’ needs. Costumer service generally involves service teamwork and service partnerships so they can meet customer expectations and produce costumer satisfaction. Costumers contact an organisation when they need something, the main reasons are: * To complain * To request/ order a service/product * To obtain information * To ask for advice * To enquire about an order * To change an order or request * To report a problem to return and exchange goods * To ask for assistance or help The organisation I have chosen to study for this is the National Maritime Museum which consists of the Royal Observatory Greenwich, Queen’s House and National Maritime Museum. Together these constitute one museum working to illustrate for everyone the importance of the sea, ships, time and the stars and their relationship with people. A customer is anyone who has the right to ask or expect a service as part of a job role; this means there are two types of customers – internal and external. Internal customers are all the colleagues who need assistance to fulfil their obligations to their own customers; these include the supervisors, staff, staff teams and managers. External customers are those who contact or visit the organisation because of what it provides or supply’s as it is something they need. There are a wide range of external customers but only a few can apply to each business, some businesses have a wider range of external costumers compared to other businesses, such as a supermarket will have a wider range of external customers as it will sell a wide range of goods whereas a youth club or nursery will have a smaller rage of external customers as its only aimed at a certain age group. The National Maritime Museum has a wide range of customers and provides everyone access to its historical buildings and unique collectors; as a result the customers have a wide range of needs so they provide products and services to fit their needs. On any average day the museum staffs have to deal with * People wishing to research their family history in our archives * Ship model-makers wanting advice on details of a ship * Film companies wanting to use our buildings as a location for an advert or television drama * Domestic tourists wanting a fun day out * Foreign tourists wanting to experience British history * School and college groups wanting to investigate the Museum to help with their studies. The Museum has 7 main categories of customers which have their own special needs and interests and they are the following 1. Individuals – Casual Visitors – Special Interest Visitors – Individual Researchers 2. Families – Parents along with Young Children 3. Groups – Mixed age groups – Special Interest and Education 4. People from different cultures with different languages – Foreign and Domestic Tourists – People from Diverse Ethnic and Religious Communities 5. People with special needs – Blind and Visually Impaired – Deaf and Hearing Impaired – Learning Difficulties – Physical, Emotional or Mental Health Needs 6. Virtual users who access the Museum via our website – People who access the museum via the website 7. Internal customers – Members of Staff who Support the Work of Others The main three types of customers the National Maritime Museum focuses on are families, disabled visitors and groups. Families are an important target audience for the museum as it is a free family-friendly place to visit; it focuses of the key needs and expectations of family audiences which are: – it’s free – the price of tickets can be a barrier for many families, especially with the costs of travel and lunches – it’s fun and educational with lots to see and touch, like the All Hands interactive children’s gallery – there’s lots to do such as special activity workshops, storytelling and treasure trails – it’s easy to get to – only 20 minutes from central London, with good transport links The Museum also has family-friendly events which bring the Museum galleries to life including practical activities for 2-to-6-year-olds (weekly); trails revealing the secrets of their vast collection of objects; action-packed art and science workshops, and actors’ performances for all ages. Their family-friendly facilities include areas for changing and feeding babies, clean and accessible toilets, cafe and picnic areas and online activities in the E-Library and on the website. The Museum aims to increase the number of families who visit the National Maritime Museum by expanding programs of events, activities and special exhibitions for families, especially during weekends and holidays. All this makes the Museum more appealing to families. Along with individuals the Museum has also built up experience in providing for different type of groups who each have a different set of needs. Foreign language students – The Museum provides souvenir guides and essential visitor information on their website in different languages. This service targets both foreign tourists and domestic visitors with English as a second language. They also have non-Eurocentric displays and events which inform customers of the history of people and cultures from all over the world. Large Groups – For large groups coach parking is easily attainable, there are special discounts given to access the charging exhibitions, pre booked tickets make it easier for large groups to book easily and guided tours and talks are especially available for larger