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.

plato :: essays research papers

Plato's Symposium provides us with many different views and theories about love. This drunken discussion of Eros presents ideas which have not lost their relevance in the millennia since. Many things have changed and there have been a lot of different views on almost every subject known to man, but the thoughts voiced in the Symposium still hold truth today. However being what it was, and that is many different peoples thoughts on the subjectof Eros, there is a wide variety of theories to choose from. Which of these speculations strikes a chord of truth in one's soul? Diotima speaks through Socrates (who is speaking through Plato) when she gives her version of where love came from. She says that Love is the child of Resource and Poverty, conceived on the day that Aphrodite was born. Poverty had come to the feast to beg and found Resource drunk and passed out. Poverty saw an opportunity to gain more resources, so she slept with him and became pregnant with Love. Love is a follower of Aphrodite because He was conceived at the party following her birth, and because "He is naturally a lover of beauty and Aphrodite is beautiful"(Gill, 203c) Because of who His mother is Love is always poor and homeless. He is quite tough from sleeping on the ground or in doorways and from wearing no shoes. Because of who His mother is, He is always in need, but because of who His father is He is constantly scheming to get good and beautiful things. He's clever, and skilled in hunting, magic and acquiring knowledge. Neither immortal nor mortal, Love can spring to life in a day and then die before that day is over. He can come back to life again like his father Resource, but cannot hold onto the resources he has. Being between mortality and immortality, Diotima calls Love "a great spirit"(Gill,202e). These great spirits are sort of go-betweens for the Gods and Humanity. They convey prayers and sacrifices from us to the Gods, and commands and gifts from the Gods to us. Because of them the universe is all interconnected and whole. The Gods never communicate directly to Humans, but always use these spirits to convey their commands. These are what priests, prophets and oracles speak to. Love is also between wisdom and ignorance, since neither the gods nor the ignorant love wisdom. The Gods already have it so the do not desire it, therefore love has no part in it. The ignorant don't love wisdom or want it, because they are satisfied with themselves. Since they do not think they need wisdom, they do not desire or love it. plato :: essays research papers Plato's Symposium provides us with many different views and theories about love. This drunken discussion of Eros presents ideas which have not lost their relevance in the millennia since. Many things have changed and there have been a lot of different views on almost every subject known to man, but the thoughts voiced in the Symposium still hold truth today. However being what it was, and that is many different peoples thoughts on the subjectof Eros, there is a wide variety of theories to choose from. Which of these speculations strikes a chord of truth in one's soul? Diotima speaks through Socrates (who is speaking through Plato) when she gives her version of where love came from. She says that Love is the child of Resource and Poverty, conceived on the day that Aphrodite was born. Poverty had come to the feast to beg and found Resource drunk and passed out. Poverty saw an opportunity to gain more resources, so she slept with him and became pregnant with Love. Love is a follower of Aphrodite because He was conceived at the party following her birth, and because "He is naturally a lover of beauty and Aphrodite is beautiful"(Gill, 203c) Because of who His mother is Love is always poor and homeless. He is quite tough from sleeping on the ground or in doorways and from wearing no shoes. Because of who His mother is, He is always in need, but because of who His father is He is constantly scheming to get good and beautiful things. He's clever, and skilled in hunting, magic and acquiring knowledge. Neither immortal nor mortal, Love can spring to life in a day and then die before that day is over. He can come back to life again like his father Resource, but cannot hold onto the resources he has. Being between mortality and immortality, Diotima calls Love "a great spirit"(Gill,202e). These great spirits are sort of go-betweens for the Gods and Humanity. They convey prayers and sacrifices from us to the Gods, and commands and gifts from the Gods to us. Because of them the universe is all interconnected and whole. The Gods never communicate directly to Humans, but always use these spirits to convey their commands. These are what priests, prophets and oracles speak to. Love is also between wisdom and ignorance, since neither the gods nor the ignorant love wisdom. The Gods already have it so the do not desire it, therefore love has no part in it. The ignorant don't love wisdom or want it, because they are satisfied with themselves. Since they do not think they need wisdom, they do not desire or love it.

