Tuesday, August 20, 2019
Gated DIBH for Left Sided Breast Cancer Patients Chapter III: Methodology 3.1 Research Objectives The research project examines left-sided breast cancer patients receiving therapy with gated DIBH technique using the commercially available RPM system. The primary objective of this research is to evaluate whether left-sided breast cancer patients will benefit from gated DIBH. The interest in performing this research arises from having many left-sided breast cancer patients that have large volume of heart in the treatment field, and hence are at risk for cardiac toxicities in the future. The secondary objectives of this research is to look at patientÃ¢â¬â¢s comfort and understanding, and radiation therapistÃ¢â¬â¢s workload. This chapter will discuss the sample selection, ethical issues, instrumentation, data collection procedures, data analysis, limitations, expected results, budget and timeline. 3.2 Sample selection and description The expected sample size was calculated using the formula (Chan, 2003) for paired samples as seen below, Total sample size = where c is 10.5 for 90% power, Ã ´ is the standardised effect size, given by the formula (Chan, 2003): where Ã ¼1 and Ã ¼2 are the means of the two treatment groups, and ÃÆ' is the common standard deviation. The 90% power represents the probability of rejecting the null hypothesis when it is false (Chan, 2003). It is postulated that a good treatment difference () between the 2 groups is 0.2 units with an SD (ÃÆ') of 0.5 units (Chan, 2003). With these values, the expected sample size is 68. Sixty-eight left-sided breast cancer patients will be selected for this research using a simple random sampling method. The patient population will be chosen at random to create a diverse group of patients with variable breast and heart volumes. The criteria for this sample would be female patients with left-sided breast cancer below the age of 70. In addition, the patients must be able to hold their breath. These patients will be recruited after being screened by the oncologists. The oncologists will do a simple breath-hold test with patients to determine if they are able to hold their breath for at least 20 seconds. This is because patients will be required to hold their breath during the CT scan for a duration of 18 seconds. This research will require 2 sets of computed-tomography (CT) scans from each patient of which one is at free breathing and the other at DIBH. Both sets will have identical patient setup. Patients will be lying supine with both arms above head on a posirest, having the visual goggles on (see Appendix M, image A) with a 6-reflective markers block on patientÃ¢â¬â¢s anterior abdominal surface (see Appendix H). With the goggles, they are able to view the screen, as seen in image B in Appendix M, in order to see their breathing patterns. For each patient, 2 treatment plans will be generated: one using the CT images at free breathing with photon electron match technique and the other using the CT images at DIBH with gated DIBH technique using RPM with 3-mm intervals. 3.3 Ethical Issues and Informed consent Any research involving human subjects conducted in the hospital would require adherence to ethical standards. The procedure requires the collation of a list of investigators in the department that intends to conduct clinical trials (see Appendix N), and to apply and attend the Singapore Guideline for Good Clinical Practice (SGGCP) course. This Course ensures that the conduct of clinical trials follows internationally acceptable ethical and scientific standards (see Appendix O). The ethics review will be carried out by the National Healthcare Group domain specific review board which is an independent committee constituted of medical, scientific and non-scientific members, whose responsibility is to ensure the protection of the rights, safety and well-being of human subjects involved in a research study by reviewing, approving and providing continuing review of research studies, and of the methods and materials to be used in obtaining and documenting informed consent of the research su bjects (National University Health System, 2010). When a principal investigator submits an application via the research online administration and management system, it is automatically routed to the department representative for endorsement, and subsequently the institution representative for endorsement, before it is delivered to the domain specific review board secretariat (National University Health System, 2010). All research studies submitted will be classified under one of the following review categories: exempt review, expedited review, full Board review (see Appendix P) (National University Health System, 2010). Based on the definitions in Appendix P, this study is classified as an expedited review. Ethics approval for research is required for several reasons. Firstly, ethical norms promote the aims of research, such as knowledge, truth, and avoidance of error (Resnik, 2011). Secondly, ethical standards promote the values that are essential to collaborative work, such as trust, accountability, mutual respect, and fairness (Resnik, 2011). For example, guidelines for authorship, copyright and patenting policies, data sharing policies, and confidentiality rules in peer review, are designed to protect intellectual property interests while encouraging collaboration (Poortmans, 2013). Ethical norms in research also help to build public support for research as people are more likely to fund research project if they can trust the quality and integrity of research (Resnik, 2011). Finally, many of the norms of research promote a variety of other important moral and social values, such as social responsibility, human rights, compliance with the law, and health and safety. This also protect the rights and welfare of participants and minimise the risk of physical and mental discomfort and harm from research procedures (Canterbury Christ Church University, 2006). Ethical lapses in research can significantly harm human subjects especially if the researcher fails to abide by the regulations and guidelines relating to radiation or biological safety (Resnik, 2011). Informed consent is the process by which the patient voluntarily confirms her willingness to participate in this research, after being informed of all the aspects of the research that are relevant to her decision-making (National Healthcare Group, 2013). The informed consent is documented by means of written signatures, date informed consent form and the language used during the explanation to the patient by the oncologist. In the consent, there should be 3 signatures: the patientÃ¢â¬â¢s, the doctorÃ¢â¬â¢s and the witnessÃ¢â¬â¢ signature. For patients who cannot read and speak English, a qualified translator will be around during the signing of the consent. 3.4 Research design and instrumentation This research is a mixture of qualitative and quantitative research methods (see Appendix Q). Quantitative research corresponds to a deductive scientific method of research which uses data in the form of numbers and statistics to test hypotheses, using a large and randomly selected sample that is a representative of the population (Pearce, et al. 2013; Johnson Christensen 2010). This is in contrast to the qualitative approach which corresponds to an inductive method of research which uses words, pictures or objects to examine a phenomenon, requiring only a small and non-randomly selected sample (Pearce, et al. 2013; Johnson Christensen 2010). Patients will be scanned using Toshiba Aquilion Large Bore CT-simulator (Toshiba, 2014). The treatment plans will be generated using Varian Medical EclipseÃ¢â ¢ Treatment Planning System and patients will be treated with DIBH technique using RPM from Varian Trilogy linear accelerator (Varian Medical System, 1999-2014). 