groups. Special Interest Groups – At the museum there are enquiry and research facilities accessible via the library, there are archives and online sources at hand and also special curator talks and tours for all the groups that have a special interest. Corporate and Private Hire Groups – There is event planning and support available for Corporate and Private Hire groups including venue hire and catering for those who want to use the museum for private hires and corporate reasons. Educational Groups – The museum provides curriculum recourses and educational talks along with support with visit planning and booking. They also have a lunchroom and cloakroom especially suited for school/ educational groups. Lastly the National Maritime Museum also focuses on developing access for all their visitors and users which includes those who are disabled. It continuously tries to exceed and improve the museums facilities to meet the basic requirements of those who are physically disabled, deaf and blind. They believe good, inclusive customer service is about understanding everybody’s special needs. For visitors with disabilities, the Museum has a range of access facilities as part of its customer service. o Installing new lifts and ramps o The Road Train service o Providing detailed information for disabled visitors o Providing alternative ways to access the Museum o Maintaining a policy of welcoming assistance dog They have added lifts to improve physical access around the Museum site. Members of staff are always at hand to help. The new lifts and ramps that have been installed provide flat or wheelchair access to all levels and galleries. Visitors may also borrow manual wheelchairs from admission areas. Special bookings for those who are disabled are also available by calling the bookings unit who will make any special arrangements. There is also information available online such as the availability of disabled car-parking, mobility buses and the access facilities on all their sites. It is also important that the customer information also describes areas that are not accessible – such as parts of the historic buildings of the Royal Observatory. This avoids frustration and disappointment on the day. Touch Sessions for Visually Impaired Visitors are also available. They have a number of alternative methods to accessing the Museum and its collections. For blind and visually-impaired visitors they provide: o Braille Guides o Raised drawing o Magnifying glasses o Large-print guides o Tactile maps o ‘touch packs’ They also run a program of pre-booked ‘touch talks and tours’ by Museum staff and guest speakers. The National Maritime Museum also has a sign-interpreted talk for deaf and hearing-impaired visitors. They have installed perimeter loops in the galleries, admission areas, information desks and key audio installations. They also run a program of pre-booked British Sign Language sign-interpreted talks and events. Customer service is important to the National Maritime Museum because without customers there would not be a business. Excellent customer service results in: * higher visitor numbers and greater customer diversity – Visits to the sites are increasing each year – provides a public service for groups of people who don’t traditionally visit or use cultural or heritage organizations like museums – Has an outreach community newsletter which has news and events for communities under-represented among the visitors * increased sales – The Museum generates increased income through shops, cafes and charging for special exhibitions – It also supplies hiring venues for corporate events and weddings and sales from the Picture Library. * increasing public image – The Museum has to compete with other organizations for people’s leisure, by providing excellent customer service it increases public image they do this using their website and leaflets * survival in terms of competition – Good customer service can give the Museum an edge over other tourist attractions or leisure facilities, as they compete for customers’ leisure time and money. * satisfied customers and greater job satisfaction for staff – As well as asking for feedback from customers and monitoring visit numbers the Museum pays a market research company to conduct surveys, the customers are asked to rate their experiences and satisfaction levels, this helps knowing the customer’s needs and satisfying them. – The staff also takes pride in being part of an organization which delivers high levels of customer service – Job satisfaction is increased by positive feedback from the customers * repeat business and customer loyalty – Museum donation box Analysis of feedback and visitor surveys indicates that 94% of visitors would recommend the Museum to their friends. – Excellent customer service results in strong customer loyalty and increased visitor numbers – especially repeat visits. The National Maritime Museum believes that to enjoy and learn from a museum’s collections, visitors must first feel welcome, secure and comfortable in their environment. Crucial factors include friendly staff to greet and help, clear signage, queuing systems, gallery plans and well-maintained washrooms and cloakrooms. Improvements to these areas can significantly increase word of mouth recommendations, repeat visits and time and money spent by visitors as competition for the public’s time and attention is intense.