The Enlightenment Essay Example for Free

The Enlightenment EssayToday we will examine the seven points made about the enlightenment that we have read in this chapter. We will excessively go over the philosophers who put forth these ideas. What influence can be felt in the present of these ideas? Well in this paper we will start out out all of these mind boggling questions.Okay the seven points of enlightenment we will start with first what is enlightenment mean to man? Well it is a mans unfitness to make use of his understanding. So to answers the first ill-treat of enlightenment basically to me means it is someones right to there own authority to subjects and objects. Okay the second step is rationalism and it offers a naturalistic alternative to appeals to religious accounts of human nature and conduct. Now to the enlightenment of movement which means, enlightenment, the movement outwards towards the world and separation is set by desire, fear, and suffering, movement, which towards to reality which gets to intui tion and apperception. That is what I pulled out of the chapter on that step. Okay step four cultural optimism I figured this one to mean that a culture of any would have an optimistic look on it optimistic meaning to look on something with a more favorable side or outcome.Now to step five which is the return to nature I believe that maybe this one means that maybe when people die and the ritual of entombment some one means that we are returning to nature. Next step natural rights, well everyone has there rights from the democratic point of view so this moldiness also mean that we have our own natural rights including the right to exist and the rights to make our own choices and such. Step seven last but not least(prenominal) human rights I would believe to include the democratic point of view it is our human right to vote or to fallow the laws and such. These seven steps and the definitions that fallow are my own definitions to these enlightenment steps.The philosophers who put f orth these enlightenment steps are the one we have read about in our Sophies world book, Including Locke, Hume, Berkeley. either there ideas views and thoughts were I believe put into effect through these seven steps. What influence can be felt in the present of these ideas? Well I believe they came form the philosophers that I have listed so basically Ianswered this question with the one before it.This chapter was fun for me to read because I learned a lot about the enlightenment steps and where they originated from. I just thought that this section of the book was great

Chicano Mexican-American Movement Essay Example for Free

Chicano Mexican-American Movement EssayChicano a semipolitical term made normal in the sixties with the Chicano well-behaved Rights Movement which followed the example of the Black civilized Rights Movement. The bulk of the Movement pick out the word Chicano for themselves just as the African Americans had adopted Black. The Chicano Movement fought for all people of the Southwest of Mexican descendancy. These people included those whose ancestors had been citizens in the southwest when it was Mexico before the United States occupied it in 1848.Chicano a political term made popular in the sixties with the Chicano Civil Rights Movement which followed the example of the Black Civil Rights Movement. The people of the Movement adopted the word Chicano for themselves just as the African Americans had adopted Black. The Chicano Movement fought for all people of the Southwest of Mexican descendancy. These people included those whose ancestors had been citizens in the southwest w hen it was Mexico before the United States occupied it in 1848.These people became citizens by default with all rights guaranteed to them under the Treaty of Guadalupe Hidalgo. The Chicano Movement also included three waves of immigrants from Mexico those who migrated be behave they were escaping the Mexican Revolution between 1900 and 1914 those who came between land War I and 1930, mainly for economic reasons and those who came between World War II and the 1960s. Several of those who came in the 1940s came with organized labor programs such as the Bracero Program and determined to stay, even if undocumented.The Chicano Movement and the Treaty of Gudalupe Hidalgo After the United States won the Mexican American War the Treaty of Guadalupe Hidalgo was executed on February 2, 1848. Under the treaty, Mexico ceded to the United States a large area including, California, Arizona, New Mexico, parts of what we know today as Colorado, Nevada, Wyoming and Utah. The annexation of Texas wa s also approved. All the citizens who had resided in what had been Mexico were given virtuoso year to apply a choice to remain in what was now the U.S. or go to what was now Mexico. It is estimated that 75,000 Mexicans decided to stay and became citizens of the U. S. by default. The treaty provided specific guarantees for the property and political rights of the native population and they were given the right to retain their language, religion and culture. Almost immediately, the treaty was broken and these people were treated like foreigners in their own land. When they muzzy their land, they lost their economic base, thus had to turn to wage labor to survive.They were subjected to great discrimination practices, as were the three waves of immigrants who came later. By the time World War II ended Chicanos were an oppressed people poor, uneducated, with no political clout and menial jobs with little hope for upward mobility. It was after the Zoot Suit Riots of 1943 and after soldi ers came back from World War II that the foundation for the Chicano Movement was built. The veterans and other concerned Chicanos refused to be treated like second class citizens. The groundwork was laid for the battle of comparison for Chicanos.When the 1960s came about Chicanos recognized that like the Blacks, they, too, had a cause and initially emulated the Black Civil Rights Movement. Scholars consider the year 1943 as the beginning of an novel design of Mexican American recital and culture. When the so-called Zoot Suit Riots occurred in the Los Angeles area it marked a stage in the heathenish development of the Mexican American in which there was a consciousness of not belonging to either Mexico or the United States and an effort to assert a separate independent identity.It introduced the Pachucos, offspring Mexican-American young men who were not accepted in their schools, nor at home. They sought their own identity. Also after World War II Mexican American veterans who had fought and died side by side with their other American counterparts now felt they had earned their rights and were call fory to participate equitably. Thus the quest for identity in new-fashioned American society was initiated and by the 1960s a younger generation made up of the children of the veterans took up the pursuit of democracy and equity in the Civil Rights Movement and explored the question