Hypothesis Testing Paper Essay Example for Free

Hypothesis Testing Paper Essay We are seeing the influence of psychosocial stress on the course of bipolar disorder being increasingly recognized. Child adversity is not just a topic that is discussed, but is a topic that is real in the society in which we live. Child adversity can hit close to home. A child experiences this by being in a state or instance of serious or continued difficulty (Merriam-Webster, 2014). Situations of these types are terrible to see and can affect the child, but just not as children. These types of situations could include: verbal, physical, or sexual abuse, neglect, parental death, bullying, or even poverty. The effects of these types of situations can carry on into an individuals adulthood as well as concerning his/her physical and mental well-being. See what we are looking into is not just child adversity, but another topic as well. The question being asked is, Does early child adversity make bipolar disorder more likely? Individuals have their own views and opinions on this topic and question. In this hypothesis testing, a description of the research issue and a hypothesis statement, regarding the research hypothesis and the null hypothesis will be addressed. For the accuracy of the research issue, the population will have to be determined and the sampling method to help in generating the sample. The data will be described as to how it was collected, the level of  measurement, and the statistical technique used in helping of the task of analyzing the data. All these steps will help in the explanation of the findings. EARLY CHILD ADVERSITY AND THE BIPOLAR DISORDER In understanding the meaning of child adversity, we want to look at the meaning of the term, bipolar disorder. Here we arent just focusing on child adversity; we are focusing on both to see if the child adversity emphasizes bipolar disorder more likely. According to U.S. National Library of Medicine (2014), Bipolar disorder is a condition in which a person has periods of depression and periods of being extremely happy or being cross or irritable In addition to these mood swings, the person has extreme changes in activity and energy (Bipolar Disorder). Symptoms of bipolar disorder can be severe and can result in damaged relationships, poor job or school performance, and even suicide (National Institute of Mental Health, 2012). Bipolar disorder affects both men and women, usually occurring between the ages of 15-25. The exact cause of bipolar disorder is unknown. However, there are factors involved that cause or trigger the occurrences. As we are researching, we are finding environment plays a role. According to Mayo Clinic (2014), An individuals stress, abuse, significant loss, or other traumatic experiences can contribute to this disorder (Causes). All these factors and experiences listed can take place in a childs life, whether we want to admit it or not. Most of the time, more often than we would care to talk about. This connection gives us a starting point in developing our hypothesis. With a research issue, it is essential a hypothesis be formulated. Hypothesis is a prediction often based on informal observation, previous research, or theory that is testing in a research study (Aron, Aron, Coups, 2013, p. 108). In a research study, the testing is referred to as a hypothesis procedure. We must first state a research hypothesis and a null hypothesis. Research hypothesis is a statement in a hypothesis testing procedure about the predicted relation between populations. Null hypothesis is a statement about a relation between populations that is the opposite of the research hypothesis (Aron, Aron, Coups, 2013, p. 108). The null  hypothesis is often said to be the opposite of what is being predicted. For this study, the research hypothesis is, Early child adversity makes bipolar disorder more likely. The null hypothesis is, Early child adversity does not make bipolar disorder more likely. In any hypothesis testing procedure, there is great emphasis in determining the population and the sampling method the researcher is using to generate the sample, The population is the entire group of people to which the researcher intends the results of a study to apply. The sample is the scores of a particular group of people studied (Aron, Aron, Coups, 2013, p. 84). For this research issue, the population would include participants consisting of 58 adults, including 29 males and 29 females. These individuals have a diagnosis of bipolar I disorder. According to National Institute of Mental Health (2012), Bipolar I disorder is defined by manic and mixed episodes that last at least seven days. Usually depressive episodes occur as well, lasting at least two weeks (How is Bipolar Diagnosed?). The sampling method used to generate the sample would be classified as nonrandom samples. With this sample method, the probability selection cannot be accurately determined. In using the nonrandom sampling method, we are focusing on the type judgmental/purposive sampling. These individuals of 58 are being chosen with a specific purpose in mind. These individuals are fit for the research compared to other individuals (Concepts and Definitions, n.d.). This sampling