Contrast Media and Intravenous Urography

Contrast Media and Intravenous Urography Introduction The practice of clinical diagnostic radiology has been made possible by advances not only in diagnostic equipment and investigative techniques, but also in the contrast media that permit visualisation of the details of the internal structure or organs that would not otherwise be demonstrable. The remarkably high tolerance of modern contrast media has been achieved through successive developments in chemical pharmacological technology. A single dose of X-ray contrast medium commonly contains upwards of 2000 times as much iodine as in the total physiological body content, and yet it is cleared from the system rapidly and naturally, usually with no adverse effects at all. The choice of contrast medium has always been a matter of debate, but is ultimately the responsibility of the radiologist. In order to be able to make a rational decision as to the selection of contrast media, it is necessary to have some understanding of the physical and physiological principles involved. The objective is to provide a background for non-specialists on this complicated specialist subject. Why contrast media are necessary Different tissues within the body attenuate the beam of X-rays to different degrees. The degree of attenuation of an X-ray beam by an element is complex, but one of the major variables is the number of electrons in the path of the beam with which it can interact. The number of electrons in the path of the beam is dependent upon three factors: The thickness of the substance being studied Its density The number of electrons per atom of the element (which is equal to its atomic number) In a complex mixture of elements, which is of course what we are concerned with in the organs of a patient, the degree of attenuation is particularly influenced by the average of the atomic numbers of all the atoms involved. Where there is a considerable difference between the densities of two organs, such as between the solid muscle of the heart and the air in the lungs, then the outlines of the structures can be visualised on a radiograph because of the natural contrast that exists. Similarly, if there is a difference between the average atomic numbers of two tissues, such as between soft tissues, which are composed of elements of low atomic number, and bone, which is partly composed of the element calcium, with a rather higher atomic number, then the outlines of the different structures can be seen by natural contrast. However, if the two organs have similar densities and similar average atomic numbers, then it is not possible to distinguish them on a radiograph, because no natura l contrast exists. This situation commonly occurs in diagnostic radiography, so that, for example, it is not possible to identify blood vessels within an organ, or to demonstrate the internal structure of the kidney, without artificially altering one of the factors mentioned earlier. Two of the factors important in organ contrast can be artificially altered, the density of an organ, and, more usefully, the average atomic number of a structure. The density of a hollow organ can be reduced by filling it with gas or air, providing negative contrast. This is mainly of historical significance, but is still used when, for example, gas is introduced into the stomach or colon during a double-contrast barium examination. The average atomic number of hollow structure such as a blood vessel can be increased by filling the cavity with a liquid of much higher average atomic number (such as iodine containing contrast medium) than that of blood. In fact this is the principle by which contrast media consist of solutions or suspensions of non-toxic substances that contain a significant proportion of elements of high atomic number, usually iodine. EXAMINATION USE CONTRAST MEDIA common are described below. It should be noted that the volume, strength, as well as the type of contrast medium, will vary between patients according to the examination type and radiologists requirements. 1. Angiography Angiography is the general term which describes the investigation of blood vessels. Usually a distinction between arteriography and venography is made, depending on the kind of blood vessel (artery or vein) which is examined. Arteriography In arteriography a contrast medium is introduced via a catheter into an artery, which makes the lumen of that vessel opaque to X-rays. The natural flow of blood carries the contrast medium peripherally, and by taking a series of radiographs the radiologist can obtain images akin to a road map of the blood supply to an organ, or a limb. Localised narrowing or obstruction of an artery or a pathological circulation in a tumour can then be identified. Sometimes the radiologist may then proceed to treat the patient using the catheter system, which was introduced initially for diagnosis. Arteriography is relatively time consuming for the radiologist depending on the complexity,  ½ hour 2 hours, or even longer can be spent on the procedure. Venography (phlebography) The natural flow of blood in veins is towards the heart, and by injection of a contrast medium into a peripheral vein, a map of the venous drainage of a limb can be obtained. The larger size and greater number of peripheral veins, and the fact that the flow of blood is much slower in veins than in arteries,means that it is usual for the radiologist to take several radiographs of each area with the limb in different positions. The commonest indication for venography is to confirm a suspected diagnosis of deep venous thrombosis of the leg. Venography is also performed on organs within the body by introducing a catheter into a peripheral vein and manipulating it into an organ. Digital subtraction angiography (DSA) A special type of angiography is digital subtraction angiography (DSA). These procedures involve the use of specialised electronic equipment, computing and radiographic hardware to produce rapid sequential images. The DSA image is produced by electronically subtracting images without contrast media from images after contrast media injection. The result of this subtraction process is the visualisation of contrast filled vessels which are free from the distraction of overlying structures. 2. Intravenous urography (IVU), intravenous pyelography (IVP) When injected intravenously, most contrast media are rapidly excreted by the kidneys, and a series of radiographs taken after the injection will demonstrate the urinary tract. Intravenous urography is still the basic radiological examination of the urinary tract. The main indication is to assess the morphology of the kidneys. Further indications are: detection of kidney stones and calcifications in the ureter or bladder, assessment of obstructed urinary flow and investigation of patients with haematuria (the passage of blood in urine). Children may be investigated for congenital abnormalities of the urinary tract. In recent years for some investigations of the urinary tract, particularly uncomplicated infection, an ultrasound examination and plain abdominal radiograph have replaced intravenous urography as the initial investigation of the urinary tract. 