of identity in all the arts.There had been very little Chicano Literature in the past so the 60s was considered a Chicano Renaissance. Hispanic an comprehensive term that reduces groups of people into the lowest common denominator of Spanish speaking peoples. This can be people who speak Spanish or whose ancestors spoke Spanish and includes, Mexican Americans, Puerto Ricans, Cubans, Dominicans and other ethnic groups. It is a most unfair label because it denies the different histories, and dilutes the importance of each different culture by lumping them all under one umbrella.T he term was given by the government during the Nixon administration. Mestizo for the scope of this class half-Spanish, half-Indian. When the conquistadores arrived in the Americas miscegenation took place between the Spaniards and the Indigenous women, thus produced a new race, the Mestizo, a mixture of Caucasian and Indian. Much of Chicano Literature is based on Indian folklore. The Mestizo is an element in Mexican American Studies meaning both the Indian and Spanish side of the Chicano.Therefore we will be studying literature that takes us back to ancient Mexico and Spain and brings elements of both cultures to produce Chicano literature. I am Joaquin, written by Rodolfo Corky Gonzales in the 1960s elaborated a version of cultural nationalism that would typify what is called Movement Poetry. It was Mexican American history all wrapped up into one poem. It was monumental because up until then there had been very little written about the Chicano. When close tothing was written, i t was usually derogatory or stereotypical.It stands alone as an epic poem of the Chicano Movement. A new breed of writers were born because of the Chicano Movement. Their writings were related to a political and social movement. They wrote about cultural identification with the Mexican American heritage within the general framework of American society. It became the most intense expression of the creative spirit of the movement. It first dictum the light in print in angry journals or newspapers such as El Grito Magazine or El Gallo Newspaper.There were many. The writing was cause writing, not just literary. It was also inspirational. The first Chicano writers of Chicano Literature in the 60s committed their literary vices to the political economic and educational struggles. Their works were often inspirational and read at organizational meetings, boycotts and before protest marches. The first Chicano poets included Abelardo Lalo Delgado Ricardo Sanchez and Alurista (Alberto Urista) .Alurista coined the term Aztlan as the Chicano homeland. It gave Chicanos a sense of place. Aztlan had been the mythical homeland of the Aztecs which was north from Mexico, probably someplace in the southwest United States. In 1967 appeared the most influential Chicano Literary Magazine, El Gallo, initiating the publishing house El Quinto so (The Fifth Sun). El Quinto Sol emphasized the Chicano culture, language, themes and styles and a Mexica/Aztec identity and promoted the Spanish Language.The fifth sun referred to the Aztec belief in a period of cultural flowering that would take place some time in the future, in a fifth age that coincided with the rise of the Chicano movement. One of the first books published by Quinto Sol was an anthology in 1986, El Espejo/The Mirror, alter by Dr. Octavio Romano Paz and Herminio Rios. In 1970 El Quinto Sol instituted a national award for Chicano Literature, Premio Quinto Sol (Fifth Sun Award) which gave the winner $1000 and published their winning manuscript.

Pros and Cons of the Quebec Separation Issue

Pros and Cons of the Quebec Separation IssueThe musical interval of Quebec is a very controversial issue in Canada, but why? Some race, such as those who lead in Quebec believe Quebec should reissue from Canada. They believe that their province would be better off on its own as its own country. Others, mainly those from other split of the country, but mute some from Quebec believe that Quebec should stay, that Quebec is a big stir up of Canada and would not be the same without it. If Quebec stays, Canada maintains its large piece of land on the map, the accounting that goes along with it, and the millions of people living there, but if Quebec separates, Canada would get rid of a large chunk of its debt (which would go to Quebec). This raises two very important arguments between for and those against the separation of Quebec from Canada.There ar salwaysal benefits of Quebec separating from Canada. If Quebec were to separate, there would be no more disputes over the cut and slope run-ins that are spoken in Canada. Canada could take a crap its bilingualism, and Quebec could amaze its own strictly French nation with no English spoken anywhere. Canada is a bilingual country French is even mandatory in English schools up to and including grade 9. It isnt right if Quebec is only going to offer a French education to its children. Quebec is already separate in a way from Canada. They have their own civil laws, and their street signs only read in French. In 1980 there was a referendum to separate Quebec from Canada. This referendum was defeated when 41.5% of the people voted yes and 56.5% voted no. But the Quebecers were still fed up. Many people still did not want to be part of Canada, so they decided to try again. This time, it seemby a 50.58 % to 49.42 % margin, the closest in the accounting of Canada.ed to have more support than ever before, even from people that didnt live in Quebec (although people who didnt live in Quebec werent involved in the vote .) It took place in 1995, and the motion to pursue independence was again narrowly defeatedWhenever there are pros to an issue, the cons are never far behind. There is a big downside to Quebec separating from Canada. Canada is a bilingual country, the worlds first in fact and despite the fact that Quebec likes to be called strictly French, it is still a huge part of its bilingualism. Almost every soul who lives in Quebec knows some form of French, and anyone who doesnt is probably in the process of learning it. People who are visiting from communicatory countries may be attracted to the Quebec area because of its French-speaking nature. This is good for the tourism industry and can bring in some extra bucks to help pay off Canadas debt.Canada is also country that has a nation of 30 million plus, that number growing each day. We are also the second largest country in the world as far as veritable land goes. If Quebec were to separate from Canada, we would lose all of this. Out po pulation would shrink by 7.4 million people, and the size of our country would fall down almost 16 percent. And just think if you took Quebec off of the map. There would be a massive whole in Canada. Would it still be possible for Canada to survive? Would the east and the atomic number 74 be able to survive or would they be forced to join the United States?Quebec has flourished in Canada and proven it doesnt have to