method makes perfect since we are attempting to research if child adversity is a contributing factor to bipolar disorder. THE DATA Regarding the 58 adults of men and women, the data would be collected and evaluated every three months, all the way up to a year. This information would be collected by structured interviews discussing stressful life events pertaining to and dealing with early child adversity. In analyzing the data, the best statistical technique to use would be the t test for independent means. T test for independent means is a hypothesis testing procedure in which there are two separate groups of people tested (Aron, Aron, Coups,  2013, p. 84). Involved in this research issue is two separate groups of people with 29 male participants and 29 female participants. We are testing both of the same number, because we want to find out the conclusion as a whole about the people. Also, we tested equal amounts of both men and women, because they both are equally likely to be diagnosed with bipolar disorder (WebMD, 2014). The data would be analyzed using the five steps of the t test for independent means. Step one consists of stating the research hypothesis and the null hypothesis. Step two consists of determining the characteristics of the comparison distribution. Step three is determining the cutoff sample score on the comparison distribution at which the null hypothesis should be rejected. Step four is determining the samples score on the comparison distribution. And last, step five is deciding to reject the null hypothesis by comparing steps three and four (Aron, Aron, Coups, 2013, p. 84). In following these steps to analyze the data, we can account for to either accept or reject the null hypothesis on early child adversity not making bipolar disorder more likely. CONCLUSION After going into detail of the research issue, formulating the hypothesis statement, determining the population, deciding and describing the sampling method, the task of collecting the data, the level of measurement, and the statistical technique for analyzing the data, now is the big intense moment. The results exhibited that the interaction of early child adversity severity and those stressful life events involved predicted an occurrence in a manner consistent with the research hypothesis for both the men and the women. Therefore, we reject the null hypothesis. There were some limitations to this research issue and the hypothesis testing procedure. The sample size and the number of past episodes were determined retrospectively, mainly through self-report. But, another thought to keep in mind is the individuals who experienced early child adversity had a significantly younger age of bipolar onset. Concerning this conclusion, it would be of great importance for the suggestion for further studies of stress mechanisms in bipolar disorder and of treatments designed to intervene early among those at risk. I would propose when and if the conditions of bipolar disorder are  identified, an effective treatment plan needs to be implemented. This approach would be of great benefit for the patients health, wellbeing, and longevity. Studies speak for themselves regarding childhood adversity being prevalent and having pervasive and long term impacts on mental and physical health. References Aron, A., Aron, E., Coups, E. (2013). Statistics for Psychology (6th ed.). Retrieved from The University of Phoenix eBook Collection database. Concepts and Definitions. (n.d.). Retrieved from http://www.ubos.org/Compendium2012/NonRandomSamplingDesign.html Mayo Clinic. (2014). _Bipolar Disorder Causes_. Retrieved from http://www.mayoclinic.org/diseases-conditions/bipolar-disorder/basics/causes/con-20027544 Merriam-Webster. (2014). _Adversity_. Retrieved from http://www.merriam-webster.com/dictionary/adversity National Institute of Mental Health. (2012). _Bipolar Disorder in Adults_. Retrieved from http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-adults/index.shtml U.S. National Library of Medicine. (2014). _Bipolar Disorder_. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001924/

America’s War on Terrorism Essay -- Terrorism Politics Foreign Policy

America’s War on Terrorism The world has been changed forever since the tragic attack on September 11, 2001. An observer described the atrocity by saying, "It just went 'bam,' like a bomb went off. It was like holy hell (CNN 1). " The new world will be different from what any American has known before. A new war has arisen, not against a foreign country or a major region of the world, but rather against a select group of people who have the capabilities to destroy the lives of so many. The war against terrorism which the United States is now forced to wage will not be an easily won battle. This war will not be fought solely on scattered battlefields in certain countries. It will instead permeate through every aspect of life as we know it. "The attack of September 11 will be the precipitating moment of a new kind of war that will define a new century. This war will be fought in shadows, and the adversary will continue to target the innocent and defenseless ("The Terrorism Research Center"). " The unconvent ional methods of terrorism make these terrorists the first