3.5 Data collection procedures The same radiation oncologist will perform all the delineation of the clinical target volume, the heart and LADCA for consistency purposes (see Appendix R). The delineation will be done according to radiation therapy oncology group (RTOG) breast contouring recommendations (Goksel, et al., 2013). PatientÃ¢â¬â¢s CT images at breath hold will be used to plan for DIBH technique while the one at free breathing will be planned for photon electron match technique. The treatments will be planned such that the clinical target volumeÃ¢â¬â¢s coverage of the dose distribution is kept between 90% and 110% of the prescribed dose. For each plan, heart and LADCA volumes were calculated in cm3. Dose volumes to the heart and LADCA will be normalized by dividing with the total organ volume. Heart and LADCA volumes receiving 5Gy to 50Gy (V5-V50) will be generated for comparison of treatment techniques. Dose distributions can be presented as DVHs and representing the statistical dose distribution in a volume of interest. These statistical data will be recorded and presented in tables. Patient education is a very important component in DIBH technique using RPM to reduce anxiety and increase their confidence about receiving radiation therapy (Halkett Kristjanson, 2007). Patient education tools can be in many forms such as video or pamphlet (Halkett Kristjanson, 2007). For this research, a pamphlet have been created to educate patients on DIBH technique using RPM (see Appendix S). A qualitative research method such as face-to-face interview is chosen to assess patientÃ¢â¬â¢s comfort and understanding at the middle of the treatment and on the last day of treatment as this only require the patients to speak the same language in which the questions are asked, and to have basic verbal and listening skills (Bowling, 2009). The primary objective of this standardised and open-ended interview (Valenzuela Shrivastava, n.d.) is to determine the degree of understanding as well as patientÃ¢â¬â¢s comfort. The questions (see Appendix T) will be asked by the oncologist durin g the middle of the treatment and on the last day of treatment. The advantages of face-to-face interviews are that reading and writing skills are not required, interviewers are able to probe fully for responses and clarify any ambiguities, they can ask more complicated and detailed questions, and patients are able to clarify if they do not understand the questions (Bowling, 2009). This would be a better technique than self-administered questionnaires because pre-coded response choices may not be sufficiently comprehensive and patients may be Ã¢â¬ËforcedÃ¢â¬â¢ to choose inappropriate pre-coded answers that might not fully represent their views (Bowling, 2009). This causes the data to be bias as the patientÃ¢â¬â¢s replies are influenced by the design of the pre-coded response choices. Self-administered questionnaires also assumed that the questions are worded in a way that is understood by the patients (Bowling, 2009). Patients may misinterpret the questions and reply based on their own interpretation and questionnaires may be a problem for p atients who are unable to read or write (Bowling, 2009). Most importantly, one-to-one interviews with standardised questions appeared to have the highest reliability (University of Leicester, n.d.). The radiation therapistÃ¢â¬â¢s workload will be measured in terms of training hours, and the comparison of treatment duration and manpower required for gated DIBH using RPM and photon electron match technique (see Appendix U) will be recorded and presented in charts. 3.6 Data analysis Paired samples t-test will be used to determine whether there is a significant difference between the average dose to the heart and LADCA values made under photon electron match plan and gated DIBH using RPM plan (Norman Streiner, 2008). This is used because the data are measured at the scale level and the data are related (Hawkins, 2009). The amount of radiation received by the heart can be recorded by comparing the DVHs of the photon electron match with gated DIBH using RPM. The statistical figures can be analysed using Statistical Package for Social Sciences (SPSS) (Yavas, et al., 2012). Paired samples t-test will be used to determine whether there is a significant difference between the average dose to the heart and LADCA values made under photon electron match plan and gated DIBH using RPM plan (Easton McColl, 2014). A p-value of PatientÃ¢â¬â¢s understanding and comfort The questions (see Appendix T) from the standardised and open-ended interview were developed by a team of 2 radiation oncologists, a nurse and 2 radiation therapists. The areas of discussion were based on the groupÃ¢â¬â¢s clinical experience with left-sided breast cancer patients and their extensive knowledge on DIBH using RPM. The interview aims to determine the patientÃ¢â¬â¢s level of comfort and understanding of the gated DIBH using RPM. The design of the questionnaire will determine the reliability and validity of the opened-ended interview to measure patientÃ¢â¬â¢s level of comfort and understanding. Reliability is defined as the extent to which questionnaire will produce the same results on repeated trials (Miller, n.d.), and is measured by its equivalence and stability. Equivalence reliability assesses the consistency of the judgement of the patientÃ¢â¬â¢s answer by the interview (Miller, n.d.). It is improved by pre-empting a range of responses that might be given by the patients and give a pre-determined rating to each response so that the interviewers will have the same level of Ã¢â¬ËjudgementÃ¢â¬â¢ (Miller, n.d.). For example, _____________- Stability reliability is correlated to the repeatability of the patientÃ¢â¬â¢s response under the same conditions after a period of time (Miller, n.d.). For this interview, the patients will be interviewed twice, once during mid-treatment and the other on the last day of their treatment. Their responses from both sessions will be compared to determine if there are any deviance. This assumes that the characteristics that is measured doesnÃ¢â¬â¢t change with time, and that the time period is long enough that the memories from the 1st interview will not influence the responses of the 2nd interview (Miller, n.d.). The validity of the interview is the extent to which the interview questions measures what it purport to measure, and it generally takes the form of content validity (Miller, n.d.). Content validity is the degree to which the questions fully assess or measure the intention of the interview (Miller, n.d.). This was determined by letting the team review the individual questions for readability, clarity and comprehensiveness and come to some level of agreement as to which items should be included in the final interview questions. The interview questions (see Appendix T) were reviewed and accepted by the team prior to the conduct of the interview. The treatment duration will be recorded as seen in Appendix U and a paired samples t-test similar to appendix V will be used to determine whether there is a significant difference, where the null hypothesis (H0) is there is no difference between the treatment time with photon electron match technique and DIBH using RPM technique. The radiation therapist workload will be analysed based on the minimum number of manpower required for gated DIBH using RPM as compared to photon electron match technique and in terms of training hours. This will be discussed among the radiation therapists and presented in charts. 3.7 Limitation This research can only sample from a small size due to constraint of resources where there is only 1 treatment unit that has the RPM equipment required for DIBH technique. The expected sample size calculated is only an estimate as the treatment difference and standard deviation are never known in advance (Norman Streiner, 2008). As such, the actual sample size may be slightly smaller than 68. 