leave to achieve its needs. It made French its official language by passing Law 101. Despite the rising increase in English-speaking, it has raised the number of Francophones in the province to the highest level ever. We sometimes fail to realize that Francophones have jumped on top of the Quebec economy to produced some of Canadas and the worlds leading technologies, companies and financial institutions like Bombardier (snowmobiles, all terrain vehicles, military aircraft, trains), Hydro Quebec, and le Cirque du Soleil. If Quebec ever separated, it would no longer be a part of NAFTA and would be forced to pay heavy duties on imports and exports of their goods. This would then cause them to raise the price of their deal which would eventually stop selling because of the availability of cheaper goods elsewhere.Does all of this mean something? Why does Quebec keep trying to separate? Obviously they dont want to be a part of Canada, so they should become a country of their own. Now some may say that the reason these referendums have not gone through is because people are scared of becoming independent. They are scared of the thought of their province, Quebec, not being a part of Canada. Does this make sense? Not at all. If you want to separate from something, then do it. If you want to stay with that something, then stay with it. But dont try and do both, that entrust get you nowhere and the fights pass on continue to raise the whole country. The real reason for this is that the people who vote for Quebec to stay a part of Canada are mostly middl e aged people while the people that want Quebec to separate from Canada are the younger people and the older people. According to the website crave.com, Eventually, the young will be a majority and the yes vote side will win. It will end with them leaving, but not before more and more conflicts between the two sides, so they might as well go now.another(prenominal) reason why Quebec should separate is that Canada has a large debt of over 150 billion dollars. This debt has been accumulating over the years, but Canada is slowly puzzleing to come out of it. 25% of this debt would be the sole responsibility of Quebec if they were to separate which would make Canada at least 35 billion dollars further out of that debt. Although we will have lost a bit of our economy through the separation, this free reinds would surely make up it for that loss. This would give Quebecers a nice discrepancy in their bank account to start off their country and eventually, they would have to start borrowi ng money from Canada. Over the years Quebec would start to pay the money back, with interest, and Canadas debt would be almost cut in half.The separation of Quebec from Canada is a very controversial issue. Should it happen or shouldnt it? Those for would like to see it happen so Canada can get rid of the French language all together, and to stop all the fighting and arguing that is constantly going on between both sides. They would also like them to separate for the sake of money that they would be paying to Canada. Others do not want Quebec to separate from Canada because they believe that it is a very important part of the Country. It connects the west to the east, the east to the west. Without it, there would be a very big hole right in the middle of the country and the rest of Canada would probably be forced to join the United States. I myself would not like to see Quebec separate from Canada for a few reasons. If they did separate, Nova Scotia would most likely join the U.S. N ow although I do like to visit the country, I would never want to be a part of it. Another reason is that I enjoy shopping in Quebec and driving through Quebec. Its a fun place to be and the shopping never ends. Canada is just not the same without Quebec. As long as these two sides continue to fight and argue, the separation of Quebec will remain a very controversial issue in Canada.http//www.bookrags.com/essay-2006/1/30/214331/583

Strategies of Financial Forecasting at Strident Marks

Strategies of fiscal Forecasting at Strident tagFinancial ForecastingRole of Financial Statements ForecastingThe role of monetary asseveration prevision at Strident Marks is to provide expected afterlife financial statements establish on conditions that management expects to exist and the action it expects to take. These statements offer financial managers insight into the prospective afterlife financial condition and performance of the social club. Financial statement includes income statement and symmetry sheet. (Horne, Wachowicz Bhaduri, 2008)Development of Income Statement ForecastThe income statement forecast is a summary of a Strident Marks expected r take downues and expenses oer approximately future period, ending with the net income for the period. The sales forecast is the key to scheduling output and estimating production costs. The detailed analysis of purchases, production based bribe and smasher costs helps to produce the most accurate forecasts. The costs of good sold atomic number 18 forecasted on the basis of preceding(a) ratios of cost of goods sold to sales.Following this the selling, cosmopolitan and administrative expenses argon forecasted. The estimates of these expenses argon fairly accurate because they argon generally calculated in advance. Usually, these expenses are not sensitive to the changes in sale, specifically to the drop-off in sales in the very short run. After this other income and expenses along with interest expenses are estimated to obtain the net income before taxes. Next to this income taxes are computed based on the applicable tax rate, which is then deducted to arrive at estimated net income after taxes. All of these are then combined into an income statement. Anticipated dividends are deducted from profit after taxes to give the expected increase in retained earnings. This anticipated increase need to agree with the balance sheet forecast figures that are developed next.Development of Balance Sheet Fo recastTo prepare balance sheet forecast for a particular period say for June 30, Strident Marks utilizes the balance sheet of the previous declination 31. Receivables at June 30 can be estimated by adding to the receivable balance at December 31, the total communicate credit sales from January through June (for which the estimation is done) and deducting the total projected credit collection for the particular period.Forecasting Assets In the absence of cash budget, the receivable balance can be estimated on the basis of a receivable turnover ratio. This ratio, which depicts the relationship between credit sales and receivables, should be based on past experience. To obtain the estimated level of receivables, projected credit sales are simply divided by the turnover ratio. If the sales forecast and turnover ratio are realistic, the method will produce a reasonable approximation of receivable balance.The estimated investment in the inventories for a particular period may be based o n the