Phobias Essay -- essays research papers

Phobias Phobias are a very common disorder in the United States these days. The definition for phobia is "an abnormal or morbid fear or aversion" ("Oxford" 655). To be considered a phobia, a fear must cause great distress or interfere with a person’s life in a major way. The word phobia is Greek, therefore, any word that proceeds it should be Greek too. To coin a new phobia name, it is proper and only accepted to follow this rule. The rule has been broken many times in the past, especially by the medical profession. The medical profession is steeped in Latin and many times when forming a name for phobia, they use Latin. There are three kinds of phobias: simple phobia, social phobia, and panic attacks. Simple phobias, also called specific phobias, are fears of a specific thing, such as spiders or being in a closed place. Most simple phobias develop during childhood and eventually disappear. Specific phobia is a marked fear of a specific object or situation. It is a category for any phobias other than agoraphobia and social phobia. The categories of specific phobias are 1. situational phobias such as: fear of elevators, airplanes, enclosed places, public transportation, tunnels, or bridges; 2. fear of the natural environment such as: storms, water, or heights; 3. animal phobias such as: fear of dogs, snakes, insects, or mice; 4. blood-injection-injury phobia such as: fear of seeing blood or an injury, or of receiving an injection. (Wood 520). Social phobias are fears of being in situations where your activities can be watched and judged by others. People with social phobias try to avoid social functions at all costs and find excuses not to go to parties or out on dates. This avoidance is the difference between having a social phobia and simply just being shy. Panic attacks are the third kind of phobia. They can change the quality of a person’s life. Someone with a phobia this bad may be shopping at the supermarket and suddenly experience dizziness and a feeling of being out of control. At that moment, the person experiences a fear of dying, with no safe place to go. When this happens more than once, the person might think they are going crazy. Someone with panic attacks soon won’t leave the house because of fear of a panic attack happening outside the house. Soon, depression s... ...6. Generalization from the original phobic stimulus to stimuli of a similar nature will occur; 7. Noxious experiences which occur under conditions of excessive confinement are more likely to produce phobic reactions; 8. Neutral stimuli which are associated with a noxious experience, may develop motivating properties. This acquired drive is termed the fear drive; 9. Responses (such as avoidance) which reduce the fear drive are reinforced; 10. Phobic reactions can be acquired vicariously (Rachman 31). These theories are used to identify how people obtain phobias and other situations that may occur with phobias. In conclusion, phobias are a big part of many people’s lives these days and a growing medical condition. People do not realize how badly phobias can affect their lives so they don’t receive medical attention. There are no cures for phobias but there are treatments which will help the phobic get over their fear. I personally believe that if people care enough about their lives, they will treat their phobias. Phobias can totally alter your life so if you have any of the symptoms I have listed above, please go and get treatment.

Pyramids :: Symbolism History Spirit Essays Research

Pyramids The image of the pyramid with the sun shinning behind it was taken from a 1996 brochure advertising a weekend seminar with Robert Kirby, an international speaker and author. Kirby's weekend seminar is titled "Manifesting Your Life - Purpose, Prosperity and Abundance." His self proclaimed fields of expertise include Corporate Negotiation, Accelerated Learning, Transformational Psychology, Kinesiology, Emotional-Spiritual Revitalism, and Energy Field Research, among others. The brochure states, "Newly researched evidence now permits you to unleash enormous latent creative capabilities through your body's dynamic electrical energy field." Robert Kirby is one of the many people currently making a living utilizing information associated with the new age spiritual movement. The new age spiritual movement is a very broad ideological umbrella covering the terminology Kirby uses, and much more. The new age movement seems to signal above all, an interest in the mind-body-spirit connection. People are pursuing the idea that the knowledge is within each individual to unite the physical, emotional, mental, and spiritual aspects of themselves to create wholeness. The pyramid seems to have been adopted as a powerful symbol for these ideas. The pyramid of the 90's is a spiritual icon for health, power, abundance, and purpose. In our country riddled by me ntal and physical health-care crisis's, where traditional western medicine clearly lacks answers, the spiritual movement is becoming increasingly wide spread, and the pyramid carries the message. The pyramid symbol carries the traditional coding of the spiritual trinity. Each side of a pyramid is a triangle and the triangle stands for the trinity of the Father, Son, and Holy Ghost. The new age trinity is a somewhat different way of looking at the traditional religious trinity ideology. The difference is in the extension of the definition. The trinity in this case is the father (spirit), mother (matter), and son (consciousness, Christ). Interaction of father spirit, with matter (mother), creates the son. The belief is that this is true of everything that exists - - all life is formed within that trinity. So ultimately the pyramid is the symbol of creation, and the symbol of God. The new age spiritual movement of the 1990's definitely includes the notion that individuals have access t o God. Interestingly enough, the meaning of the pyramid in the 1990's is not that far removed from the meaning of the original pyramids of Giza. When first looking at the two images and deciding exactly what each represents, it seems at first as if the entire meaning of the original structure is lost in today's use; however, there is a connection of meaning on a deeper level on close examination.