3.8 Expected Results The results from this research are expected to show optimal radiation exposure volumes and doses for the heart and LADCA when treated with gated DIBH using RPM compared to photon electron match technique at free breathing. These results are expected to be compatible with findings from previous studies (Pedersen, et al., 2004; Korreman, et al., 2005; Shim, et al., 2012; Mast, et al., 2013). As such, showing that patients with left sided breast cancer will benefit from gated DIBH using RPM. Treatment time duration for gated DIBH using RPM is expected to have a significant difference and be faster than photon electron match technique. As gated DIBH using RPM is new to the radiation therapists, the workload is expected to be heavier in the beginning. 3.9 Budget There will be no additional cost for this research as the RPM equipment is already available together with the linear accelerator from Varian (Varian Medical System, 1999-2014). There will be no cost for training on the usage for RPM by Varian as it was included in the package when the linear accelerators were bought in 2013. Patients recruited for this research will be charged the same cost as photon electron match treatment technique. 3.10 Expected Timeline This research aims to commence from January 2015 till December 2015. The work plan for both the principal investigator and research assistants can be seen in Appendix W. Chapter IV: Conclusion This research aims to review gated DIBH using RPM as a treatment technique for left-sided breast cancer patients as compared to photon electron match in terms of the radiation dose received by the heart and LADCA. Paired t-test is chosen to measure the significant difference between the dose received by the heart in photon electron match technique and DIBH using RPM technique. Based on literatures that were review, the results are expected to be in favour of gated DIBH using RPM. Interviews will be conducted to assess patientÃ¢â¬â¢s comfort and understanding about gated DIBH using RPM. And data collection will be done gauge the workload of the radiation therapist. The results from interview and data collection will allow us to gauge further if it is really practical to implement gated DIBH using RPM in our department. If the results are clinically significant and positive, gated DIBH using RPM will be implemented into our department. 4.1 Recommendation For future recommendation to try contrast-enhanced CT scan in left-sided breast patients so that the LADCA can be seen clearly in the scan and able to be delineated by the doctor effectively (Yu, et al., 2013). This is to increase the accuracy of the delineation of LADCA as well as the accurate amount of radiation dose received by it. After this research, another study can be done in the future on the reproducibility of patientÃ¢â¬â¢s breath holding level for every fraction using a cine acquisition mode (CAM) of a linear accelerator during treatment (Goksel, et al., 2013).
Monday, August 19, 2019
In Ã¢â¬Å"Distant View of a MinaretÃ¢â¬ by Alifa Rifaat, a lonely wife describes life with her husband as Ã¢â¬Å"a world from which she had been excludedÃ¢â¬ (Rifaat, 1996, p. 256). While a woman paints a picture of a seemingly mundane afternoon, a minaret viewed in the distance provides the reader with vivid symbols of the underlying resignation of expectation and desire she once had for her marriage and her husband. The very first paragraph of the story describes the wife looking at her husband through Ã¢â¬Å"half-closed eyesÃ¢â¬ and being only Ã¢â¬Å"half-aware of the movements of his bodyÃ¢â¬ (Rifaat, 1996, p. 256). While it seems as if the wife is simply depicting waking up from sleep and noticing her husband, immediately upon reading the second paragraph the reader is made aware that the husband and wife are actually having sex. The immediate impression that the reader gets is that this woman is not only not having her needs met and has obviously resigned herself to this type of encounter with her husband by the offhand way she talks about noticing a spiderÃ¢â¬â¢s web on the ceiling. The bleak tone of this story takes a particularly sad and disturbing tinge when the wife illustrates a scene from early on in her marriage where she tries to get her husband to satisfy her desire and provide her with mutual satisfaction, only to have him rebuke and reprimand her. In fact, the husband responds in such a particularly brusque and hysterical manner that the reader can see how traumatized the wife would have been at ...
Sunday, August 18, 2019
A Comparison Between the Sunnis and Shiites Have you ever wondered about other religions that are out there and why they are out there? I have and that is why I chose to write my paper on the Sunnis and Shiites. Read on to learn more about a brief history and then I will break each of them into separate religions. In books written on Islam the word "hadith" usually refers to the sayings or "traditions" which have been given from the Prophet. Muslims hold these to be the most important source of Islamic teachings after the QurÃ¢â¬â¢an. A lot of books have been written in English about what the hadith means in Islam and a number of important translations have been made. Almost all the studies have been limited to the point of view of Sunni Islam and based on Sunni sources and collections. Practically no one has ever paid any attention to the different nature of the hadith literature in Shiism and the different sources from which the hadiths are recieved. The main difference to be made between Shiite and Sunni hadiths is that in Shiism the traditions are not limited to those of the Prophet, but include those of the Imams as well. I will explain more of the distinctions later on. The difference between the two religions is still hard to distinguish even with easy to understand books like the Encyclopedia of World Faiths. There, the author of the article is aware that there is some difference between Shiism and Sunnism on the question of which hadiths are included, but he thinks that it lies in the fact that the Shiite collections accept "only traditions traced through 'Ali's family." But this is incorrect, since a lot of traditions are also gotten through other sources. What the author fails to mention is that the hadith literature as understood by Shiites is not limited to the sayings of the Prophet, but includes those of the Imams as well. The most famous and reliable collections of Shiite hadiths are four books. These books relate to the Six Correct Collections in Sunni Islam. These are al-Kafi fi 'ilm al-din (The Sufficient in the Knowledge of Religion) by Thiqat al-Islam Muhammad ibn Ya'qub al-Kulayni (d. 329/940), Man la yahduruhu al-faqih (For him not in the Presence of Jurisprudent) of Shaykh al-Saduq Muhammad ibn Babuyah al-Qummi (d. 381/991), Tahdhib al-ahkam (Rectification of the Statutes) by Shaykh al-Ta'ifah Muhammad al-Tusi (d. 460/ 1068) a... ...egarding the holding of spiritual and political authority remained strong even after the end of the Caliphate itself in the 13th century. The SunnitesÃ¢â¬â¢ strongest belief has an emphasis on the views and customs of the majority of the community, as distinguished from the views of other groups. The Sunnites compromised by allowing the other groups to bring their beliefs and customs that had nothing to do with the QurÃ¢â¬â¢an. The Sunnites recognize the six "authentic" books of the Hadith, which contain the spoken tradition attributed to Muhammad. In the 20th century the Sunnites constituted the majority of Muslims in all nations except Iran, Iraq, and perhaps Yemen. They numbered about 900 million in the late 20th century and made up nine-tenths of all the followers of Islam. In conclusion I would like to comment on a couple of things. First of all the Shiism makes up 10 percent and Sunnism makes up the other 90 percent of the Muslim religion. Second of all the Shiites and Sunnis both are closely related, but have many differences. The two religions are both very complicated and difficult to understand. I hope after reading this paper you have learned a little more about both.