formidable opponent the United States has faced in years, since the ending of the Cold War. Due to its victory in the Cold War, the United States is now the last remaining superpower in the world, and along with that supremacy comes an inherent responsibility. The responsibility of a superpower can be interpreted in two distinctly different ways. One of these is for a country to become semi-isolationist. The other is the opposite, in the sense that it deals with a country imposing its authority on other countries, thus not being in any way isolationist. Both of theses have their benefits while at the same time, their disadvantages. The first possible respon... ...undamentalist terrorists, mainly the Al'Qa'ida, have for America and all that America stands for. Now that the Islamic fundamentalists have openly attacked America, the war on terrorism has arrived upon the world. The atrocities that the world will soon face will not be like any experienced before and the world will be forever changed after this war is complete. September 11th has forced America to face the hatred it has created for itself throughout the world, especially in the Middle East, for its unethical foreign policy tactics. America is once again tested to prove its dominance in the world, but will it pass the test of terrorism? Only the future holds the answer. Works Cited CNN (1), World Trade Center Survivors Describe 'Holy Hell'. http://www.cnn.com/2001/US/09/11/new.york.scene/. "The Terrorism Research Center". http://www.terrorism.com/index.html

Patient Recording System Essay

The system supplies future data requirements of the Fire Service Emergency Cover (FSEC) project, Fire Control, fundamental research and development. Fire and Rescue Services (FRSs) will also be able to use this better quality data for their own purposes. The IRS will provide FRSs with a fully electronic data capture system for all incidents attended. All UK fire services will be using this system by 1 April 2009. Creation of a general-purpose medical record is one of the more difficult problems in database design. In the USA, most medical institutions have much more electronic information on a patient’s financial and insurance history than on the patient’s medical record. Financial information, like orthodox accounting information, is far easier to computerize and maintain, because the information is fairly standardized. Clinical information, by contrast, is extremely diverse. Signal and image data—X-Rays, ECGs, —requires much storage space, and is more challenging to manage. Mainstream relational database engines developed the ability to handle image data less than a decade ago, and the mainframe-style engines that run many medical database systems have lagged technologically. One well-known system has been written in assembly language for an obsolescent class of mainframes that IBM sells only to hospitals that have elected to purchase this system. CPRSs are designed to review clinical information that has been gathered through a variety of mechanisms, and to capture new information. From the perspective of review, which implies retrieval of captured data, CPRSs can retrieve data in two ways. They can show data on a single patient (specified through a patient ID) or they can be used to identify a set of patients (not known in advance) who happen to match particular demographic, diagnostic or clinical parameters. That is, retrieval can either be patient-centric or parameter-centric. Patient-centric retrieval is important for real time clinical decision support. â€Å"Real time† means that the response should be obtained within seconds (or a few minutes at the most), because the availability of current information may mean the difference between life and death. Parameter-centric retrieval, by contrast, involves processing large volumes of data: response time is not particularly critical, however, because the results are us ed for purposes like long-term planning or for research, as in retrospective studies. In general, on a single machine, it is possible to create a database design that performs either patient-centric retrieval or parameter-centric retrieval, but not both. The challenges are partly logistic and partly architectural. From the logistic viewpoint, in a system meant for real-time patient query, a giant parameter-centric query that processed half the records in the database would not be desirable because it would steal machine cycles from critical patient-centric queries. Many database operations, both business and medical, therefore periodically copy data from a â€Å"transaction† (patient-centric) database, which captures primary data, into a parameter-centric â€Å"query† database on a separate machine in order to get the best of both worlds. Some commercial patient record systems, such as the 3M Clinical Data Repository (CDR)[1] are composed of two subsystems, one that is transaction-oriented and one that is query-oriented. Patient-centric query is considered more critical for day-to-day operation, especially in smaller or non-research-oriented institutions. Many vendors therefore offer parameter-centric query facilities as an additional package separate from their base CPRS offering. We now discuss the architectural