3. Computed tomography (CT) Since 1973 an imaging technique known as computed tomography (CT) has developed to become one of the most important radiological examinations in the industrialised countries. CT uses conventional X-rays in a thin nondivergent beam to produce cross sectional images of the body. The X-ray tube and an array of detectors mounted within a supporting framework, rotate round the patient with each scan. CT produces digitalized images, although these are usually printed onto hard copy film in a format that is useful for transfer and viewing throughout the hospital. By electronic means CT improves via a higher contrast sensitivity, the natural radiological contrast between organs. However, it cannot create contrast where none exists naturally. CT is exceptionally sensitive to contrast media and can detect abnormalities, caused by disease, following an injection of an intravenous dose of contrast medium. This procedure is known as enhancing the scan. About 43% of all CT procedures involve the use of a contrast medium. CT is widely used throughout the body but the most frequently investigated areas using this technique are neuroradiology (brain and lumbar spine) and general radiology of the chest, abdomen and pelvis. It is particularly useful for the diagnosis, staging and follow up of malignant disease. 4. Myelography The spinal cord and the attendant nerve-roots which radiate from it cannot be visualised using conventional X-rays alone without the use of contrast media. They can be visualised directly using magnetic resonance imaging (MRI). They can be visualised if contrast medium is injected in the cerebrospinal fluid (CSF), which surrounds the spinal cord, rendering the CSF radio-opaque but not the cord of nerve roots. Specific contrast media have been developed for this examination. The majority of myelograms (or radiculograms) were performed to examine the lumbar region to confirm the clinical suspicion of a prolapsed intervertebral disc. However, CT and MRI have now largely replaced myelography as the initial investigation of the lumbar spine. Myelography, particularly combined with CT scanning is still used however to investigate the cord and cervical region and its nerve roots in difficult cases when other investigations are equivocal or normal. Interventional Techniques/Procedure Many radiologists are now specialised in therapeutic procedures that have bee developed from radiological diagnostic techniques using catheters and guidewires. These procedures include: The dilation of pathologically narrowed arteries angioplasty, percutaneous transluminal angioplasty (PTA). The deliberate occlusion of arteries supplying abnormal areas such as tumours, aneurysms and vascular malformations, so depriving them of their blood supply. The placement of artificial tubes or stents into blood vessels, bile ducts or ureters to bypass a pathological narrowing. These procedures often necessitate the use of high doses of contrast medium, because several examinations of the same vessels may be required during the control of the therapeutic process. Safety of Contrast Media Contrast media are among the safest of all of the pharmaceutical products available to the doctor today. They are anomalous in that they are not intended to have therapeutic activity: indeed, the ideal contrast medium would have no pharmacological activity at all. For this reason the concept of therapeutic ration, which can be applied to medicines, does not apply to contrast media. The development of a contrast medium from the first design of the molecule through to product licence takes many years. The minimum period of time that can reasonably be allotted to preclinical and clinical development is six years, and in practice it is not uncommon to take nine years or even more. During this long period, the tolerance of the medium is rigorously tested by collecting data from various preclinical and clinical trials to establish a profile for the product. One critical area examined during its development is the incidence of adverse reactions. The rate of adverse reactions to iodinated co ntrast media on the market is extremely low, but such reactions do occur just as they do with every pharmaceutical product. The adverse reactions associated with contrast media can be divided into two groups: Those reactions that are clearly dependent on the dose and concentration of the contrast medium administered and those that are almost independent of dose and concentration. Dose-dependent adverse reactions are mostly due to the physiochemical effects of the contrast medium, such as its osmolality, or electrical charge. Possible adverse reactions include heat, pain, vasodilation, cardiac depression and hypotension. The adverse reactions which are almost independent of dose and concentration are nausea and vomiting as well as allergy-like or hypersensitive reactions such a urticaria (hives), certain cardiovascular reactions, bronchospasm and laryngospasm, but there is little evidence of any antigenantibody interaction. These reactions cannot be predicted and their underlying cause remains unknown. For clinical purposes it is meaningful to divide contrast media reactions into three categories: Minor e.g. Flushing, nausea, vomiting, pruritis, mild rash, arm pain Moderate e.g. More severe urticaria, facial oedema, hypotension, bronchospasm Severe e.g. Hypotensive shock, laryngeal oedema, convulsions, respiratory and cardiac arrest Most contrast media reactions are minor and need no treatment. Moderate reactions are encountered rarely (about 1%) and severe reactions very rarely (about 0.1%), but all moderate and severe reactions require adequate treatment. Deaths following contrast media administration are extremely rare. Reported mortality rates vary between 1 in 10,000 and 1 in 169,000 averaging around 1 in 75,000. Katayama et al. (Radiology 1990; 175: 621-628) found that there is a reduction in adverse reaction rate of about four times using low osmolar contrast media (LOCM) for intravenous injection compared to high osmolar contrast media (HOCM). There is surprisingly no documented difference in mortality between intravenous LOCM and HOCM in large series from Japan and Australia. It is not usually possible to predict severe reactions, even by looking at the effect of a small test dose of a contrast medium. Guidelines have been produced for the use of low osmolar contrast agents. Risk Renal adverse reactions Contrast media-induced nephropathy is defined as impairment in renal function (an increase in serum creatinine by >25% or 44à £Ã¢â€š ¬Ã¢â€š ¬mol/L (0.5mg/dL) occurring within 3 days following the intravascular administration of contrast media in the absence of an alternative etiology Risk factors include raised s-creatinine levels particularly secondary to diabetic nephropathy, dehydration, congestive heart failure, age over 70 years old, concurrent administration of nephrotoxic drugs, e.g., non-steroidal ant-inflammatory drugs Systematically effective 1. Adequate hydration in terms of oral fluid intake or intravenous normal saline (depending on the clinical situation) at least 100 ml per hour starting 4 hours before to 24 hours after contrast administration is recommended. Concurrent administration of nephrotoxic drugs should be stopped for at least 24 hours. High osmolar contrast media, large doses of contrast media, or multiple studies with contrast media within a short period of time should be avoided. Alternative imaging techniques that do not require the administration of iodinated contrast media should be considered. Recent work in preventing and ameliorating contrast medium-induced nephropathy with N-acetyl cysteine 4-6 and various hydration regimens including use of sodium bicarbonate has been promising but is not conclusive yet. No measure has yet