Lab Report 1Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Principles of Biology 1(BIOL 100) Fall 2001Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Gerard ChretienÃ Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã Living cells perform a multitude of chemical reactions very rapidly because of the participation of enzymes. Enzymes are biological catalysts, compounds that speed up a chemical reaction without being used up or altered in the reaction. The material with which the catalysts reacts, called the substrate, is modified during the reaction to form a new product. But because the enzyme itself emerges from the reaction unchanged and ready to bind with another substrate molecule, a small amount of enzyme can alter a relatively enormous amount of substrate. This report will illustrate the enzymatic action of the enzyme catecholase, which is common in plants. To study this particular enzyme in a laboratory, the natural substrate catechol is oxidized by the removal of two hydrogen atoms. The substrates of the enzyme are catechol and oxygen. These substates react with one another within the active site of the enzyme. The products formed by this reaction are benzoquinone has a brown color, you can see that the reaction has taken place. This is called the fruit browning reaction. Benzoquinone inhibits the growth of microorganisms and prevents damaged fruit from rotting. In undamaged cells catecholase is stored in vesicles and does not interact with catechol.Ã Ã Ã Ã Ã In the presence of the enzyme catecholase:Ã Ã Ã Ã Ã Catechol+1/2O2 benzoquinone+H2O The structure of the enzyme is mainly dependent on the active site and variable groups. Extreme temperatures or extreme pHs can alter the structure of an enzyme. Enzymes function to lower the activation energy to break the bonds. They achieve this by putting stress and pressure on the bonds or creating a microenvironment for the substrate. A change in the temperature or a fluctuation in pH can alter... ... questions and test answers. The method has five stages: 1. Making observation. 2. Asking questions. 3. Forming hypotheses, or tentative answers to the questions. 4. Making predictions based on the hypotheses. 5. Testing the predictions by making additional observations or conducting experiments. The information gained may support or yield opposite results based on predictions being tested. My independent variable would be time and the dependent one would be the enzyme pectinase. I believe the key feature of my experimentation is the control of most factors so that the influence of a single factor can be seen clearly. The setting would take place within a laboratory, equipped with various components such as tubes, microscope and other related equipment. I would try to investigate the physical properties of pectin such as molecular weight, molecular conformation and aggregation of pectin molecules in the solution. In regards to the pulpiness of the applesauce, I would use the pectin as a emulsifier and stabilizer. This procedure would reduce the pulp of the applesauce considerably without making the solution too watery. Ã Ã Ã Ã Ã Ã Ã Ã Ã Ã
Saturday, August 17, 2019
Breast malignant neoplastic disease is a disease in which the tissues of the chest signifier malignant malignant neoplastic disease cells. Normally the tubing which carry the milk to the mammilla ( canals ) and secretory organ ( lobules ) . It is common in both work forces and adult females ; male chest malignant neoplastic disease is rare although, it is considered a heterogenous disease differing by single, age group, and even the sorts of cells within the tumor themselves.Types of Breast Cancers:Ductal Carcinoma: it is the non-invasive chest malignant neoplastic disease, which starts in the cell line of the chest Ã¢â¬Ës canals, beneath the mammilla and areola. The canals supply milk to the mammilla. Between 85 % and 90 % of all chest malignant neoplastic diseases are ductal. Lobular Carcinoma: it begins in the lobes, or secretory organs which produce milk in the chest. These are located inside the chest, under the canals. About 8 % of chest malignant neoplastic diseases are lobular Inflammatory Breast Cancer: It is the least common, rapid signifier of chest malignant neoplastic disease, which can be progress about 1 % to 3 % to name. This chest will appears conceited and inflamed it causes by redness by taking the signifier of sheets or nests. It can get down in the soft tissues of the chest under the tegument, or it can look in the tegument Paget Ã¢â¬Ës disease of the nipple/areola: this malignant neoplastic disease appears as skin roseola on the mammilla or unsmooth tegument. It can be resembles as itchy. The marks of rubing and may be under the surface of the tegument. This will bespeak a little Ductal carcinoma in suit ( DCIS )Phases of Breast Cancer:Phase 0: is sometimes used to depict unnatural cells that are non invasive malignant neoplastic disease. For illustration, Stage 0 is used for Ductal carcinoma in situ ( DCIS ) . DCIS is diagnosed when unnatural cells are in the liner of a chest canal, but the unnatural cells have non invaded nearby breast tissue or spread outside the canal. Although many physicians do n't see DCIS to be malignant neoplastic disease, DCIS sometimes becomes invasive chest malignant neoplastic disease if non treated. Phase I: is an early phase of invasive chest malignant neoplastic disease. Cancer cells have invaded chest tissue beyond where the malignant neoplastic disease started, but the cells have non spread beyond the chest. The tumour is no more than 2 centimeters ( three-fourthss of an inch ) across. Phase Two: is one of the followers: The tumour is no more than 2 centimeters across. The malignant neoplastic disease has spread to the lymph nodes under the arm. The tumour is between 2 and 5 centimeters The malignant neoplastic disease has non spread to the lymph nodes under the arm. The tumour is larger than 5 centimeters.The malignant neoplastic disease has non spread to the lymph nodes under the arm. Phase Three: is locally advanced malignant neoplastic disease. It is divided into Phase III A: Breast Cancer-the tumour is larger than two centimeters but smaller than five centimeters ( about one to two inches ) and has spread to up to nine subsidiary underhand lymph nodes. Phase III B: Breast Cancer- the malignant neoplastic disease has spread to tissues near the chest including the tegument, chest wall, ribs, musculuss, or lymph nodes in the chest wall or above the clavicle. Phase Four: is distant metastatic malignant neoplastic disease. The malignant neoplastic disease has spread to other parts of the organic structure, such as the castanetss or liver.Incidence:How common is breast malignant neoplastic disease:As per the study in 2007, 45,700 adult females were victim of the chest malignant neoplastic disease. While in the same twelvemonth the work forces count goes to 277 were diagnosed. Incidence rate of chest malignant neoplastic disease in females around by 50 % over the last 20 five. Out of 10 eight of adult females 50 old ages of age were enduring from chest malignant neoplastic disease. Breast malignant neoplastic disease rates have increased up to 5 % in last 10 old ages. National Health Service ( NHS ) testing programmes were conducted in that more than 16,000 instances found in UK in 2007/2008. Among that NHS testing programme claim to salvage 1,000 lives each twelvemonth. Throughout the universe around 1.38 million adult females were diagnosed with the chest malignant neoplastic disease. Incidence rate of chest malignant neoplastic disease were extremely considerable in western in Europe, as per low rates considerable in Africa and Asia Europeans brotherhood shows breast malignant neoplastic disease were diagnosed around 332,000 in the twelvemonth of 2008. 