Japan’s Occupation: An American Operation

The occupation of Japan was, from start to finish, an American operation. General Douglans MacArthur, sole supreme commander of the Allied Power was in charge. The Americans had insufficient men to make a military government of Japan possible; so they decided to act through the existing Japanese gobernment. General MacArthur became, except in name, dictator of Japan. He imposed his will on Japan. Demilitarization was speedily carried out, demobilization of the former imperial forces was completed by early 1946. Japan was extensively fire bomded during the second world war. The stench of sewer gas, rotting garbage, and the acrid smell of ashes and scorched debris pervaded the air. The Japanese people had to live in the damp, and cold of the concrete buildings, because they were the only ones left. Little remained of the vulnerable wooden frame, tile roof dwelling lived in by most Japanese. When the first signs of winter set in, the occupation forces immediately took over all the steam-heated buildings. The Japanese were out in the cold in the first post war winter fuel was very hard to find, a family was considered lucky if they had a small barely glowing charcoal brazier to huddle round. That next summer in random spots new ho uses were built, each house was standardized at 216 square feet, and required 2400 board feet of material in order to be built. A master plan for a modernistic city had been drafted, but it was cast aside because of the lack of time before the next winter. The thousands of people who lived in railroad stations and public parks needed housing. All the Japanese heard was democracy from the Americans. All they cared about was food. General MacArthur asked the government to send food, when they refus ed he sent another telegram that said, Send me food, or send me bullets. † American troops were forbidden to eat local food, as to keep from cutting from cutting into the sparse No food was was brought in expressly for the Japanese durning the first six months after the American presence there. Herbert Hoover, serving as chairman of a special presidential advisory committee, recommended minimum imports to Japan of 870,000 tons of food to be distributed in different urban areas. Fish, the source of so much of the protein in the Japanese diet, were no longer available in adequate quantities because the fishing fleet, particularly the arge vessels, had been badly decimated by the war and because the U. S. S. R. closed off the fishing grounds in the north. The most important aspect of the democratization policy was the adoption of a new constitution and its supporting legislation. When the Japanese government proved too confused or too reluctant to come up with a constitutional reform that satisfied MacArthur, he had his own staff draft a new constitution in February 1946. This, with only minor changes, was then adopted by the Japanese government in the form of an imperial amendment to the 1889 constitution and went into effect n May 3, 1947. The new Constitution was a perfection of the British parliamentary form of government that the Japanese had been moving toward in the 1920s. Supreme political power was assigned to the Diet. Cabinets were made responsible to the Diet by having the prime minister elected by the lower house. The House of Peers was replaced by an elected House of Councillors. The judicial system was made as independent of executive interference as possible, and a newly created supreme court was given the power to review the constitutionality of laws. Local governments were given greatly increased powers. The Emperor was reduced to being a symbol of the unity of the nation. Japanese began to see him in person. He went to hospitals, schools, mines, industrial plants; he broke ground for public buildings and snipped tape at the opening of gates and highways. He was steered here and there, shown things, and kept muttering, â€Å"Ah so, ah so. † People started to call him â€Å"Ah-so-san. Suddenly the puyblic began to take this shy, ill-at-ease man to their hearts. They saw in him something of their own conqured selves, force to do what was alien to them. In 1948, in a newspaper poll, Emperior Hirohito was voted the Civil liberties were emphasized, women were given full equality with men. Article 13 and 19 in the new Constitution, prohibits discrimination in political, economic, and social relations because of race, creed, sex, social status, or family origen. This is one of the most explicitly progressive statements on human rights anywhere in law. Gerneral Douglas MacArthur emerged as a radical feminist because he was â€Å"convinced that the place of women in Japan must be brought to a level consistent with that of women in the western democracies. † So the Japanese women got their equal rights amendment long before a oncerted effort was made to obtain one in America. Compulsory education was extened to nine years, efforts were made to make education more a traning in thinking than in rote memory, and the school system above the six elementary grades was revised to conform to the American pattern. This last mechanical change produced great confusion and dissatisfaction but became so entrenched that it could not be revised even after the Americans departed. Japan's agriculture was the quickest of national activities to recover because of land reform. The Australians came up with the best plan. It was basis was this: There were to be no absentee landlards. A person who actually worked the land could own up to 7. 5 arcers. Anyone living in a village near by could keep 2. 5 acres. Larger plots of land, exceeding these limits, were bought up by the government and sold on easy terms to former tenants. Within two years 2 million tenants became landowners. The American occupation immediately gained not only a large constituency, for the new owners had a vested interest in preserving the change, but also a psychological momentum for other changes they wanted to initiate. The American labor policy in Japan had a double goal: to encourage the growth of democratic unions while keeping them free of communists. Union organization was used as a balance to the power of management. To the surprise of the American authorties, this movement took a decidedly more radical turn. In the desperate economic conditions of early postwar Japan, there was little room for successful bargaining over wages, and many labor unions instead made a bid to take over industry and operate it in their own behalf. Moreover large numbers of workers in Japan were government employees, such as ailroad workers and teachers, whose wages were set not by management but by the government. Direct political action therefore seemed more meani ngful to these people than wage bargaining. The Japanese unions called for a general strike on February 1, 1947. MacArthur warned the union leadership that he would not countenace a nationwide strike. The strike leaders yieled to MacArthur's will. The reafter the political appeal of radical labor action appeared to wane. The Americans wanted to disband the great Zaibatsu trust as a means of reducing Japan's war-making potential. There were about 15 Zaibatsu families such as – Mitsui, Mitsubishi, Yasuda, and Sumitomo. The Zaibatsu controled the industry of Japan. MacArthur's liaison men pressured the Diet into passing the Deconcentration Law in December 1947. In the eyes of most Japanese this law was designed to cripple Japanese business and industry forever. The first step in breaking up the Zaibatsu was to spread their ownership out among the people and to prevent the old owners from ever again exercising control. The stocks of all the key holding companies were to be sold to the public. Friends of the old Zaibatsu bought the stock. In the long run the Zaibatsu were not exactly destroyed, but a few were weakened and others underwent a considerable shuffle. The initial period of the occupation from 1945 to 1948 was marked by reform, the second phase was one of stabilization. Greater attention was given to improvement of the economy. Japan was a heavy expense to the United States. The ordered breakup of the Zaibatsu was slowed down. The union movement continued to grow, to the ult imate benefit of the worker. Unremitting pressure on employers brought swelling wages, which meant the steady expansion of Japan domestic onsumer market. This market was a major reason for Japan's subsequent economic boom. Another boom to the economy was the Korean War which proved to be a blessing in disguise. Japan became the main staging area for military action in Korea and went on a war boom economy with out having to fight in or pay for a war. The treaty of peace with Japan was signed at San Francisco in September 1951 by Japan, the United States, and forty-seven other nations. The Soviet Union refused to sign it. The treaty went into effect in April 1952, officially terminating the United States ilitary occupation and restoring full independence. What is extraordinary in the Occupation and its aftermath was the insignificance of the unpleasant. For the Japanese, the nobility of American ideals and the essential benignity of the American presence assuaged much of the bitterness and anguish of defeat. For the Americans, the joys of promoting peace and democracy triumphed over the attendant fustrations and grievances. Consequently, the Occupation served to lay down a substantial capital of good will on which both America and Japan would draw in the years ahead.