production schedule, which in turn is based on the sales forecast. This schedule should re posit expected purchases, the expected use of inventory in the production and the expected level of finished goods. On the basis of this information along with the beginning inventory level, an inventory forecast can be made (Horne, Wachowicz Bhaduri, 2008)Estimates of future inventory can be based on an inventory turnover ratio, instead of the use of production schedule,. This ratio is applied in the similar carriage as for the receivables, except that now we solve for the ending inventory position.Inventory Turnover Ratio = cost of goods sold (Ending) InventoryFuture net mulish asset are estimated by adding planned expenditures to existing net fixed assets and subtracting from this sum the book value of any fixed assets sold along with disparagement during the period. Fixed assets are fairly easy to forecast because capital expenditure are planned in advance.Forecasting Liabilities and Shareholder Equity for instance if the company wants to estimate the liabilities for June 30, the accounts payable are estimated by adding the projected purchases for January through June and deducting total projected cash payments for purchases for the period to the balance of December 31.The calculation of the accrued wages and expenses is based on the production schedule and the historical relationship between these accruals and production. The shareholders equity at June 30 will be equity at December 31 plus profits after taxes for the period minus the amount of dividends paid. Generally cash and notes payable (short term bank borrowings) serve as reconciliation factors in the preparation of forecast balance sheets, whereby assets and liabilities plus shareholders equity are brought into balance.Once all the components of the balance sheet are estimated, they are combined into a balance sheet format. (Horne, Wachowicz Bhaduri, 2008)Importance of Financial Statement Forecas tThe information that goes into a cash budgets can be used to prepare forecast financial statements. Financial mangers can make direct estimates of all the items on the balance sheet by projecting financial ratios into the future and then making estimates on the basis of these ratios. Receivables, inventories, accounts payable and accrued wages and expenses are frequently based on historical relationships to sales and production when a cash budget is not available.Forecast statements allow us to study the composition of expected future balance sheets and income statements. Financial ratios are computed for analysis of the statements these ratios and the raw figures may be compared with those for present and past financial statements. Using this information, the financial manager can analyze the direction of change in the financial condition and performance of the company over the past, the present and the future. If the firm is accustomed to making accurate estimates, the preparatio n of a cash budget, forecast statements or both forces it to plan ahead and to coordinate policy in the various areas of operation.Continual revision of these forecasts keeps the company alert to changing conditions in its environment and in its internal operations. In addition, forecast statements can even be constructed with selected items taking on a range of probable values rather than single point estimates. (Horne, Wachowicz Bhaduri, 2008)Comparison between financial statement forecasting answer and budgeting processThe budgeting process starts with forecasting of future income statements. These statements are made on monthly or weekly basis and may stretch for dozen months in the future.Both budgeting and forecasting are important management tools that we use to anticipate needs and avoid crisis. (Laura, 2000)Budgeting process gives us information about solely the prospective future cash position of the company, whereas forecast statements embody expected estimates of all assets and liabilities as well as of the income statement items.The key differences between budgeting process and forecasting are as follows The budget obtained by budgeting process is generally more detailed than a forecast.Expenditures are more specifically matched to sources of income in a budget than in a forecast.Budgeting is a tool for management to achieve the objectives, whereas, forecasting is a used by management to formulate the budget.Budgeting is related to future definite period only, whereas, forecasting is related to past, present and future for pure estimation.Budgeting is bloodsucking on forecasting but forecasting is not dependent on the budgeting.The preparation of budgets ids essential to achieve the production targets but the forecasting is essential to prepare a business budget.Budgets are quantitative, whereas, forecasting is qualitative in nature.Budgeting is a business process for management whereas forecasting is a mental process for management.The succe ss of budgeting is dependent on sound forecasting whereas, success of forecasting is dependent on proper use and analysis of scientific and statistical methods.Budgeting process starts after forecasting while the forecasting is a pre process of budgeting.Budgeting is a warning itself whereas forecasting helps in preparing budget as a standard.Budgeting highlights the whole business while the forecasting helps the budget to highlight the business. (Khan, Jain, 2002)ReferencesHorne, J.C., Wachowicz, J.M. Bhaduri, S.N. (2008). Fundamentals of Financial Management. Delhi Dorling Kindersley (India) Pvt. Ltd.Khan, M.Y. Jain, P.K. (2002). Financial Management. in the altogether Delhi Tata McGraw-Hill Publishing Company Ltd.Laura, E. (2000). Budgeting for the Future Why Firms Need to Forecast and Budget Their Cash Flows. Retrieved June 2, 2008, from http//www.allbusiness.com/accounting-reporting/budget-budget-forecasting/622015-1.html

Chronic Opiod Use after Hysterectomy

degenerative Opiod Use later on HysterectomySpecific AimsThe rapid increase in the incidence of opioid-related overdoses and deaths has become a big man wellness threat in the United States. This opioid epidemic affects more women than men due to spiriteder opioid prescribing and dose, longer end single-valued function, and more opioid dependence in women.1 From 1999 to 2010, the outrank of opioid overdose ca utilize death increase 5-fold among women.2 Besides the illicit purchase for some women, the sign ikon to opioids for many others may overly come from the regular medical treatment as prescription opioids are widely utilisationd for pain management after surgery.3 As such, the critical research gap on opioids use is that the evidence is insufficient to draw conclusions about optimal strategies for initiation and titration of opioid therapy.4 Several observational studies have askd the patterns of opioid use for noncancer pain in patients pre and military post-surge ry, and identified the adventure factors of continuing opioid use post-surgery.5-11 Most of these studies