12,000 adult females and 70 work forces were died from chest malignant neoplastic disease in 2008 in the UK. More than half of 70 old ages of age are died from chest malignant neoplastic disease. Worldwide 458,000 adult females are died from chest malignant neoplastic disease in 2008. It is the 2nd most common cause of decease of adult females after lung malignant neoplastic disease. In Europe brotherhood around 89,000 died from chest malignant neoplastic disease in 2008.Signs and Symptoms:Early chest malignant neoplastic disease normally does n't do symptoms but as the tumor grows, it can alter how the chest looks or feels. The common alterations include: Ã¢â¬ ¢ A ball or thickener in or near the chest or in the underhand country Ã¢â¬ ¢ A alteration in the size or form of the chest Ã¢â¬ ¢ Dimpling or rumpling in the tegument of the chest Ã¢â¬ ¢ A mammilla turned inward into the chest Ã¢â¬ ¢ Discharge ( fluid ) from the mammilla, particularly if it Ã¢â¬Ës bloody Most symptoms of chest upset do non turn out to stand for implicit in chest malignant neoplastic disease. Benign chest diseases such as mastitis and fibro adenoma of the chest are more common causes of chest upset symptoms. The visual aspect of a new symptom should be taken earnestly by both patients and their physicians, because of the possibility of an implicit in chest malignant neoplastic disease at about any age.Hazard Factors:Many of the most of import hazard factors for chest malignant neoplastic disease are beyond your control, such as age, household history, and medical history. However, there are some hazard factors you can command, such as weight, physical activity, and intoxicant ingestion. Age: The opportunity of acquiring chest malignant neoplastic disease increases as you get older. Most adult females are 60+ old ages old when they are diagnosed. Personal wellness history: Having chest malignant neoplastic disease in one chest increases your hazard of acquiring malignant neoplastic disease in your other chest. Besides, holding certain types of unnatural chest cells ( untypical hyperplasia, lobular carcinoma in situ [ LCIS ] , or Ductal carcinoma in situ [ DCIS ] ) increases the hazard of invasive chest malignant neoplastic disease. These conditions are found with a chest biopsy. Family wellness history: Your hazard of chest malignant neoplastic disease is higher if your female parent, male parent, sister, or girl had breast malignant neoplastic disease. The hazard is even higher if your household member had breast malignant neoplastic disease before age 50. Having other relations ( in either your female parent Ã¢â¬Ës or male parent Ã¢â¬Ës household ) with chest malignant neoplastic disease or ovarian malignant neoplastic disease may besides increase your hazard.Hazard factors you can command:Weight: Being overweight is associated with increased hazard of chest malignant neoplastic disease, particularly for adult females after climacteric. Fat tissue is the organic structure Ã¢â¬Ës chief beginning of estrogens after climacteric, when the ovaries stop bring forthing the endocrine. Having more fat tissue means holding higher estrogens degrees, which can increase chest malignant neoplastic disease hazard. Exercise: Evidence is turning that exercising can cut down chest malignant neoplastic disease hazard. The American Cancer Society recommends prosecuting in 45-60 proceedingss of physical exercising 5 or more yearss a hebdomad. Alcohol ingestion: Surveies have shown that chest malignant neoplastic disease hazard additions with the sum of intoxicant a adult female drinks. Alcohol can restrict your liver Ã¢â¬Ës ability to command blood degrees of the endocrine estrogens, which in bend can increase hazard. Smoke: Smoke is associated with a little addition in chest malignant neoplastic disease hazard.Treatment:Womans enduring with chest malignant neoplastic disease have many types of intervention options. The intervention options are best for one adult female may non be best for another. The intervention options are: Surgery Radiation therapy Hormone therapy Chemotherapy Targeted therapy Among this Surgery and radiation therapy are types of local therapy. They remove or destroy malignant neoplastic disease in the chest. Hormone therapy, chemotherapy, and targeted therapy are types of systemic therapy. The drug enters in to bloodstream and destruct or controls malignant neoplastic disease throughout the organic structure. The intervention that Ã¢â¬Ës right for you depends chiefly on the phase of the malignant neoplastic disease, the consequences of the endocrine receptor trials, the consequence of the HER2/neu trial, and your general wellness.SurgeryPresents Surgery is the most common intervention for chest malignant neoplastic disease. It consist of 2 types Breast-sparing surgery: This type of surgery is to take the malignant neoplastic disease but non the chest. It besides called breast-conserving surgery. It can be a lumpectomy or a segmental mastectomy. Sometimes an excisional biopsy is the lone surgery a adult female needs because the sawbones removed the whole ball. Mastectomy: This type of surgery is to take the full chest ( or ) as much of the chest tissue as possible. In some instances, a skin-sparing mastectomy may be an option. Approach the sawbones removes every bit small tegument as possible. The sawbones normally removes one or more lymph nodes from under the arm to look into for malignant neoplastic disease cells. If malignant neoplastic disease cells are found in the lymph nodes, other malignant neoplastic disease interventions will be needed. ( For more about information about lymph node biopsy, you may take to hold breast Reconstruction. This is fictile surgery to reconstruct the form of the chest. It may be done at the same clip as the malignant neoplastic disease surgery or subsequently. In