challenges, and consider why creating an institution-wide patient database poses significantly greater hurdles than creating one for a single department. During a routine check-up, a clinician goes through a standard checklist in terms of history, physical examination and laboratory investigations. When a patient has one or more symptoms suggesting illness, however, a whole series of questions are asked, and investigations performed (by a specialist if necessary), which would not be asked/performed if the patient did not have these symptoms. These are based on the suspected (or apparent) diagnosis/-es. Proformas (protocols) have been devised that simplify the patient’s workup for a general examination as well as many disease categories. The clinical parameters recorded in a given protocol have been worked out by experience over years or decades, though the types of questions asked, and the order in which they are asked, varies with the institution (or vendor package, if data capture is electronically assisted). The level of detail is often left to individual discretion: clinicians with a research interest in a particular condition will record more detail for that condition than clinicians who do not. A certain minimum set of facts must be gathered for a given condition, however, irrespective of personal or institutional preferences. The objective of a protocol is to maximize the likelihood of detection and recording of all significant findings in the limited time available. One records both positive findings as well as significant negatives (e.g., no history of alcoholism in a patient with cirrhosis). New protocols are continually evolving for emergent disease complexes such as AIDS. While protocols are typically printed out (both for the benefit of possibly inexperienced residents, and to form part of the permanent paper record), experienced clinicians often have them committed to memory. However, the difference between an average clinician and a superb one is that the latter knows when to depart from the protocol: if departure never occurred, new syndromes or disease complexes would never be discovered. In any case, the protocol is the starting point when we consider how to store information in a CPRS. This system, however, focuses on the processes by which data is stored and retrieved, rather than the ancillary functions provided by the system. The obvious approach for storing clinical data is to record each type of finding in a separate column in a table. In the simplest example of this, the so-called â€Å"flat-file† design, there is only a single value per parameter for a given patient encounter. Systems that capture standardised data related to a particular specialty (e.g., an obstetric examination, or a colonoscopy) often do this. This approach is simple for non-computer-experts to understand, and also easiest to analyse by statistics programs (which typically require flat files as input). A system that incorporates problem-specific clinical guidelines is easiest to implement with flat files, as the software engineering for data management is relatively minimal. In certain cases, an entire class of related parameters is placed in a group of columns in a separate table, with multiple sets of values. For example, laboratory information systems, which support labs that perform hundreds of kinds of tests, do not use one column for every test that is offered. Instead, for a given patient at a given instant in time, they store pairs of values consisting of a lab test ID and the value of the result for that test. Similarly for pharmacy orders, the values consist of a drug/medication ID, the preparation strength, the route, the frequency of administration, and so on. When one is likely to encounter repeated sets of values, one must generally use a more sophisticated approach to managing data, such as a relational database management system (RDBMS). Simple spreadsheet programs, by contrast, can manage flat files, though RDBMSs are also more than adequate for that purpose. The one-column-per-parameter approach, unfortunately, does not scale up when considering an institutional database that must manage data across dozens of departments, each with numerous protocols. (By contrast, the groups-of-columns approach scales well, as we shall discuss later.) The reasons for this are discussed below. One obvious problem is the sheer number of tables that must be managed. A given patient may, over time, have any combination of ailments that span specialities: cross-departmental referrals are common even for inpatient admission episodes. In most Western European countries where national-level medical records on patients go back over several decades, using such a database to answer the question, â€Å"tell me everything that has happened to this patient in forward/reverse chronological order† involves searching hundreds of protocol-specific tables, even though most patients may not have had more than a few ailments. Some clinical parameters (e.g., serum enzymes and electrolytes) are relevant to multiple specialities, and, with the one-protocol-per-table approach, they tend to be recorded redundantly in multiple tables. This violates a cardinal rule of database design: a single type of fact should