examined the prediction of baseline demographic and clinical characteristics of patients for prolonged opioid surgical use and suggested that surgery is a encounter factor for chronic opioid postoperative use.5-9 Only two studies examined the initial opioid exposure within 6 or 7 solar days of the surgery date and results are controversial.10,11 One study describe that initial exposure of opioid poses 44% increase risk of chronic postoperative opioid use and another i suggested that this risk would be low and statistically in meaningful.10,11 connatural investigation has not been done specifically for hysterectomy, the most frequently performed non-obstetric surgeries in the United States for women of reproductive age.3,12 Pain has been present as a common symbol before and after hysterectomy.13,14 A small cross-sectional study has examined the predictors for opioid prescription in women of productive age and identified that opioid use was authorisedly associated with hysterectomy status and pain-related dysfunction.15 some other cross-sectional survey study reported that 32% patients had chronic pain after hysterectomy.14 Neither chronic opioid postoperative use nor initial opioid exposure for astute surgery pain was examined in these two studies.14,15 Filling this gap in knowledge is critical since commiting the risk factors of chronic opioid postoperative use could lead to optimized initial opioid prescribing for acute pain management and recoild chronic opioid postoperative use and improved women health.Our long-term goal is to help reduce chronic use of opioids and optimize the pain management in women after obstetric and gynecologic surgery through identification and dissemination the safer initial opioid prescribing for acute post-operative pain. Our objective here, which is the next step in our long-term goal, is to compare the p atters of opioid use pre and post hysterectomy and determine the important risk factors that associate with chronic use of opioids in women post hysterectomy.The national OptumInsight Clinformatics info offers an essential resource to investigate these aims. The availability of clinical diagnoses and pharmacy medical dispensing offers a significant advantage for investigating drug utilization with corresponding clinical conditions in bad population.Our team is well suited to conduct this research given extensive expertise in contemporary pharmacoepidemiology, many years of develop on opioid abuse research, prior drug utilization studies utilize large claims data, and clinical expertise from obstetric and gynecologic physicians.Our specific aims are to investigate patterns and predictors of chronic opioid use in women pre and post hysterectomy with the adjacent analysesAim 1 To characterize the patterns of chronic opioid use in women after hysterectomy.Aim 2 To determine the sig nificant risk factors for chronic use of opioids in women after hysterectomy.The first specific aim for this study is to identify patients who chronically take opioids during six months post hysterectomy, and investigate the period and geographical patterns of chronic opioid use in women after hysterectomy. The pattern of chronic opioid use pre- and post-surgery exit also be compared in women with varied age, comorbidities, co-medications, as well as types and doses of initial opioid prescribing. The second specific aim is to determine the risk factors that significantly relate to chronic opioid use, and determine if characteristics of initial filled opioid prescriptions significantly associate with the chronic use of opioids after adjusting for other potential risk factors. Many pain related studies have demonstrated that long term opioid prescribing was significantly predicted by patients clinical characteristics and psychosocial factors, including pain conditions, psychiatric d isorders, frequency of medical visits, smoking, and pain-related dysfunction.16-18 Therefore, the correct covariates in this study would include both demographic and clinical characteristics.B. Significance and debutCurrently the United States is experiencing an unprecedented opioid epidemic. According to the Centers for Disease Control and Prevention (CDC), opioid-related deaths increased 200% overall from 2000 to 2014.19 During 2014, about 1.9 million people had an addiction of opioids, with overall 47,055 overdose deaths, 18,243 overdose deaths in women, and 18,893 overdose deaths related to prescription pain relievers.20,21 Based on the data reported by the CDC, women are more believably to have chronic pain, be prescribed opioids with higher dose and longer period, and hence progress to dependence.22 Although opioid abuse is a public health crisis, opioid analgesics are up to now the mainstay for treatment for acute pain after major surgery. In 2014, total 245 million pres criptions for opioids were dispensed from U.S. retail pharmacies.23,24During 1998-2010, approximately 7.4 million hysterectomies were performed, making hysterectomy one of the most frequently performed surgeries for women in the United States.25 With over 60% of hysterectomies performed abdominally and up to 85% of patients experiencing moderate-to-severe pain after hysterectomy, postoperative pain management becomes very important.26,27 assure suggests that intense and long-lasting postsurgical pain can increase postsurgical morbidity, delay recovery, and lead to chronic pain.28 Opioids such as morphine, meperidine, and oxycodone are widely used postoperatively to reduce and manage pain in patients after hysterectomy.29 Women with hysterectomy and high levels of pain-related dysfunction were almost twice as likely to have opioid prescription. More than 85% of women with hysterectomy and a high level of pain-related dysfunction were found to use opioid.15 Hormonal disturbance, hype ralgesia, and iatrogenic do are potential adverse effects from opioid use in women after hysterectomy.14,15 The interaction of opioid-induced adverse effects and post-hysterectomy hormonal dysregulation may intensify pain and promote continued use of opioids.15 There are no known studies that rate the company between acute and chronic postsurgical opiate prescription in women experienced hysterectomy. In consideration of the current opioid epidemic it is important to understand how post-surgical pain is managed, and if this setting presents increased risk of opioid addiction among certain groups, or related to particular prescribing practices. The goal of this proposed study is to examine whether opioids prescribed in women following hysterectomy is associated with chronic use of opioids, and to evaluate which factors may predict patterns of opioid use that taper overuse or addiction. Accordingly, this study first aims to describe the incidence pattern of chronic opioid use in women post hysterectomy. The second aim is to explore the significant risk factors and determine if the characteristics of initial opioid prescribing significantly associate with chronic opioid use