breast-sparing surgery, the sawbones removes the malignant neoplastic disease in the chest and some normal tissue around it.Radiation TherapyIt besides called as radiation therapy it can be used to kill high-energy beams of malignant neoplastic disease cells. It affects cells merely in the portion of the organic structure that is treated. These are 2 types External radiation therapy: in this therapy radiation comes from a big machine outside the organic structure. A intervention is normally 5 yearss a hebdomad for 4 to 6 hebdomads. External radiation is the most common type used for chest malignant neoplastic disease. Internal radiation therapy: ( implant radiation therapy or brachytherapy ) . The physician places one or more thin tubings inside the chest through a bantam scratch. A radioactive substance is loaded into the tubing. The intervention session may last for a few proceedingss, and the substance is removed. When it Ã¢â¬Ës removed, no radiation remains in your organic structure. Side effects chiefly depend on the dosage and type of radiation. It Ã¢â¬Ës common for the tegument in the treated country to go ruddy, dry, stamp, and itchy. Your chest may experience heavy and tight. Internal radiation therapy may do your chest expression red or bruised Hormone Therapy: It may besides name anti-hormone intervention. If laboratory trials show that the tumour in your chest has hormone receptors, so hormone therapy may be an option. Hormone therapy supports malignant neoplastic disease cells from acquiring or utilizing the natural endocrines ( estrogen and Lipo-Lutin ) they need to turn. Chemotherapy: In Chemotherapy we have to utilizations drugs to kill malignant neoplastic disease cells. The drugs that are treated in chest malignant neoplastic disease are normally given through a vena ( endovenous ) . The side effects depend chiefly on which drugs are given and how much. Chemotherapy kills aggressive malignant neoplastic disease cells, but the drugs can besides harm normal cells that divide quickly. They are blood cells, cell in hair roots, cells in the digestive path. Targeted Therapy: In Some adult females with breast malignant neoplastic disease may have drugs called targeted therapy. These drugs can barricade the growing of chest malignant neoplastic disease cells. For illustration, targeted therapy may barricade the action of an unnatural protein which stimulates the growing of chest malignant neoplastic disease cells. Class Action ExamplesSERMs ( selective estrogen-receptor modulators )Bind to estrogen receptors in chest malignant neoplastic disease cells, hungering malignant neoplastic disease cells Estrogen antagonist Evista ( raloxifene ) Fareston ( toremifene )Aromatase inhibitorsIt stops the production of estrogen in adrenal secretory organ Armasin ( exemestane ) Femera ( cletrozole ) Arimidex ( ahastrozole )Biologic response qualifierIt binds the protein on chest malignant neoplastic disease cells and prevents their growing Herceptin ( megestrol ) Other hormonal therapies Breast malignant neoplastic disease dependant on estrogen for endurance treated on other hormonal therapy zoladex ( goserelin ethanoate ) Faslodex ( fulvestrant )
Friday, August 16, 2019
The definition of professional development varies in school districts and educators agree that the term is ever changing and involves the use of technology. Some educators have said that the term has an operational definition. In the article, key design factors in durable instructional technology professional development, author John Wells offers the following definition for educators within the context of the technological age:Professional developmentÃ¢â¬ ¦goes beyond the term training with its implications of learning skills, and encompasses a definition that includes formal and informal means of helping teachers not only learn new skills, but also develop new insights into pedagogy and their own practices, and explore new or advanced understandings of content and resources. [This] definition of professional development includes support for teachers as they encounter the challenges that come with putting into practice their evolving understanding about the use of technology to sup port inquiry-based learning (p.2). Professional development may encompass various characteristics such as goals and outcomes aligned to the districts, relevant topics in trainings, opportunities for staff collaboration, development maintained by an on-site coordinator, high quality and professional training and evaluations to determine effectiveness of program. James Polk, author of traits of effective teachers, states, Ã¢â¬Å"the need for a strong professional development program is well established in researchÃ¢â¬ (p.2). Mr. Polk (2006) cites a recent study of factors contributing to three aspects of the teaching process that, Ã¢â¬Å"teachers ranked professional development in the top third of importance on each aspectÃ¢â¬ (p. 2). In analyzing the professional development plan of my school district, Richland County School District One, I noticed several issues that were identified by Mr. Polk. Mr. Polk outlined several problems associated with the traditional in-service programs that are deemed ineffective. Mr. Polk (2006) states that:assumptions, such as periodic in-service being sufficient to develop new teaching methods and improve practice, teachers being able to learn by listening to a speaker, and professional development being a luxuryÃ rather than an integral part of district improvement, are all negating factors in the implementation of patronization of training programs (p. 2). Mr. Polk further identifies research-based, more effective assumptions such as professional development should be perpetual, and school change involves external and internal organizations and personal development. In professional development programs, the instructions to teacher should be demonstrated or modeled, practiced with feedback and professional development should be integrated into the daily life of teachers. Mr. Polk (2006) states that Ã¢â¬Å"if professional growth rests solely on bimonthly, two-hour in-service sessions after the students are dismissed early, then any training received will unlikely be reflected in student masteryÃ¢â¬ (p.2). Richland County School District OneÃ¢â¬â¢s (RSDI) professional development program has several components such as the Plan Do Check Act (PDCA), Avatar, and classroom walkthrough. According to the Richland County School District OneÃ¢â¬â¢s website, Plan Do Check Act is used in Ã¢â¬Å"designing curriculum and delivering classroom instruction, in providing student support services, staff goal setting and evaluation, developing any new program, product or process design, planning strategically and starting a new improvement project or implementing any changeÃ¢â¬ . The Plan component is