resulted in avoidance of its occurrence in all patients.Non-renal adverse reactions.These are generally classified as idiosyncratic or chemotoxic. Idiosyncratic (i.e., anaphylac toid) reactions occur unpredictably and independently of the dose and concentration of the agent. Most anaphylactic reactions relate to the release of active mediators. Conversely, chemotoxic-type effects relate to the dose, the molecular toxicity of each agent, and the physiologic characteristics of the contrast agents (i.e., osmolality, viscosity, hydrophilicity, calcium binding properties, and sodium content). Chemotoxic-type effects are more likely in patients who are debilitated or medically unstable 2. Acute reactions to contrast media can be divided into minor, intermediate, and severe life-threatening. Minor reactions include flushing, nausea, arm pain, pruritus, vomiting, headache, and mild urticaria. Such reactions are usually mild in severity, of short duration, selflimiting and generally require no specific treatment. Intermediate reactions are more serious degrees of the same symptoms, moderate degrees of hypotension, and bronchospasm. The reactions usually respond readily to appropriate therapy. Severe life-threatening reactions include severe manifestations of all the symptoms described as minor and intermediate reactions, plus convulsions, unconsciousness, laryngeal oedema, severe bronchospasm, pulmonary oedema, severe cardiac dysrhythmias and arrest, cardiovascular and pulmonary collapse. The prevalence of adverse reactions with lowosmolar contrast media is less than with high-osmolar contrast media by a factor of 5-6. Lethal reactionsrarely occur. The actual risk of death is less than one in 130,000 at most 3. The incidence of severe adverse reactions increases in patients with previous contrast medium reaction, bronchial asthma and allergy requiring medical treatment. Premedication with corticosteroid prophylaxis has been proved safe and effective in preventing minor adverse events in high-risk patients when ionic agents are used 4. The data indicating a protective effect of corticosteroid prophylaxis are less established when non-ionic agents are used. Opinion is divided about the value of premedication when nonionic agents are used. Even if it is given, there is a wide variety of regimes with different doses, number of doses, and frequency for corticosteroid prophylaxis. 5. A variety of symptoms (e.g. nausea, vomiting, headache, itching, skin rash, musculoskeletal pains, fever) have been described, but many are unrelated to the contrast medium. Allergy-like skin reactions are welldocumented side effects of contrast media, with an incidence of approximately 2%. Most late skin reactions after contrast medium exposure are probably T-cellmediated allergic reactions. Patients at increased risks are those with history of previous contrast medium reaction and those undergoing interleukin-2 treatment. Most skin reactions are usually mild to moderate, selflimiting and likely resolve within a week. Treatment is symptomatic and similar to the treatment of other druginduced skin reactions.Extravasation of contrast material is a well-recognised complication. The introduction of automated power injection has increased the incidence because power injection may result in extravasation of large volumes in a short period of time and may lead to severe tissue damage. Intravenous Urography Introduction Intravenous urography is a radiographic study of the  urinary system  using an intravenous contrast agent (dye). It is a medical procedure used to visualise the kidney and lower urinary tract to help diagnose problems such as infections. A contrast dye is injected into a vein on your hand or arm, and then x-rays are taken. The dye helps to outline more clearly the structure of the kidneys and lower urinary tract. The  kidneys excrete the contrast into the urine, which becomes visible when x rayed (radiopaque), creating images of the urinary collection system. An intravenous urogram is ordered to demonstrate the structure and function of the kidneys, ureters, and bladder. Patients complaining of abdominal pain radiating to the back may require this exam to rule out  kidney stones. Hematuria may also be an indication of kidney stones,infection, or tumors. Patients with high blood pressure (hypertension) and recurrent bladder infections may also require an intravenous urogram (b ut hypertension usually is imaged with MRA or nuclear medicine imagery and this exam is done when renal artery stenosis is the suspected cause of refractory hypertension). Sometimes the exam is ordered to evaluate the function of the kidney in a renal transplant patient. The transplanted kidney is located in the iliac fossa, so special films of the pelvis area are done instead of the normal routine views. The radiographic technologist may also be required to take x rays in the operating room when a retrograde pyelogram is ordered by a urologist during a C and P (cystoscopy  and pyelography). Indication A normal intravenous urogram indicates no visible abnormality in the structure or function of the urinary system. The radiologist looks for a smooth non-lobulated outline of each kidney, no clubbing or other abnormality of the renal calyces (collecting system), and no abnormal fluid collection in the kidneys that could suggest obstruction. The ureters must contain no filling defects (stones) or deviations due to an adjacent tumor. The bladder must have a smooth outline and empty normally as visualized on the post-void film. Abnormal results include hydronephrosis (distension of the renal pelvis and calices due to obstruction) as a result of tumors or calculi (stones). Cysts or abscesses may also be present in the urinary system. A delay in renal function can also indicate renal disease. An abnormal amount of urine in the bladder after voiding may indicate prostate or bladder problems. Intravenous urograms are often done on children to rule out a rapid developing tumor in the kidneys, called a Wilms tumor. Children are also prone to infections of the bladder and kidneys due to urinary reflux (return back-flow of urine). Procedure The patient will be required to change into a hospital gown and empty his or her bladder. The x-ray technologist will verify that the patient has followed the bowel preparation and complete a detailed questionnaire on the current medical history of the patient. This includes previous contrast reactions, known  allergies, risks of  pregnancy, and current medications. The x-ray technologist will explain the exam in detail to the patient as well as the risks of the contrast material that will be injected intravenously. All departments require that the patient sign a consent form before the examination is started. The x-ray technologist will relay this information to the radiologist who will decide on what type of contrast will be used. Patients who have had an injection with no reaction can be given less expensive iodine based contrast, whereas patients who take various  heart  medications or those with known allergies or  asthma will be injected with a more expensive contrast agent (known as non-ionic contrast) that has fewer side effects. Some departments use the non-ionic contrast exclusively. The patient will be instructed to lie supine (face-up) on the x-ray table and a preliminary KUB will be done. This is an abdominal view of the kidneys, ureter, and bladder used to verify patient preparation, centering, and the radiographic technique needed to