after adjusting for other potential risk factors.This study ordain reveal important insights regarding post-surgical pain management for a common procedure, and determine if certain patient or treatment characteristics increase the risk of chronic opioid use in this setting. We expect that this research will provide evidence for the need to improve clinical practice towards optimized pain management and cut back chronic opioid use in women after hysterectomy through identification the specific opioid, drug type ( brief-acting or long-acting), and doses that significantly associate with chronic opioid use in women after hysterectomy. Our study will provide sufficient evidence to draw conclusion about optimal strategies for initiation and titration of post-surgery opioid therapy, and enha nce evidence-based medicine for opioid use in Rhode Island, and also the United State.This award would enhance my capabilities on handling interdisciplinary studies and further help me to develop my own research projects and seek for external funding. originOur proposed observational studies based on the administrative claims data will allow for investigation of time trends and geographic variation of drug use in large population and address for well-characterized clinical conditions. Our approach will employ state of the art, innovative pharmacoepidemiologic study designs and statistical modellings, to improve the precision of outcome definition and downplay measured and unmeasured confounding and bias in our estimation of significant predictors for chronic opioid use after hysterectomy.The unintended outcomes from adverse drug effects retain the prospective trials unethical. In this circumstance, a well-designed, retrospective observational study with sufficient sample size offe rs an efficient design to determine if there is an adequate communicate for impropriate opioid prescribing to women post obstetrics and Gynecology surgery.The generalizability of study results are guaranteed due to the across the nation large health plan data that the analyses are based upon.C. Approach information SourcesStudy data will be derived from the national OptumInsight Clinformatics Data MartTM, a research database spanning January 01, 2010 through December 31, 2013. The Optum Research Database includes about 23 million beneficiaries from the nationwide commercial health insurer, United Healthcare. The data contains health care utilization with transactional reimbursement data from outpatient pharmacy dispensing, inpatient and outpatient services.30 It links administrative enrollment data with the important medical codes including the national drug code (NDC) for pharmacy dispensing, the Current Procedural Terminology (CPT) code for medical procedure, and International C lassification of Diseases, Ninth Revision, Clinical qualifying (ICD-9-CM) code for diagnosis. The claims data in this database have been adjudicated, ascertained, and deidentified for research purpose. The University of Rhode Island (URI) and OptumInsight Inc have approved utilization of these data. URI already licenses this database that it is freely available for faculties to use.Study PopulationThis study will include adult women who receive the hysterectomy surgery between July 01 2010 and June 31 2013 and have at least 6 months of continuous prior coverage under this health insurance plan. This continuous 6-month coverage provides a baseline for defining new drug users, as well as baseline clinical characteristics, such as comorbidities and co-medications. The hysterectomy procedures will be derived from the ICD-9-CM diagnostic codes 68.3x-68.7x, and 68.9x, where 68.3x indicates a subtotal abdominal hysterectomy, 68.4x indicates a total abdominal hysterectomy, 68.5x indicates a vaginal hysterectomy, 68.6x indicates a al-Qaida abdominal hysterectomy, 68.7x indicates a radical vaginal hysterectomy, and 68.9x indicates other and unspecified hysterectomy.13,31 Patients with pelvic evisceration (ICD-9-CM 68.8x) will be excluded. We also will exclude patients with any cancer diagnoses, including malignant neoplasm of the female genitourinary organs-cancer (ICD-9-CM 179-184), and carcinoma in situ of female genitourinary system (ICD-9-CM 233).Exposure AssessmentOpioids in this study include the following medications codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone. Tramadol and propoxyphene, considered as weak opioids or already off market, will not be included.11,15 The exposure group involves adult women who receive the hysterectomy surgery and fill more than one prescription for opioids on the day of hospital discharge or within 7 days after hysterectomy surgery, provided that they have no exposure to opioids for at least 6 months prior to hysterectomy.11 The 7 days of window is based on the assumption that a filled prescription during this period would likely to treat acute postoperative pain caused by hysterectomy. A comparison group, defined as the patients with no opioids use on the day of hospital discharge or within 7 days after hysterectomy surgery, will serve as a control to make a comparison of risks for chronic use of opioids. The control patients also have no exposure to opioids for at least 6 months prior to hysterectomy. The exposure of opioids will be identified using NDC codes from pharmacy claims data.In this study, exposure assessment includes all characteristics of the initial filled opioid prescription at the day of hospital discharge from hysterectomy or during 7 days post-hysterectomy. The different type of opioids (classified as long or short acting), number of supply days, and oral morphine equivalent daily dose (milligrams) will be assessed and analyzed .Outcome AssessmentSince the study focuses on the risk of chronic opioid use after initial exposure to opioids following hysterectomy, patients were followed from the 8th day after hysterectomy to the first day of outcome occurrence. The outcome, chronic use of opioids after hysterectomy, will be defined using flying models.11 in which patients with exchangeable patterns of medication filling during follow-up will be grouped together. The trajectory model was initially posed for the purpose of the assessment of medication adherence.32,33In order to classify the trajectory groups for opioid use during the defined follow-up window, we first generate 6 dichotomous variables to indicate if a study participant fills a prescription of an opioid medication during each of 6 consecutive 30 day follow-up periods.11 we then model these 6 binary indicators of using opioids in each 30 day follow-up period as a longitudinal response in a logistic group-based trajectory.34,35 With a trajectory model, we will enter the probability of membership of patients in each group, and the probability of the certain opioid exposure over time as a smooth function of time. We will fit the model using 2 to 4 opioid exposure groups with comparison of the Bayesian Information Criterion.36 The number of groups will