identifying the learning problem and gathering the needed data. The Do component is analyzing the causes and implementing the plan on a trial of pilot basis. The Check component of PDCA is gathering the data results of the solution and analyzing the data. The Act component is implementing the instruction for all students and modifying the improvement plan. Avatar is the districtÃ¢â¬â¢s professional development management system that allows for teaches to sign up for trainings offered by the district. All the trainings are offered after school or in the summer; this contradicts the recommendation offered by Mr. Polk that professional development should be integrated into the daily life of the teacher during the school day. The classroom walkthrough team is a district employee, the principal, assistant principal, and the professional development on-site coordinator. The team conducts the classroom walkthrough by observing the instructional strategies of a teacher for a total of five to ten minutes. The teacher is not offered prior information or feedback on the classroom walkthrough to correct or enhance his instructional strategies. The Richland County School District One website offers the levels of engagement of the students who the team should identify during the walkthrough. The levels; Authentic Engagement, Ritual Engagement, Passive Compliance, Retreatism, and Rebellion and their definitions are cited on the web page but teachers would not know their level due to lack of communication from the classroom walkthrough team. The problem of the poor quality of professional development was identified in the South Carolina schools that I have researched. For example, in Richland County School District Two, the districtÃ¢â¬â¢s professional development program mirrors Richland County School District OneÃ¢â¬â¢s program by only focusing on providing monthly in-service trainings on half-days for students or summer in-service activities. Both districts also provide the occasional monthly state or national conference in the teacherÃ¢â¬â¢s subject area and online training, i.e. Educational Television. Richland County School District Two differs by offering their Richland School District TwoÃ¢â¬â¢s Technology Education Collaboration Mentors Program. The program is for school-selected representatives from every school in the district. The program focuses on helping fellow staff members develop personal technology skills and integrate technology into their classroom. Besides this program, I was unable to find any difference from the two districts and the professional development training. Richland County School District One and District Two professional development programs consist of low quality training once a month, irrelevant topics, lack of feedback from teachers and administrators, and concepts but lack of implementation. The districtsÃ¢â¬â¢ programs lack the scope, high quality, accessibility (besides the Avatar system in RSDI), relevancy, and feedback from students. The majority of the districtÃ¢â¬â¢s professional development program is the poor quality program described by Mr. Polk; two-hourÃ in-service sessions after the students are dismissed early from school. Reference Polk, J. (2006). Traits of effective teachers. Arts Education Policy Review, 107, p. 23-30. Wells, J. (2007). Key design factors in durable instructional technology professional development. Journal of Technology and Teacher Education, 15, p. 101-123. www.richlandone.org/ipda/Training_Tools/pdca.htm and www.richland2.org
Thursday, August 15, 2019
In most cases, the legality of adoption is based very strongly upon the principle of consent. Consent refers to the agreement by the childÃ¢â¬â¢s parents or the childÃ¢â¬â¢s guardian (the person or the agency under whose custody the child is) to accede the child for adoption and to expel the rights and duties with regard to the child. The process of consenting requires that the birth parents of the child notify a judge or court officials in writing.Alternatively, a part from the biological parents, other people issuing their consent can be the agency in charge of the child, the guardians, the court of law, or a close relative or the next friend who has already attained the legal age. In some states such as the Virgin Islands and the District of Columbia for instance, the child should issue consent when or when above 14. Sometimes this may be abnegated if the child is mentally ill. The execution of the consent normally takes 13 days while cases with the fastest ratification speed may take 12-24 hours.Heretofore, the next stage may differ since rules are state-specific. In most states, the written consent is notarized to the concerned public, while in other states; the consenting parents are taken for counseling as touching the matter. A provision for the revocation of the consent is normally very limited but in most cases, the adoption process is irrevocable. States in which there are absolutely no provision for the revocation include; Mississippi, Samoa and the Nebraska.The limited provision come in when the parents or guardians were defrauded, coerced or were under duress when issuing their consent. Some states also issue a time frame within which any case of disgruntlement can be aired by the parents. Conversely if the application to revoke the consent has been found to be in the interest of the child or if both the biological parents and the adoptive parents have reached this consensus, it will be the duty of the court of law to consider the petition.The 14th amendment of the American constitution, a post civil war judicial reconstruction, was originally intended to bolster the 13th amendment which in turn had brought slavery to a grinding halt. This amendment was to promote the rights of the former slaves. When it was proposed in the June 13, 1866, it spelt out equal protection of all by the law, birthing the Ã¢â¬Å"Separate but equalÃ¢â¬ doctrine. This amendment placed all persons on the same pedestal since all became under one law. It is upon this concept of equality that the marginalized groups began to come out for equal recognition.Privacy rights such as abortion, homosexuality became subject to debates. Currently perhaps the most heated form of debate is the one touching on the prospects of gay adoption (Ricketts, 1991). The laws for the best interest of the child assume that for any normal child to develop well, this should happen under the jurisdiction of the two parents. It is on this backdrop that in the best interest of the child, the law has come up with regulations which are geared towards the childÃ¢â¬â¢s protection for instance, in case of a divorce.By default, the law stipulates that upon divorce, both parents should have equal access and responsibility to and over the child. This can only be negated upon a parent being found to