demonstrate all the required structures. Kidney stones may or may not be visualized on the preliminary film. The x-ray technologist prepares the required amount of contrast to be used depending on the weight of the patient (1 ml per pound). This is normally 50-75 cc of contrast for an average-sized patient. The contrast will be injected all at once (bolus injection) or in some cases, through an intravenous drip. Some radiologists prefer to start an intravenous drip with saline as a precautionary measure while others inject with a small butterfly needle. The needle usually remains in place for 10-15 minutes, in case more contrast is needed or in case drugs need to be administered because of an allergic reaction. Most reactions occur immediately but some can take place 10 or 15 minutes after the injection. The first film is taken immediately after the injection to see a detail of the renal outline (nephrogram). Films are usually taken at five-minute intervals depending on the routine of the radiologist. Compression may be applied to the lower abdomen with a wide band to keep the contrast material in the kidneys longer. This creates a more detailed image of the renal collecting system. When the compression is released after approximately 10 minutes the contrast material drains quickly and a detailed, filled image of the ureters is obtained. Films done in the upright or prone (face-down) position may also be ordered to better visualize the lower ureters. Some departments require routine renal tomographic images to be done as well when the kidneys are well visualized. This allows the kidneys to be seen free of gas or fecal shadows. Sometimes the radiologist requires oblique views of the kidneys or bladder to determine the exact location of calculi (stones). At approximately 20 minutes aft er the injection a film centered on the bladder may be required. The x-ray tube is angled slightly caudad (towards the feet) so that there is no superimposition of the pubic area of the pelvis over the bladder. The films are shown to the radiologist and if no further films are necessary the patient will be asked to void (urinate) and a post-void film will be taken. The exam can take from 30 minutes to one hour depending on the number of films required. If the kidney is obstructed, delayed films may be required to complete the exam. Patient care The x-ray technologist must work in conjunction with the doctors and nurses in making sure the patient has not had a previous allergic reaction to a contrast agent. All hospitals have an emergency team ready to react in such a situation, so the technologist must be aware of the procedure to follow when assistance is necessary due to a severe reaction. Details of patient preparation must also be communicated to the hospital wards. In some hospitals the radiologic technologists are trained to give injections, but if this is not the case nurses may be asked to install an intravenous drip before the patient is brought to the radiology department. The x-ray technologist must explain the risks of an allergic reaction to each patient even though severe reactions are extremely rare due to the advances made in the preparation of contrast agents. The x-ray technologist explains to the patient that a warm, flushed feeling or a metallic  taste  in the mouth are normal reactions in some patients. Breathing instructions are also important since the kidneys change position depending on the phase of respiration and to prevent motion artifacts. Sometimes an emergency patient with renal colic (acute abdominal pain) is asked to urinate through a special filter used to trap small stones. All radiographic technologists must be certified and registered with the American Society of Radiologic Technologists or an equivalent organization. Continued education credits are mandatory to remain registered. Risk and side effect Some of the side effects and possible complications including minor reactions to the contrast dye. It may include flushing, warmth and a metallic taste in the mouth. These usually resolve quickly. These symptoms are much less common with the newer contrast dyes. Some patient might experience severe allergic reactions. It may occur in a small percentage of the population. Symptoms range from relatively mild to severe, and can include hives (skin rash), breathing difficulties, swelling of the lips and tongue, low blood pressure and loss of consciousness. There is case when a patient experienced acute renal failure  but it occurs in less than 0.5 per cent of cases. Risk factors include advanced age, diabetes, dehydration and a past history of kidney disease. For patients with these risk factors, extra intravenous fluids, pre-treatment with acetylcysteine, and a reduced dose of contrast dye may be recommended, or they may undergo different procedures altogether. Problems that found There are several limitations of ultrasonography, CT, and MRI: lack of visualization for large portions of the urinary tract with ultrasonography, necessity of contrast agent administration and excretory images with CT, inability to visualize subtle urothelial abnormalities with sufficient spatial resolution with both CT and MRI, and insufficiency in visualizing calcifications with MRI[1]. Additional disadvantages of MRI are inconspicuousness of small intrarenal calculi, susceptibility artifact due to metallic objects that interfere with the visualization of ureteral segments, flow-related artifact in some sequences, and interference of hemorrhage into renal collecting system with static-fluid MR urography[8]. The patient effective dose, and therefore radiation risk, of CT urography is 1.5 times that of conventional urography. The increased radiation risk from a CT urography compared with an IVU should be considered in the context of the amount of information that is necessary for th e diagnostic task. Radiation risk is increased for smaller patients in CT urography and for larger patients in IVU[5]. Although CT falls short of IVU in the evaluation of urothelium, helical CT technology continues to evolve with introduction of multidetector row scanning (MDCT)[3,9]; MDCT may eventually replace IVU for the evaluation of hematuria[2,4]. Finally, there is not an optimum or ideal examination technique for CT urography[10] or MR urography. Examination techniques must be constructed according to suspected pathology of the patient and urinary system status. Although advances in imaging technology have given CT and MR urography advantages over IVU, many centers still use IVU as a part of routine radiological practice. Therefore, techniques or modifications for improving application and diagnostic capabilities of IVU should still be considered. For decades, intravenous urography has been the primary imaging modality for evaluation of the urinary tract. In recent years, however, other imaging modalities including ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging have been used with increasing frequency to compensate for the limitations of intravenous urography in the evaluation of urinary tract disease . Like intravenous urography, however, these examinations have their limitations. Large portions of the urinary tract are not visualized at US; CT requires contrast material administration and excretory images (at times with a prolonged delay), often with image reformatting for evaluation of the urothelium; and MR imaging may not demonstrate calcifications or show the urothelium with sufficient resolution for evaluation of subtle