be chosen based on the value of the Bayesian Information Criterion. In each group, a third-order polynomial (including linear, squared, and cubic terms) of time will be used to model the probability of being exposed to opioids. Patients will be appoint to different trajectory groups, which are generated from these models and have highest probability of the membership. Based on the model results, the group of patients with the highest probability of filling opioids over time will be defined as the chronic use. Other trajectory groups were classified as nonchronic users. The trajectory models provide new in advance(p) approaches to utilize the observed data to determine distinc t filling patterns of opioids in our study population during the year after hysterectomy surgery. It classifies patients into groups with similar opioid exposure patterns without relying on a priori and subjective cutoff line for the definition of chronic opioid use. The trajectory models will be conducted using SAS Proc Traj (SAS, version 9.4, SAS Institute Inc., Cary, NC, USA).Patterns of Chronic Opioid UseAfter chronic opioid use is defined using trajectory models, we will compare the frequency of the incidence of chronic opioid use over time from 2010 to 2013. The secular trend will be analyzed using Joinpoint regression program (National Cancer Institute, Calverton, MD) to identify the joint points and slopes. The rates of chronic opioid use in women post hysterectomy will also be compared with varied age, comorbidities, co-medications, as well as characteristics of initial opioids exposure, including opioid types and doses.The geographic variation of chronic opioid use will be mapped and analyzed using ArcGIS 10.5 geographic information systems software (ESRI, Redlands, CA). The opioid prescription policies and socioeconomic status in different states will be compared with the geographic variation of chronic opioid use.Predictors of Chronic Opioid UseWe will identify the predictors of chronic opioid use at baseline or the time of the initial opioid prescription. A previous study demonstrated that hysterectomy, older age, and higher levels of pain-related dysfunction were associated with opioid prescription.15 Potential predictors in this study would include age, year of surgery, smoking, illicit substance abuse, alcohol abuse, hysterectomy type, psychotropic medication use, pre-operative depression, pre-operative pain condition, autochthonic indication for hysterectomy, co-medications, and characteristics of the initial opioid exposure. Although the benefits of minimally invasive surgical procedures have been documented,37 hysterectomies performed for b enign indications in 2010 in the US still consisted of 40.1% total or subtotal abdominal hysterectomies, 30.5% laparoscopic hysterectomy, 19.9% vaginal hysterectomy, and 9.5% robotic-assisted hysterectomy.21,25 Hysterectomy type has been related to the initial opioid prescription,15 however, the results from randomized clinical trials showed that abdominal hysterectomies didnt increase postoperative chronic pain.38,39The primary indication for hysterectomy is defined based on the following algorithm (i) precancerous conditions will be assigned the primary indication if endometrial cystic hyperplasia or carcinoma in situ of female genitourinary system is listed as an indication associated with hysterectomy surgery (ii) whichever is listed first of endometriosis, uterine prolapse, or uterine leiomyoma will be assigned the primary diagnosis associated with hysterectomy if cancer or a precancerous condition is not listed (iii) endometrial cystic hyperplasia is combined with in situ unde r precancerous and that pain and bleeding were included as reported reasons for hysterectomy, and (iv) other was assigned the leading for the remaining diagnoses.19Over 60% of patients have reported pain as pre-operative symptoms for hysterectomy.39 After hysterectomy, the prevalent pain was reduced to 4.7% to 31.9% during 1-2 years after surgery, charm new onset pain at follow-up was reported in 1-14.9% patients and increased pain was in 2.9-5% of patients with pre-operative pelvic pain.39 Therefore, in our study, we plan to assess pre- and post-operative pain, as well as the pain conditions, including pelvic pain, back pain, fibromyalgia, and migraine or other headache syndromes using ICD-9-CM codes.Patients with pharmacy claims for opioids or diagnoses for opioid abuse (ICD-9-CM 304.xx) during the 6-month baseline period will be identified as opioid users prior to hysterectomy.Preoperative depression that has been found significantly associated with postoperative chronic pain,40 will be identified using diagnoses, as well as medication use at baseline. Antipsychotropic medication use will be obtained using prescription information. The psychiatric comorbidity, will be assessed using prescription information instead of ICD-9-CM codes for greater specificity.11 Co-medications refer to the use of other medications on postoperative pain management. The postoperative use of Nonsteroidal anti-inflammatory drug drugs (NSAIDs) or Acetaminophen with opioids has been found safe and effective on pain relieve with reduced opioid dose.41All potential predictors, including characteristics of initial opioid use, will be adjusted in multivariate analyses to identify the significant predictors for chronic use of opioids in patients post hysterectomy.Statistical AnalysisStatistical tests and modeling will be conducted to identify potential significant risk factors for chronic use of prescribed opioids in women post-hysterectomy. Categorical variables will be examined and co mpared using Chi square or the fisher exact test. Continuous variables will be compared using the student t test. The covariates will be selected from all demographic and clinical variables using statistical modeling. A univariate analysis will be performed with the initial opioid exposure variable and then with each covariate added one at a time to monitor the change of the estimate of the major exposure variable. The covariates that modify the estimate of opioid exposure (variable 5%) or significantly predict the chronic use of opioids will be selected for further multivariate analysis. To report card for many confounding factors, we will also utilize propensity score matching method to combine all confounding factors into a propensity score. The patients with initial opioid exposure will be 15 matched with the patients without initial opioid exposure using the propensity score with a caliper of 0.01. A multivariate qualified logistic regression model will be utilized to measure the adjusted odds ratio of initial opioid exposure on chronic opioid use in two matched groups.A probability of type 1 error (alpha) = 0.05 will be considered to be the threshold of statistical significance. Tukey-Kramer method will be applied to correct the inflated p value due to multiple comparisons. Statistical analysis will be performed using SAS software (version 