be harmful to the child. As far as the issue of the best interest of the child in relation to gay parenting is concerned, the law is not yet unified and therefore varies from one state to another. For instance gay parenting is prohibited in Florida but reconstructions are underway to recognize it in Alabama, Georgia, Ohio and Tennessee.The pro-gay parenting legal practitioners argue that it is better for a child to have a two parent family than a one parent one, and that it will be furthering the interest of the child since a two parent family can easily fend for the childÃ¢â¬â¢s needs than if the child had one or no parent at all. A case these lawyers have bro ught to the fore is the fact that there are presently (Clifford, Hertz, Doskow, Curry 2007)119,000 needy children in the US alone waiting to be adopted. Furthermore, they posit that children have more serious concerns than their parentÃ¢â¬â¢s sexual orientation.Discrimination against children raised by gay parents is not so far fetched compared to the discrimination encountered by gay parents. In America, this is not much of a problem compared to Australia where the parents are discriminated against in areas touching on taxation, social security, and workersÃ¢â¬â¢ compensation. The only case of discrimination against children with gay parents witnessed in Australia is limited to the peer groups and is always manifested in schools and in the neighborhood.This is because the Article 2 of the Convention of the Rights of the Child which was ratified in the 1990 sternly warns against child discrimination of any kind (Ricketts, 1991). Although some maintain that there is no strong bas is for the prohibition of the adoption by gay parenting, yet children rights and welfare agencies cite the child bearing studies on the other hand to maintain that children raised in heterosexual marriages thrive best emotionally, physically and mentally.They maintain that spates of violence are 2-3 times higher in homosexual marriages when compared to the heterosexual ones. In addition to this, they posit that homosexual marriages are always susceptible to dissolution with the normal gay marriage lasting 2-3 years and that homosexual activities are often marked with substance dependence, mental illnesses, suicidal tendencies and a shortened lifespan in comparison to heterosexual marriages.The proponents of same sex marriage and the adoption by the same sex parents have countered that these dysfunctions accrued by this group are as a result of the US socio-economic pressure, to which the opponents of adoption by the gay parents rebutted that the same pressure rests on the normative/ conservative form of marriage without yielding such results (Lerner and Nagai 2001). They further deliberate that children adopted or reared under the same sex marriage are highly vulnerable to sexual confusion, homo sexual behavior and premature sex.Nevertheless, it must be kept in mind that numerous strides have been made to entrench gay adoption and this has also produced gradual acceptance of the practice. A testimony to this is Florida which since 1977 had proscribed gay adoption but as per now efforts are in the offing to abrogate this law due to the push by the American Civil Liberties Union (ACLU) on the Supreme Court. In the same vein, the 1997 ACLU fact sheet, Ã¢â¬Å"the gay parenting statisticsÃ¢â¬ to confirm this discloses that approximately, 6-14 million children are living under gay parenting.This could still be an understatement since most gays and lesbians are always reserved about disclosing the structure of their families due to fear of losing children (Mc Gurry , 2003). These changing prospects can be attributed to the fact that the emphasis on traditional form of marriage is gradually waning, and the subsequent overturning of state laws to assimilate gay marriages is in force. A case in point is when the then president Bill Clinton, signed the Defense On Marriage Act (DOMA), thus giving way to same sex marriage in Hawaii (Rimmerman, Wald, Wilcox, 2000).Gay adoption is also growing because of the fast rate with which gay parenting is spreading. Gay parenting, apart from the normal procedure of adoption occurs when one partner pulls out of a heterosexual marriage while still maintaining the custody of a child and moves into a gay marriage or, through lesbians opting for an artificial insemination upon siring a child enters into an agreement with gay partners for adoption. The co-parent adoption occurs when one gay who has an adopted child with him moves in with a partner who automatically assumes the role of a co- parent.This practice is co mmon in Washington, District of Columbia, Vermont, California, Minnesota, Alaska, and Oregon (Tonnerson, Andenaes and Wintemute, 2001). As touching on the stability of the children, the children grow up healthy and well adjusted compared to those who have one or no parent at all. This scores highly with the concept of the best interest of a child since the childÃ¢â¬â¢s financial and material needs are met. Conversely, the children under gay adoption turn out successfully just as the ones under heterosexual care.The American Psychological Association (AMA), out of its research maintained categorically that there was no evidence that children brought under gay adoption and parenting were susceptible to maladjustment or that they turned out less intelligent or suffered low self esteem; neither was there a connection between homosexuality and pedophilia or direct influence in the childÃ¢â¬â¢s sexual orientation in future. On the contrary, the AMA observed that 90% of child sexual ab uses were carried out by heterosexual men (Baker, 2005).To further dispel the misgivings on gay adoption, both the parents who want to adapt a child undergo a screening procedure which is a meticulous exercise meant to filter out those who have less prospects of making good parents. The fact that many potential gay parents navigate successfully these enchanted waters is a testimony of the type of parents they would make. Bibliography. Baker P. Public Discourses of Gay men. Rutledge: United States, 2005. Clifford D. Hertz F. Doskow E. Curry H. A Legal Guide for Lesbian and Gay Couples. Nolo: United States, 2007. Lerner R. Negai A.No Basis: What studies donÃ¢â¬â¢t tell us about parenting. Marriage Law Projects /Ethics and Public Policy Center: United States, 2001. Mc Garry J. K. Fatherhood for Gay Men: Emotional and Practical Guide to becoming a gay dad. Haworth Press: United States, 2003. Ricketts W. Lesbians and Gay men as foster parents. Wendel/ Ricketts: United States, 1991. Rim merman A. C. Wald D. K. Wilcox C. The Politics of Gay Rights University of Chicago: United States, 2000. Tonnerson M. Andenaes R. Wintemute M. Legal Recognition of Same Sex Partnership: A Study of National and European Law. Hart Publishing