abnormalities. Thus, despite increasing use of these alternative modalities, the ideal global urinary tract examination remains controversial . Axial imaging with con trast material opacification of the urinary tract will likely evolve as the most efficient imaging evaluation. However, the declining use of intravenous urography in clinical practice reduces the opportunity to learn important interpretive skills. Formal urography (or the urographic equivalent of conventional radiography of the urinary tract following administration of contrast material for CT) is frequently performed in the evaluation of hematuria. Urography may also be performed in the pre- or posttherapeutic evaluation of stone disease that has been discovered with other modalities. BARIUM SWALLOW Introduction A barium swallow and meal is type of X-ray test that allows your doctor to examine your throat, oesophagus (the pipe that goes from your mouth to your stomach), stomach and the first part of the bowel (duodenum). X-rays usually pass straight through parts of the gut such as the oesophagus, stomach and bowel and so these structures dont show up well on plain X-ray images. However, if the gut wall is coated with barium, a white liquid that X-rays cant pass through, a much clearer image of the outline of the gut can be captured. If your stomach is being examined, the test is called a barium meal. If your oesophagus is examined at the same time, its called having a barium swallow and meal. A barium swallow and meal test can help work out why youre getting symptoms such as difficult or painful swallowing, heartburn, reflux and abdominal pain. The tests give your doctor information about the swallowing action, and

Henry Flemming Age Comparison :: essays research papers

Henry Flemming Age Comparison Henry Flemming underwent a major change as he became older. He became more courageous as an older man than he was as a youth. It may have been that he had not matured at the time of the war or that the war had changed him and made him more courageous. Regardless the reason, the older Henry Flemming was much more courageous than he was as a youth and there are a few situations in which he was able to prove that his courage had grown.  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Many times Henry would sit around and tell his stories of war. When he was asked if he was ever scared, Henry would tell the people listening that in fact he did get scared during battles. In fact, he even told them that at his first battle, he was so frightened that he fled from it. Telling a group of people that you had a weakness and were so scared that you had to flee from the danger takes a lot of courage. When Henry was a youth at war, he was terrified that someone would find out that he had fled and he was terrified of what people would say if they found out that he had fled, but Henry developed the courage to be able to freely admit to it and even laugh about it.   Ã‚  Ã‚  Ã‚  Ã‚  Then, when he was in bed one evening, he arose out of bed to find his drunken help blabbering that the barn was on fire. When Henry ran outside, he discovered that the drunken help’s lantern had caused the fire. Then, without thinking twice, Henry ran into the barn to rescue the animals. He rescued them even after he had been injured by one or more of them. When Henry was younger at war, he would always think twice or even more than twice before he went into battle, but the older Henry did not.   Ã‚  Ã‚  Ã‚  Ã‚  After Henry thought he had rescued all of the animals and that they were safe, the drunken help reminded him of the colts that he had left in the burning barn. Henry automatically decided that he had to get the colts out of the barn. The crowd of neighbors that had gathered told him that it was too dangerous and that it was just a suicide mission. Henry looked at the burning barn and, knowing that he was risking his life, he said that he had to at least attempt to rescue the colts anyways. Henry Flemming Age Comparison :: essays research papers Henry Flemming Age Comparison Henry Flemming underwent a major change as he became older. He became more courageous as an older man than he was as a youth. It may have been that he had not matured at the time of the war or that the war had changed him and made him more courageous. Regardless the reason, the older Henry Flemming was much more courageous than he was as a youth and there are a few situations in which he was able to prove that his courage had grown.  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Many times Henry would sit around and tell his stories of war. When he was asked if he was ever scared, Henry would tell the people listening that in fact he did get scared during battles. In fact, he even told them that at his first battle, he was so frightened that he fled from it. Telling a group of people that you had a weakness and were so scared that you had to flee from the danger takes a lot of courage. When Henry was a youth at war, he was terrified that someone would find out that he had fled and he was terrified of what people would say if they found out that he had fled, but Henry developed the courage to be able to freely admit to it and even laugh about it.   Ã‚  Ã‚  Ã‚  Ã‚  Then, when he was in bed one evening, he arose out of bed to find his drunken help blabbering that the barn was on fire. When Henry ran outside, he discovered that the drunken help’s lantern had caused the fire. Then, without thinking twice, Henry ran into the barn to rescue the animals. He rescued them even after he had been injured by one or more of them. When Henry was younger at war, he would always think twice or even more than twice before he went into battle, but the older Henry did not.   Ã‚  Ã‚  Ã‚  Ã‚  After Henry thought he had rescued all of the animals and that they were safe, the drunken help reminded him of the colts that he had left in the burning barn. Henry automatically decided that he had to get the colts out of the barn. The crowd of neighbors that had gathered told him that it was too dangerous and that it was just a suicide mission. Henry looked at the burning barn and, knowing that he was risking his life, he said that he had to at least attempt to rescue the colts anyways.

Project Network Survey Essay

Besides the basic physical security of a site, the next most important aspect is controlling digital access into and out of the organization’s network. In most cases this means controlling the points of connectivity to the outside world, typically the Internet. Partitioning the boundary between the outside Internet and the internal intranet is a critical security piece. Any services not actually needed should be turned off so that they will not become avenues of attack for security threats. Different systems will have different services running by default. The firewall process can tightly control what is allowed to traverse from one side to the other. As with most aspects of security, deciding what type of firewall to use will depend upon factors such as traffic levels, services needing protection and the complexity of rules required. The difficulty for firewalls is distinguishing between legitimate and illegitimate traffic. Firewalls, if configured correctly, can be a reasonable form of protection from external threats including some denial of service (DOS) attacks. If not configured correctly they can be major security holes in an organization. The most basic protection a firewall provides is the ability to block network traffic to