A Famous Personality Who Has a Great Influence on Me

In the world, most of people need to change themselves. It might be they meet somebody who inspires them to do something that never done before and I am one of those people. I love volleyball so much since I watched SAORI KIMUEA on a TV. She is a Japanese volleyball player and very famous because of her beauty, talent, and skills of competition which are reasons for me want to be like her. The previously, I met her. I disliked exercising very much I had never thought that sports were very exciting. I wasn't interested in any sports.I was very an inert person and didn't prepare to study, do activities with friends, or the challenging things until I had seen the fierce volleyball game that SAORI KIMURA played, I felt enjoyable and wanted to play, the same time I really admired her smile, beauty, and sweet moving which are the important things for me or can say another way that I want to change myself form an inert person into an enthusiastic person. Initially, I just only watched I did n't know the rules of volleyball and how to play it.I didn't have courage I was afraid of the mistakes, but I want to be the best volleyball player, so I decided to play for my dream. I tried to play, but my first time wasn't easy I began to use my arms to hit the ball, suddenly the ball was backward. In fact, it should be forward, at that time my friends laughed very loud. It was so embarrassing, but I had never surrendered, I tried again I practiced harder and harder. Finally, I can play volleyball better than before, and last year, I became to be a volleyball player of my school team I was very glad.The volleyball taught me many things such as what is the teamwork? Don't be afraid and technical of doing new things because everything has to practice the same as playing volleyball. For those reasons, I don't have to worry about mistakes when I do the challenging things. I have to thank Miss SAORI KIMURA who is my inspiration she makes me know the endeavor and have more daring espec ially, I can play the volleyball like her even thought I haven't been good enough yet, but I promise that one day I will be the famous volleyball player like SAORI KIMURA.