be stored in a single place. If the same fact is stored in multiple places, cross-protocol analysis becomes needlessly difficult because all tables where that fact is recorded must be first tracked down. The number of tables keeps growing as new protocols are devised for emergent conditions, and the table structures must be altered if a protocol is modified in the light of medical advances. In a practical application, it is not enough merely to modify or add a table: one must alter the user interface to the tables– that is, the data-entry/browsing screens that present the protocol data. While some system maintenance is always necessary, endless redesign to keep pace with medical advances is tedious and undesirable. A simple alternative to creating hundreds of tables suggests itself. One might attempt to combine all facts applicable to a patient into a single row. Unfortunately, across all medical specialities, the number of possible types of facts runs into the hundreds of thousands. Today’s database engines permit a maximum of 256 to 1024 columns per table, and one would require hundreds of tables to allow for every possible type of fact. Further, medical data is time-stamped, i.e., the start time (and, in some cases, the end time) of patient events is important to record for the purposes of both diagnosis and management. Several facts about a patient may have a common time-stamp, e.g., serum chemistry or haematology panels, where several tests are done at a time by automated equipment, all results being stamped with the time when the patient’s blood was drawn. Even if databases did allow a potentially infinite number of columns, there would be considerable wastage of disk space, because the vast majority of columns would be inapplicable (null) for a single patient event. (Even null values use up a modest amount of space per null fact.) Some columns would be inapplicable to particular types of patients–e.g., gyn/obs facts would not apply to males. The challenges to representing institutional patient data arise from the fact that clinical data is both highly heterogeneous as well as sparse. The design solution that deals with these problems is called the entity-attribute-value (EAV) model. In this design, the parameters (attribute is a synonym of parameter) are treated as data recorded in an attribute definitions table, so that addition of new types of facts does not require database restructuring by addition of columns. Instead, more rows are added to this table. The patient data table (the EAV table) records an entity (a combination of the patient ID, clinical event, and one or more date/time stamps recording when the events recorded actually occurred), the attribute/parameter, and the associated value of that attribute. Each row of such a table stores a single fact about a patient at a particular instant in time. For example, a patient’s laboratory value may be stored as: (, 12/2/96>, serum_potassium, 4.1). Only positive or significant negative findings are recorded; nulls are not stored. Therefore, despite the extra space taken up by repetition of the entity and attribute columns for every row, the space is taken up is actually less than with a â€Å"conventional† design. Attribute-value pairs themselves are used in non-medical areas to manage extremely heterogeneous data, e.g., in Web â€Å"cookies† (text files written by a Web server to a user’s local machine when the site is being browsed), and the Microsoft Windows registries. The first major use of EAV for clinical data was in the pioneering HELP system built at LDS Hospital in Utah starting from the late 70s.[6],[7],[8] HELP originally stored all data – characters, numbers and dates– as ASCII text in a pre-relational database (ASCII, for American Standard Code for Information Interchange, is the code used by computer hardware almost universally to represent characters. The range of 256 characters is adequate to represent the character set of most European languages, but not ideographic languages such as Mandarin Chinese.) The modern version of HELP, as well as the 3M CDR, which is a commercialisation of HELP, uses a relational engine. A team at Columbia University was the first to enhance EAV design to use relational database technology. The Columbia-Presbyterian CDR,[9],[10] also separated numbers from text in separate columns. The advantage of storing numeric data as numbers instead of ASCII is that one can create useful indexes on these numbers. (Indexes are a feature of database technology that allow fast search for particular values in a table, e.g., laboratory parameters within or beyond a particular range.). When numbers are stored as ASCII text, an index on such data is useless: the text â€Å"12.5† is greater than â€Å"11000†, because it comes later in alphabetical order.) Some EAV databases therefore segregate data by data type. That is, there are separate EAV tables for short text, long text (e.g., discharge summaries), numbers, dates, and binary data (signal and image data). For every parameter, the system records its data type so that one knows where it is stored. ACT/DB,[11],[12] a sys tem for management of clinical trials data (which shares many features with CDRs) created at Yale University by a team led