certain destinations. This includes both IP addresses and particular network service ports. Many network devices and computer hosts startup network services by default, each of these services could represent an opportunity for attackers, worms and Trojans. Very often all of these default services are not needed. Doing port lockdown by turning off services reduces this exposure. Port 25: Is the virtual pathway that most e-mail traffic follows when it travels from your computer to a server. Port 25 can get clogged with spam e-mails when computers on a network become infected with a virus or other malicious software. Because of the potential threat our host computers sending spam email Port 25 will remain closed. Port 80: This is the primary port used by the World Wide Web (www) system. Web servers open this port then listen for incoming connections from web browsers. Similarly, when a web browser is given a remote address (like grc.com or amazon.com), it assumes that a remote web server will be listening for connections on port 80 at that location. This port will generally be open only when a web server of some sort is running on the machine. Due to the popularity of this port for malicious exploitation, it should never be open unless it is being actively and deliberately used to serve web pages. Port 139: Is typically used for file/printer sharing, including directory replication with Active Directory, trusts, remote access of event logs, etc. This port should be open. If you block port 139 on a Domain Controller you will kill AD replication. If you block 139 in a typical business network, you will lose the ability to do much of anything on a remote computer such as remotely manage clients/servers, install software, share printers, or files. Since the NetBIOS vulnerability is quite well-known a long time ago and heavily popularized, patches have been already released. The last remote exploits that targeted NetBIOS/139 were in the Windows NT/2000 era. Ports 1900 and Port 2869: These UDP port are opened and used by Universal Plug N’ Play (UPnP) devices to receive broadcasted messages from other UPnP devices. UPnP devices broadcast subnet-wide messages to simultaneously reach all other UPnP devices. UPnP Internet servers were found to have remotely exploitable unchecked buffers that would allow, in principle, remote malicious hackers. Microsoft Windows is vulnerable to a buffer overflow, caused by improper bounds checking by the Universal Plug and Play (UPnP) service. By sending a specially-crafted HTTP request, a remote attacker could overflow a buffer and execute arbitrary code on the system with elevated privileges when combined with another exploit. Unused Internet servers and services should not be left running if they are not actively needed, for this reason this port should be closed until needed. Port 5357: This port is opened because  you have Network Discovery enabled in a Public Network profile. The port is vulnerable to info leak problems allowing it to be accessed remotely by malicious authors. This port should be closed if network discovery is not required. Port 6839: This port is not associated with any particular services and should be closed unless it is assoc iated and used. Port 7435: This port is not associated with any particular services and should be closed unless it is associated and used. Port 9100: This TCP port is used for printing. Port numbers 9101 and 9102 are for parallel ports 2 and 3 on the three-port HP Jetdirect external print servers. It is used for network-connected print devices. This port should remain open to allow print services. Ports 9101 and 9102: Is the Bacula Director. This TCP port is used for printing. Port numbers 9101 and 9102 are for parallel ports 2 and 3 on the three-port HP Jetdirect external print servers. It is used for network-connected print devices. This port should remain open to allow print services. Port 9110: SSMP Message protocol – This protocol is intended to be used to implement thread-to-thread messaging locally or over the Internet. Ports registered with IANA are shown as official ports. The same port number may be unofficially used by various services or applications. Unofficially or sometimes with conflict, the same port may be used by different applications. This port is not associated with any particular services and should be closed unless it is associated and used. Port 9220: This port is for raw scanning to peripherals with IEEE 1284.4 specifications. On three port HP Jetdirects, the scan ports are 9290, 9291, and 9292. It is used for network-connected print devices. This port should remain open to allow print services. Port 9500: TCP Port 9500 may use a defined protocol to communicate depending on the application. In our case we are using port 9500 to access the ISM Server. The ISM Server is used for exchanging backup and recovery information between storage devices. This port should remain open while services are in use. Port 62078: This port is used by iPhone while syncing. The Port used by UPnP for multimedia files sharing, also used for synchronizing iTunes files between devices. Port 62078 has a known vulnerability in that a service named lockdownd sits and listens on the iPhone on port 62078. By connecting to this port and speaking the correct protocol, it’s possible to spawn a number of different services on an iPhone or iPad. This port should be blocked or closed when service is not required  on the device. References Gibson, S. (n.d.). GRC | Port Authority, for Internet Port 139 . Retrieved October 10, 2014, from https://www.grc.com/port_139.htm Gibson, S. (n.d.). GRC | Port Authority, for Internet Port 2869 . Retrieved October 10, 2014, from https://www.grc.com/port_2869.html Gibson, S. (n.d.). GRC | Port Authority, for Internet Port 80 . Retrieved October 10, 2014, from https://www.grc.com/port_80.htm Gibson, S. (n.d.). GRC | Port Authority, for Internet Port 9101 . Retrieved October 10, 2014, from https://www.grc.com/port_9101.html HP Support document – HP Support Center. (n.d.). Retrieved October 10, 2014, from http://h20565.www2.hp.com/portal/site/hpsc/template.PAGE/public/kb/docDisplay/?sp4ts.oid=412144&spf_p.tpst=kbDocDisplay&spf_p.prp_kbDocDisplay=wsrp-navigationalState%3DdocId%253Demr_na-c02480766-2%257CdocLocale%253D%257CcalledBy%253D&javax.portlet.begCacheTok=com.vignette.cachetoken&javax.portlet.endCacheTok=com.vignette.cachetoken HP Support document – HP Support Center. (n.d.). Retrieved October 10, 2014, from http://h20566.www2.hp.com/portal/site/hpsc/template.PAGE/public/kb/docDisplay?docId=bps53634&ac.admitted=1413144875821.876444892.199480143 Network Printer Ports. (2003, March 28). Retrieved October 10, 2014, from http://technet.microsoft.com/en-us/library/cc728404(v=ws.10).aspx networking – Is port 139 still vulnerable? – Server Fault. (2009, June 20). Retrieved October 10, 2014, from http://serverfault.com/questions/29065/is-port-139-still-vulnerable Port 5357 TCP on Windows 7 professional 64 bit? – Super User. (2009, October 18). Retrieved October 10, 2014, from http://superuser.com/questions/56781/port-5357-tcp-on-windows-7-professional-64-bit Port 62078 (tcp/udp) :: SpeedGuide.net. (n.d.). Retrieved October 10, 2014, from http://www.speedguide.net/port.php?port=62078 Port 6839 (tcp/udp) – Online TCP UDP port finder – adminsub.net. (2014, August 26). Retrieved October 10, 2014, from http://www.adminsubne t.net/tcp-udp-port-finder/6839 Port 7435 (tcp/udp) – Online TCP UDP port finder – adminsub.net. (2014, August 26).