Child development Essay

1. Understand the development and learning of babies and young children. 1.1 Explain the pattren of developments in the first three years of life and the skills typically acquired at each stage. Babies and toddlers show amazing progress in all aspects of their development from birth to three years, considering they are born with simple reflexes and are quite helpless and dependent. It is essential to have a good understanding of the development stages in this group in order to support their development. The changes that occur in a child’s development in the first few years of life are truly remarkable. Practitoners note children’s development as they begin to smile, laugh, sit, crawl, babble and talk. Children begin to socialize and play cooperatively with other children. They acquire important skills to get along with others such as turn-taking, sharing and following instructions, as well as skills that will help them academically such as drawing, counting, reading, and writing.(REF:http://www.beststart.org/OnTrack_English/3-childrensdevelopment.html) Early child development usually follows a sequence, as the child needs to master one skill before he/she can a cquire the next, but all children develop at their own rate. At times, a child may take a long time to master a new skill; at other times, he/she may seem to skip a skill in the expected sequence in his/hers speed of development. Through careful observation, assessment and communication with the child’s key worker, they can draw a clear picture of the child within their setting. 1.2 Explain: How development and learning are interconnected How and why variations occur in rate and sequence of development of learning That learning may take place in different ways The importance of play Development and learning are closely tied. Children need to develop certian  skills in order for them to learn, but also the desire to learn something or achieve a goal can motivate a child to develop the necessary skills. A good example of this is walking, for a baby to begin to walk, a level of coordination and growth is required, but the baby must also have the desire to walk. during the process of learning to walk, the child will develop balance, strength in the legs, and improved coordination. Once the child can walk, a whole new world can be discovered as the child can now reach things and see things from an different level. Therefore, Learning to walk has improved both the child’s physical development, and his or her cognition. It is not fully understood why some children appear to learn faster than others, but it is thought that there both genetic and environmental factorsat play. Some children have learning difficulties that prevent them from learning in the same wa y – or at the same rate – as other children. The causes of learning difficulties vary and include chromosomal conditions, medical conditions and others that are not yeat understood, however, although the term ‘ learning difficulties’ is used, it does not mean that such children will have difficulties in learning in every area of their lives. So some children will learn some skills, for example the ability to draw or socialise, at the same rate as others. Some children are seen as ‘bright’ very early on. Adults may notice how quicky the remember things and how fast they are to learn new skills. For these children, it would seem that they are able to process information more quickly and effectively than other children of the same age. This is thought to be linked to the presence of a stimulating environment combined with a strong genetic component. Children can learn in a variety of ways. They can copy adults and other children, they can also learn from thier own experiences as they will repeat activities that fascinate them or are enjoyable. Interestingly, most of what babies and toddlers will learn comes from ‘doing’ rather than being ‘taught’ by adults. As children can learn in variety of ways, it is important for us to provide them with a range of different opportunities and experiences. Play is essential for children’s development. through play, children can delelop a variety of skills that support every area of development. Good play opportunities allow children not only to have fun and to explore, but also to learn about materials, concepts and how to socialise. Play begins very early on in babies’ lives as long as they have an adult who can engage  with them. As ch ildren grown an develop, they are able to choose and create their own play; Physical – A range of physical skills, including fine and gross motor skills, are developed as children make movements, balance or sit in order to play with toys or engage in games with adluts. Cognitive – Children learn concepts and about the world around them by playing with materials, resources and learning by trial and error what things can do. Language – Play gives children a reason for taking and communicating. At first this is with adluts, but as children can play together, they talk to each other. Emotional – Play is fun. It makes children feel happy and also helps them to feel powerful and learn about feelings; when they engage in role play they also learn about different perspectives. Social – From playing with adults, babies learn social skills such as talkingturns and co-operating. They so learn to ‘read’ faces. With age and language skills. children also learn to play with other children. 