by this author, uses this approach. From the conceptual viewpoint (i.e., ignoring data type issues), one may therefore think of a single giant EAV table for patient data, containing one row per fact for a patient at a particular date and time. To answer the question â€Å"tell me everything that has happened to patient X†, one simply gathers all rows for this patient ID (this is a fast operation because the patient ID column is indexed), sorts them by the date/time column, and then presents this information after â€Å"joining† to the Attribute definitions table. The last operation ensures that attributes are presented to the user in ordinary language – e.g., â€Å"haemoglobin,† instead of as cryptic numerical IDs. One should mention that EAV database design has been employed primarily in medical databases because of the sheer heterogeneity of patient data. One hardly ever encounters it in â€Å"business† databases, though these will often use a restricted form of EAV termed â€Å"row modelling.† Examples of row modelling are the tables of laboratory test result and pharmacy orders, discussed earlier. Note also that most production â€Å"EAV† databases will always contain components that are designed conventionally. EAV representation is suitable only for data that is sparse and highly variable. Certain kinds of data, such as patient demographics (name, sex, birth date, address, etc.) is standardized and recorded on all patients, and therefore there is no advantage in storing it in EAV form. EAV is primarily a means of simplifying the physical schema of a database, to be used when simplification is beneficial. However, the users conceptualisethe data as being segregated into protocol-specific tables and columns. Further, external programs used for graphical presentation or data analysis always expect to receive data as one column per attribute. The conceptual schema of a database reflects the users’ perception of the data. Because it implicitly captures a significant part of the semantics of the domain being modelled, the conceptual schema is domain-specific. A user-friendly EAV system completely conceals its EAV nature from its end-users: its interface confirms to the conceptual schema and creates the illusion of conventional data organisation. From the software perspective, this implies on-the-fly transformation of EAV data into conventional structure for presentation in forms, reports or data extracts that are passed to an analytic program. Conversely, changes to data by end-users through forms must be translated back into EAV form before they are saved. To achieve this sleight-of-hand, an EAV system records the conceptual schema through metadata – â€Å"dictionary† tables whose contents describe the rest of the system. While metadata is important for any database, it is critical for an EAV system, which can seldom function without it. ACT/DB, for example, uses metadata such as the grouping of parameters into forms, their presentation to the user in a particular order, and validation checks on each parameter during data entry to automatically generate web-based data entry. The metadata architecture and the various data entry features that are supported through automatic generation are described elsewhere.[13] EAV is not a panacea. The simplicity and compactness of EAV representation is offset by a potential performance penalty compared to the equivalent conventional design. For example, the simple AND, OR and NOT operations on conventional data must be translated into the significantly less efficient set operations of Intersection, Union and Difference respectively. For queries that process potentially large amounts of data across thousands of patients, the impact may be felt in terms of increased time taken to process queries. A quantitative benchmarking study performed by the Yale group with microbiology data modelled both conventionally and in EAV form indicated that parameter-centric queries on EAV data ran anywhere from 2-12 times as slow as queries on equivalent conventional data.[14] Patient-centric queries, on the other hand, run at the same speed or even faster with EAV schemas, if the data is highly heterogeneous. We have discussed the reason for the latter. A more practical problem with parameter-centric query is that the standard user-friendly tools (such as Microsoft Access’s Visual Query-by-Example) that are used to query conventional data do not help very much for EAV data, because the physical and conceptual schemas are completely different. Complicating the issue further is that some tables in a production database are conventionally designed. Special query interfaces need to be built for such purposes. The general approach is to use metadata that knows whether a particular attribute has been stored conventionally or in EAV form: a program consults this metadata, and generates the appropriate query code in response to a user’s query. A query interface built with this approach for the ACT/DB system[12]; this is currently being ported to the Web. So far, we have discussed how EAV systems can create the illusion of conventional data organization through the use of protocol-specific forms. However, the problem of how to record information that is not in a protocol–e.g., a