The Energy Consumption Of The United States - 1392 Words

Have you ever wondered how many sources for energy you use during your day? We use energy to drive our cars, heat and light our homes, and provide efficiency at our jobs. We live hectic and demanding lives and little thought is given about the types of energy resources we have used from the time we wake up to our alarm clocks to the time we lay our head down in our warm cozy bed at night. According to the Energy Information Agency, in 2012, the primary energy consumption in the United States was about 95 quadrillion British thermal units (Btu). That is equal to 18% of world total primary energy consumption. The world total primary energy consumption was about 529 quadrillion Btu. (n.d.). Merriam-Webster Defines a Btu as â€Å"the quantity of heat required to raise the temperature of one pound of water one degree Fahrenheit at a specified temperature (as 39 °F)† (2015). So how many types of energy sources do we use throughout our day? 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Being Is Not Everything The Importance Of Becoming Nothing

Leah B. Mitchell Professor John Gist Philosophy 300-70 10 November 2016 Being Is Not Everything: The Importance of Becoming Nothing Heidegger believed that â€Å"Philosophizing is questioning the extra-ordinary† (Heidegger, et al. 14). He suggests, however, that when science questions existence, it simply focuses on what is, while dismissing that which is not (the nothing), and that because of this oversight, scientists do not see the full picture of existence. As a philosopher, Heidegger sought a deeper understanding of the purpose of human existence − his secular version of â€Å"God†, if you will, and he may have discovered it in the Nothing. After contemplation of Martin Heidegger’s philosophies, one could reasonably argue that his â€Å"Nothing† is none other than that which humanity collectively refers to as â€Å"God† – i.e. the source of all that is. Further, that becoming is the telos of our existence; the result, Being, is far less significant. 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Japan s Laws Of The Trafficking Of Women And Children Is...

Japan is a Tier 2 source, transit, and destination country for forced labor, sexual exploitation, and forced marriages. Men, women, and children are all susceptible to trafficking. The government actively participates in the exploitation of its people, especially through the program of TITP, or the Technical Intern Training Program. The proliferation of the sexual trafficking of women and children is driven by sex tourism. Runaway girls are among the victims of this horrific trade. Japan does not meet the minimum standard of the 2000 UN TIP Protocol and is the only G-8 member who did not accede to neither its standards nor the 2000 Transnational Organized Crime Convention. There are no convictions for perpetrators of forced labor and no laws enacted to prosecute traffickers. Japan’s laws are not collusive with international definitions of trafficking. In 2015, Japan had a modest increase in the enforcement of ant-trafficking laws. However, Japan’s laws do not exclude al l forms of trafficking, rather there are large gaps in their criminal laws. Under the 1956 Prostitution Prevention Law, Articles 7 through 12 criminalizes the procurement of prostitutes and forced prostitution. Article 226-2 also criminalizes the buying and selling of humans. Under the 1947 Employment Security Act, it criminalizes the engagement of labor recruitment through violence, intimidation, or confinement. It also criminalizes the recruitment of labor for work that is harmful to public health and moralShow MoreRelatedSex Tourism Essay4993 Words   |  20 PagesTO5101: Tourism systems analysis Sai kumar Nalla Student ID- 12325398 Executive summary: In the recent years Sex tourism is the most attracting and increasing sector in terms of tourism studies. There are increased research, paper work, books, articles and several magazines released in the market related to sex tourism. Today there are many forces at work in the normalization of the international sex industry (Jeffeys, 1997). As sex industryRead MoreItaly - Research Paper10557 Words   |  43 Pagesconstitutional court holds the supreme judicial power in Italy, while a lower and upper house were set up and were given the legislative power. (Killinger, 2002) After World War II, Italy entered a period known as the ‘Economic Miracle’, which was driven by multiple industries and firms that contributed to the production of cars. These included the steel, rubber, and oil industries. (Amyot, 2004) Oil was discovered in the South, in the Northern Po Valley, and in Sicily in 1949. Natural gas was foundRead MoreCultural Analysis Thailand9709 Words   |  39 Pagesof 2004, the government coup in 2006, the flooding of 2011 and is preparing for a change in the views of the nation with the demise of their king. The AIDS explosion in the late eighties and early nineties seems to have targeted the country and the sex industry placing Thailand on the map for many of the wrong reasons. As Thailand continues to confront its own inner demons, the country is attempting to emerge as a major player in the developing nations field. This paper will focus on the idealsRead MoreOne Significant Change That Has Occurred in the World Between 1900 and 2005. Explain the Impact This Change Has Made on Our Lives and Why It Is an Important Change.163893 Words   |  656 PagesPolitical Woman: Florence Luscomb and the Legacy of Radical Reform Michael Adas, ed., Agricultural and Pastoral Societies in Ancient and Classical History Jack Metzgar, Striking Steel: Solidarity Remembered Janis Appier, Policing Women: The Sexual Politics of Law Enforcement and the LAPD Allen Hunter, ed., Rethinking the Cold War Eric Foner, ed., The New American History. Revised and Expanded Edition E SSAYS ON _ T WENTIETH- C ENTURY H ISTORY Edited by Michael Adas forRead MoreThe Walt Disney Company and Disney Management25371 Words   |  102 PagesUltrasound Machines, India, China, and a Skewed Sex Ratio CASE 2ïš º1 The Not-So-Wonderful World of BONJOUR, MICKEY! In April 1992, EuroDisney SCA opened its doors to European visitors. Located by the river Marne some 20 miles east of Paris, it was designed to be the biggest and most lavish theme park that Walt Disney Company (Disney) had built to date—bigger than Disneyland in Anaheim, California; Disneyworld in Orlando, Florida; and Tokyo Disneyland in Japan. Much to Disney management’s surprise, Europeans

Distance Education Versus Face-to-Face Learning free essay sample

December 1 , 2009 Persuasive Essay Game Theories Has Virtual Reality Taken Things Too Far? Distance Education versus Face-to-Face Learning In Clive Thompsons Game Theories, the author illustrates how virtual worlds, such as Everquest and Second Life, have surprisingly become much like the real world. Everquest is an online virtual reality video game that allows individuals to create fictional characters to generate goods as they play, often by killing creatures for their treasure and trading it (Thompson 332). This has created an economy-like setting in he game but has eventually evolved to leak into the real world economy by exchanging real money for the purchase of virtual characters and their winnings. Thompsons article shows how the line between virtual reality and real world reality often becomes blurry, encouraging people to consider ways where virtual technology can enhance and possibly replace the current systems already in place. However, not everything done through computers and virtual technology are as effective as one thinks. Sometimes, the traditional way of doing things are perfectly fine and more effective Just the way they are. Distance education, in particular, is a phenomenon that has been a growing popular alternative to traditional face-to-face education. I am here to argue that learning behind a computer at home cannot effectively replace the traditional face- to-face education offered at colleges and