1.3 Explain the potential effects on development, of pre-conceptual, pre-birth and birth experiences. All babies and children show different rates of development,but some do so because of difficulties linked to experiences during conception, pregnancy and birth. We know that even before a baby is conceived, the lifestyle of the parents can have an effect on thier potential development. this is because men’s sperm and woman’s ova can be easily damaged. Parents are advised to think about stopping smoking, about taking folic acid supplements, cuttting down on alcohol and avoiding recreational drugs. They are also advised not to leave starting a family too late because not only does it become harder for a woman to conceive as they get older, but also the quality of a woman’s eggs can deteriorate over time. Conception At the moment of conception, when a sperm and egg fuse, a transfer of genetic information takes place. the fertilised eggs will have 23 chromosomes from the father and 23 chromosomes from the mother, which are used to determine its development. This is mixing of genetic information is often described as  nature’s lottery, as some medical conditions and disabilities are the result ofthis genetic combination. Pregnancy Between conception and birth, babies can be affected by the health of their mother as well as her lifestyle choices. Stress, deit and alcohol are examples of factors that can affect development. It is now recognised that the first twelev weeks of pregnancy is when the foetus is at it’s most vulnerable. During this time the foetus becomes recognisably human and all the organs are formed. Smoking Smoking restricts the amount of oxygen the unborn baby is getting and affects the groth and development. Bbaies born to mothers who smoke are therefore more likely to be lighter at birth and also premature. Ther seems to be other long-lasting effects on health as well. These include a higher incidence of cot death and a greater predisposition to asthma. Substance abuse the use of recreational and prescribed drugs can affect the developing foetus. Drugs enter the mother’s blood stream and the cross via the placenta into the baby. the effect of drugs can be devastating – especially in the first twelve weeks when the foetus is developing. Pregnant woman are therefore advised not to take any drugs during their pregnacy unless told to do so by a doctor. Alcohol Alcohol can enter the foetus’s blood stream in the same way that drugs can. Again this can have a serious impact, especially in the first few weeks of a pregnancy when sometimes mothers may not even know their pregnant but the baby is at a critical point of development. During the rest of the prgnancy alcohol can effect the development of the bay an so doctors advised mothers not to drink threw out their pregnancy. A specific condition known as Foetal Alcohol Syndrome, which is cuased by alcohol during pregnancy, has now been identifed. This condition negatively affects aspects of the children’s cognitive development including their concentration. Infections Some infections that a mother may pick up during pregnancy can affect the  development of the foetus. The common cold is harmless, but food poisoning, rubella or sexually transmitted disease such as genital herpes can put the unborn baby at risk. Babies who have been exposed to rebella often have sight and hearing problems. Maternal Health Most women should have healthy pregnancies, but some woman can develop complications, including diabetes and pre-eclampsia (which can even be fatal). If left undereated, these conditions can affect the health of both mother and baby. This is why pregnant women are offered refu;ar antental check ups. Maternal Diet Diet is particularly important in the first twelve weeks of pregnancy when lack of a mineral called folic acid, found in green leafy vegetables, can cause spina bifida. Women who are consirdering a pregnancy are therfore urged to take supplements of 400mcg of folic acid daily untilthe twelfth week of their pregnancy. Pregnant woman can also become deficient in iron and so are encouraged to eat high in iron such as red meat, green vegetables, dried apircots and fortified breakfeast cereals. The process of birth can present various dangers to both mother and child, which is why mothers are monitored before and during birth. Most women give birth vaginally but sometimes a Caesarean Section is given. This is when an incision of approximately 20cm is made across the lower abdomen and the baby is delivered through this opening; the mother is given an anaesthetic beforehand. A Caesarean may be planned in advance, for example when a woman is carrying triplets, or may have to be carried out at short notice if there are difficulties when giving birth. The main danger for babies during the birthing process is a lack of oxygen. During labour, the oxygen supply to the baby might be interrupted for several reasons, including the umbilical cord becoming entangled or the baby being slow to breathe at birth. In extreme cases anoxia can be fatal or leave the baby with permanent brian damage. It is important to emphasise. However, that this is relatively rare and most abies are born safe ly.