clinician’s impressions–has not been addressed. One way to tackle this is to create a â€Å"general-purpose† form that allows the data entry person to pick attributes (by keyword search, etc.) from the thousands of attributes within the system, and then supply the values for each. (Because the user must directly add attribute-value pairs, this form reveals the EAV nature of the system.) In practice, however, this process, which would take several seconds to half a minute to locate an individual attribute, would be far too tedious for use by a clinician. Therefore, clinical patient record systems also allow the storage of â€Å"free text† – narrative in the doctor’s own words. Such text, which is of arbitrary size, may be entered in various ways. In the past, the clinician had to compose a note comprising such text in its entirety. Today, however, â€Å"template† programs can often provide structured data entry for particular domains (such as chest X-ray interpretations). These programs will generate narrative text, including boilerplate for findings that were normal, and can greatly reduce the clinician’s workload. Many of these programs use speech recognition software, thereby improving throughput even further. Once the narrative has been recorded, it is desirable to encode the facts captured in the narrative in terms of the attributes defined within the system. (Among these attributes may be concepts derived from controlled vocabularies such as SNOMED, used by Pathologists, or ICD-9, used for disease classification by epidemiologists as well as for billing records.) The advantage of encoding is that subsequent analysis of the data becomes much simpler, because one can use a single code to record the multiple synonymous forms of a concept as encountered in narrative, e.g., hepatic/liver, kidney/renal, vomiting/emesis and so on. In many medical institutions, there are non-medical personnel who are trained to scan narrative dictated by a clinician, and identify concepts from one or more controlled vocabularies by looking up keywords. This process is extremely human intensive, and there is ongoing informatics research focused on automating part of the process. Currently, it appears that a computer program cannot replace the human component entirely. This is because certain terms can match more than one concept. For example, â€Å"anaesthesia† refers to a procedure ancillary to surgery, or to a clinical finding of loss of sensation. Disambiguation requires some degree of domain knowledge as well as knowledge of the context where the phrase was encountered. The processing of narrative text is a computer-science speciality in its own right, and a preceding article[15] has discussed it in depth. Medical knowledge-based consultation programs (â€Å"expert systems†) have always been an active area of medical informatics research, and a few of these, e.g., QMR[16],[17] have attained production-level status. A drawback of many of these programs is that they are designed to be stand-alone. While useful for assisting diagnosis or management, they have the drawback that information that may already be in the patient’s electronic record must be re-entered through a dialog between the program and the clinician. In the context of a hospital, it is desirable to implement embeddedknowledge-based systems that can act on patient data as it is being recorded or generated, rather than after the fact (when it is often too late). Such a program might, for example, detect potentially dangerous drug interactions based on a particular patient’s prescription that had just been recorded in the pharmacy component of the CPRS. Alternatively, a program might send an alert (by pager) to a clinician if a particular patient’s monitored clinical parameters deteriorated severely. The units of program code that operate on incoming patient data in real-time are called medical logic modules (MLMs), because they are used to express medical decision logic. While one could theoretically use any programming language (combined with a database access language) to express this logic, portability is an important issue: if you have spent much effort creating an MLM, you would like to share it with others. Ideally, others would not have to rewrite your MLM to run on their system, but could install and use it directly. Standardization is therefore desirable. In 1994, several CPRS researchers proposed a standard MLM language called the Arden syntax.[18],[19],[20] Arden resembles BASIC (it is designed to be easy to learn), but has several functions that are useful to express medical logic, such as the concepts of the earliest and the latest patient events. One must first implement an Arden interpreter or compiler for a particular CPRS, and then write Arden modules that will be triggered after certain events. The Arden code is translated into specific database operations on the CPRS that retrieve the appropriate patient data items, and operations implementing the logic and decision based on that data. As with any programming language, interpreter implementation is not a simple task, but it has been done for the Columbia-Presbyterian and HELP CDRs: two of the informaticians responsible for defining Arden, Profs. George Hripcsak and T. Allan Pryor, are also lead developers for these respective systems. To assist Arden implementers, the specification of version 2 of Arden, which is now a standard supported by HL7, is available on-line.