9.4, Cary, NC).Sensitivity StudiesIn order to address unmeasured confounding factors, sensitivity analyses will be conducted in two sections subgroup analyses and instrumental variables.Subgroup analysisIn order to investigate the effects of initial opioid exposure in women post hysterectomy, multivariate analysis will be conducted in the following subgroups women with postoperative chronic pain, women without postoperative chronic pain, women with postoperative NSAIDs use, women without postoperative NSAIDs use, women with postoperative Acetaminophen use, and women without postoperative Acetaminophen use. Interactio ns between the drug exposure and the important factors will be examined in the multivariate analyses. Subgroup analyses will likewise be conducted if the interaction is statistically significant.Instrumental Variable We plan to use propensity score matching to address all measurable confounding factors and generate two balanced comparison groups. However, the unmeasurable confounding factors, like confounding by indication, may still impact the study validity. Instrumental variable is an advanced methodology that has been utilized in pharmocoepidemiological studies to control for the unmeasurable confounding factors, such as confounding by indication. In the sensitivity study, we will use the physicians gustation as an instrumental variable and reexamine the initial opioid exposure on chronic use of opioids post hysterectomy.D. TimelineTable. Study Timeline of the Study.Time PeriodStudy jump onBefore 07/01/2017Obtain IRB approval and Optum data use permission07/01/2017 08/01/2017 Complete data cleaning, manipulating, and variable editing.08/01/2017 10/01/2017Complete analyses for demographic and clinical characteristics10/01/2017 01/31/2018Complete trajectory modeling to determine chronic opioid use. Analyze the time and geographic trends.02/01/2018 02/28/2018Submit an abstract to the annual meeting of International fraternity of Pharmacoepidemiology (ISPE)03/01/2018 06/30/2018Complete analyses for specific aim 107/01/2018 01/31/2019Complete predictive modeling as described in specific aim 202/01/2019 02/28/2019Submit an R21 to NIH, and an abstract to the annual meeting of ISPE03/01/2019 06/30/2019Compete analyses for specific aim 2, including all sensitivity studies. Submit a final melodic theme to a high impact journal09/01/2017 12/15/2017Complete course PHP 209001/01/2018 05/15/2018Complete course PHP 2470

The Grande Odalisqe :: Art Analysis

The Grande OdalisqeThe Grande Odalisque painted in 1884, drew many criticisms.There were complaints around the lifelessness of the subject, the fact that she has three vertebrae too many. It illustrates the rather strange mixture of Ingress artistic allegiances.His subject, the reclining nude figure, is traditional, going back to Giorgione and Titian but by converting her into an odalisque, an inhabitant of a Turkish harem, he makes a strong concession to the contemporary Romantic taste for the exotic. Ingres treats the figure in his take sculpturesque style spiffed up surfaces and simple rounded volumes controlled by rhythmically flowing contours. The smoothness of the planes of the body is complemented by the broken, busy shapes of the drapery. His admiration for Raphael is shown in the borrowing of that masters lineament of female head and headdress, and an inclination of the head, as it can bee seen in Raphaels Madonna of the Chair. But Ingres is drawing not only fro m the High Renaissance, for his figures languid rate and her proportions (small head, elongated limbs) betray his debt to such Mannerists as Parmigianino, as does the generally cool colour scheme.Often Criticized for not being a colourist, Ingres in fact, had a smart as a whip colour sense. It is true that he did not seem to think of his paintings primarily in terms of colour, as did Delacroix, but he did far more than evidently tint his drawings for emphasis. In this painting Ingres creates colour and tonal relationships so tasteful and subtle as to render them unforgettable. Never insisting on likeness for its own sake, Ingres rarly fails to produce a striking characterization and, analogously to the smooth, formal treatment he gives his nudes, never fails to impart to both characterization and setting an air of flat elegance.

Rural HIV/AIDS in Southeast Ohio :: Case Management

Rural HIV/acquired immune deficiency syndrome in Southeast OhioHistoryOf all the known cases of HIV / AIDS in the United States 5.5 part were reported from nonmetropolitan statistical argonas (non-MSAs). The Office of Management and Budget defines a metropolitan statistical area (MSA) as a county or group of counties that includes a metropolis of 50,000 residents or an urbanized area with at least 50,000. Nonmetropolitan counties are all remaining counties (Gwinn & Wortley, 1996). 6 percent of the female AIDS cases reported to the Center for unsoundness Control (CDC) during 1994 were residing in non-MSAs at the time of AIDS diagnosis (CDC, 1996). This is the case in Southeast Ohio where the nearest metropolitan area is Columbus an hour and a half away from Athens.Rural HIV/AIDS patients tend to be diagnosed in later stages of the disease because their physicians do not consider them to be at risk for HIV (Calonge, Petersen, Miller, & Marshall, 1993 Miller, et al., 1995). Many of th e clients that apply for services at the Athens AIDS Task Force do so only after a referral from a medical professional after they have been hospitalized with a serious illness. Most already have Center for Disease Control (CDC) diagnosis for AIDS (T-Cell count below 200, normal count is 800 1500).Even as the spread of AIDS into small towns escalates, HIV-infected patients who live outside urban areas continue to confront hearty obstacles to effective care. Nearly all doctors who specialize in the treatment of HIV are located in cities. Quality of life for HIV-infected clownish residents is potentially worse, very much for reasons that involve a lack of person-to-person contact both at the medical level and at the personal support level. Researchers have noted that country HIV/AIDS patients often travel two or more hours to obtain medical care because they lack confidence in their local physicians, are unable to find a local physician who will see them, and are concerned about confidentiality. (Mainous & Matheny, 1996 Rounds, 1988 Rumley, et al., 1991). This is certainly the case in Rural Ohio, many an(prenominal) clients travel to Columbus, Akron, Pittsburgh, Pennsylvania and Parkersburg, West Virginia for medical treatment. Many fear that they will run into acquaintances or relatives if they should visit physicians closer to home. People living in rural areas are still generally afraid of casual contact with anyone with the AIDS virus. We also see less intervention and prevention efforts directed toward rural areas, in part because they tend to be more conservative and not as open to sexuality education and safer sex education.