universities. Difficulty in self-directed learning and instructional misunderstandings can occur in any online course, a lack of a set schedule allows for distractions and procrastination, non-existent interaction inhibits growth and learning, and the probability of cheating is greater among online tudents versus campus students. Although there are many people who favor the online-learning alternative, this paper will challenge their confidence and counter- arguments on the issue. Distance education can be quite difficult. There are several courses that have concepts that can be quite tricky and complicated to understand, especially if one is learning on their own using a textbook. Shelia Tucker, an assistant professor at East Carolina University, stated that students learn far too little when the teachers personal presence is not available because the student has far more to learn from he teacher than texts (par. 2). For example, an accounting teacher can easily explain the advanced calculation of earnings per share and diluted earnings per share through the use of their own methods and organizational charts. Learning the same topic but reading texts from a course book can be quite challenging without a teacher to provide tips and tricks for remembering the formulas. As I am an accounting student aspiring to be a CGA, I am tremendously afraid of entering their factors influencing completion and non-completion of community college online ourses, students indicated that online learning did not fit their learning style preference. Comments were received from students that they could not get a response from their instructor, the materials were not available, and the course was confusing (Aragon Johnson 155). Because of the difficulty experienced in online courses, some community colleges are reporting drop-out rates 20% higher than in face-to- face classrooms (Aragon Johnson 146). Another drawback of online learning is the lack of a set schedule. Without a fixed timetable, the opportunity for distractions and procrastination often presents itself. These online courses require motivation and self-discipline to complete the courses and programs in a timely manner. This will be especially hard for those who tend to procrastinate and need the extra push from teachers to complete the work or require constant reminders of assignment due dates and examination dates. Because the online courses are quite flexible, these courses can often be put on the backburner, because the students are aware that some of these courses are self-paced. One major downfall of distance education is non-existent interaction that results from learning and working behind a computer. Communication with the teacher is limited to text correspondences and even replies to the emails may be delayed. Comparing this scenario to a classroom course, questions are answered and uncertainties are clarified immediately after the teacher is asked. There is no personal attention given to students and these learners are expected to find their own resources for completing assignments. Not only is interaction limited with teachers, but interaction with other students is limited as well. Randy S. Hanson, Ph. D. , made a point that the only interaction with classmates are through email, chat ooms and discussion boards. Parties and offline get-togethers [were] rarely experienced among online students (par. 17). In her article about the controversy of distance education, Roda Joanna Abaya asserts that students do not learn only on formal and educational conversations. As social beings, it is important that they too interact with others and have informal talks or converse with lighter topics (par. 8). Another concern that Abaya has about distance education is the lack of hands-on training in online courses (par. 7). Interaction with people and objects are vital in the earning process and because of these missing components in online courses, the effectiveness of education falls short when compared to the traditional face-to-face classes. According to an article about academic honesty in online courses, some claim that because students and faculty do not interact directly in such classes, online classes will invite more cheating than traditional classes (GriJalva, Therese C. et al. par. 2). This is certainly true in that distance education is being carried out at home, away from teacher supervision. Anne Mullens exclaims that cheating appears to be ncreasing at universities, especially at the larger campuses and impersonal classes (23). In an examination of cheating in both traditional and online criminal justice and legal studies courses, Lanier (2006) found the behavior to be more common in online courses (Dobbs, Rhonda R. et al 13). Who knows how many students cheat during an online exam, having their books open in front of them while actual student writing the exam? Cheating is unethical and universally wrong but there are many students who cannot help themselves from getting all the help they can get to score th e good grades. There are several counter arguments that can be raised against the thesis of this paper. After googling and researching the pros of distance education, the recurring and most significant point was the flexibility of online courses. There are no set class times and it is the students discretion when to complete the assignments and readings so those with busy schedules are able to accommodate education. Stephen Downes states that there is more work in the distance ed version simply because it tries to make up for the lack of any class contact (par. 1). I have heard students and riends complain about the amount of work required for the online LIBS 7001 course at BCIT, where as the in-class version compares much favorably. With the course load being heavy for online courses, the flexibility to dedicate time to other priorities is hindered with the stress of work to be done for distance education. Some argue that online learning benefits those who requires more time, are language challenged, or are introverted. But on the contrary, it hinders rather than allows growth and learning. Those who require more time will always have that excuse to fall back on. Next thing they know, a year has passed since having started the course. The things learned at the beginning of the on-line class will have been forgotten and time would have been wasted. Those who are foreign students that struggle with the language barrier would benefit much more with an available teacher who is able to give them personal attention and needed help. To leave them on their own, trying to understand the course concepts from a textbook or a set of written notes can leave them overwhelmed and confused. Even those who are shy do not gain any benefit for enrolling in online courses. In fact, it is more of a detriment to their development and knowledge. Attending campuses and universities allows students to interact with classmates, and even encourages group projects to develop team buildings skills for individuals. At BCIT, students are often required to do presentations in front of the class and even in lecture halls. This is because the real world will often put people in similar situations and the training for that is attained easily when attending school on campus. This will also develop individuals interpersonal skills, and will help them overcome any shyness they may have. Another counter argument that can be raised is that costs are reduced when taking distance education. Not only are travel costs and commuting time decreased, but the necessary housing costs and meal plans are also saved if one is required to move to campus for attending university. However, the cost of training teachers, the cost of hardware and software, human resources such as technicians and other people involved are to be considered, we can say that establishing online education is not as cheap as it may seem for others (Abaya par. 6). These costs will certainly rickle down to the students, eventually having them pay through the increasing course fees.