[20] Arden-style MLMs, which are essentially â€Å"if-then-else† rules, are not the only way to implement embedded decision logic. In certain situations, there are sometimes more efficient ways of achieving the desired result. For example, to detect drug interactions in a pharmacy order, a program can generate all possible pairs of drugs from the list of prescribed drugs in a particular pharmacy order, and perform database lookups in a table of known interactions, where information is typically stored against a pair of drugs. (The table of interactions is typically obtained from sources such as First Data Bank.) This is a much more efficient (and more maintainable) solution than sequentially evaluating a large list of rules embodied in multiple MLMs. Nonetheless, appropriately designed MLMs can be an important part of the CPRS, and Arden deserves to become more widespread in commercial CPRSs. Its currently limited support in such systems is more due to the significant implementation effort than to any flaw in the concept of MLMs. Patient management software in a hospital is typically acquired from more than one vendor: many vendors specialize in niche markets such as picture archiving systems or laboratory information systems. The patient record is therefore often distributed across several components, and it is essential that these components be able to inter-operate with each other. Also, for various reasons, an institution may choose to switch vendors, and it is desirable that migration of existing data to another system be as painless as possible. Data exchange/migration is facilitated by standardization of data interchange between systems created by different vendors, as well as the metadata that supports system operation. Significant progress has been made on the former front. The standard formats used for the exchange of image data and non-image medical data are DICOM (Digital Imaging and Communications in Medicine) and HL-7 (Health Level 7) respectively. For example, all vendors who market digital radiography, CT or MRI devices are supposed to be able to support DICOM, irrespective of what data format their programs use internally. HL-7 is a hierarchical format that is based on a language specification syntax called ASN.1 (ASN=Abstract Syntax Notation), a standard originally created for exchange of data between libraries. HL-7’s specification is quite complex, and HL-7 is intended for computers rather than humans, to whom it can be quite cryptic. There is a move to wrap HL-7 within (or replace it with) an equivalent dialect of the more human-understandable XML (eXtended Markup Language), which has rapidly gained prominence as a data interchange standard in E-commerce and other areas. XML also has the advantage that there are a very large number of third-party XML tools available: for a vendor just entering the medical field, an interchange standard based on XML would be considerably easier to implement. CPRSs pose formidable informatics challenges, all of which have not been fully solved: many solutions devised by researchers are not always successful when implemented in production systems. An issue for further discussion is security and confidentiality of patient records. In countries such as the US where health insurers and employers can arbitrarily reject individuals with particular illnesses as posing too high a risk to be profitably insured or employed, it is important that patient information should not fall in the wrong hands. Much also depends on the code of honour of the individual clinician who is authorised to look at patient data. In their book, â€Å"Freedom at Midnight,† authors Larry Collins and Dominic Lapierre cite the example of Mohammed Ali Jinnah’s anonymous physician (supposedly Rustom Jal Vakil) who had discovered that his patient was dying of lung cancer. Had Nehru and others come to know this, they might have prolonged the partition discussions indefinitely. Because Dr. Vakil respected his patient’s confidentiality, however, world history was changed.

Movie Review The Scarlet Letter - 1794 Words

Sequel to The Scarlet Letter Once the recent mutiny came to a close, all the townspeople hoped that their quiet little Puritan town would return to the normality that they held so dearly. Now, of course, they missed their beloved reverend, Arthur Dimmesdale, but many believed that the sacrificing if his life was a fair payment to end the madness. His dramatic demise would never be forgotten in the town and he, even being the sinner that he is, would be gravely missed and hold a special place in their hearts. The main purpose for this was the fact that he showed such great courage in his confession. The great reverend could have just slipped into the hands of God without telling any of the townspeople what he had done. This would have spared him the public humiliation that surfaced in his last few seconds of life. For this reason, most of the settlers in the community saw him as a very courageous man. 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