Strategy Assingment Essay Example | Topics and Well Written Essays - 1250 words

Strategy Assingment - Essay Example Also an attempt to identify and understand the generic strategy used by the company has also been discussed. An attempt to help the company improve the strategies has also been laid down and a few tactics that can be used by the company have been discussed. Finally recommendations for the company to assist them scan the food industry in order to keep the strategies live and keep the company blooming have also been included. Kudler Fine Foods has used technology to a great extent and has been able to implement information and technology systems well into their work processes. The company utilizes several technologies like a wide area network (WAN), which allows storing the real time communication and all details of inventory and vendors effectively. This system ensures that the operations of the company run smoothly and in an uninterrupted manner at all times. The stores have also incorporated several other inventory servers like the University of Phoenix and the Information Technology networks. The systems used for the POS systems also allow the company to record the data in a more effective and efficient manner. The impact of the use of technology on the company has been vast and has led the company to a great level of success. As discussed earlier, the company is customer centric and it also concentrates to a great extent on the employees as well. All the information that is gained from the database and all information of the customers, orders, inventory and also the vendors, assist the company to determine the style and strategy that it requires to adopt in a more informed manner (Housel and Nelson 2005). Hence the use of technology allows the company to make more informed and well thought out decisions. The company in the current time uses a very centralized strategy for the day to day processes. The overall working

Marketing communication Plan for Aer Lingus Essay

Marketing communication Plan for Aer Lingus - Essay Example The major focus of the airline is on B2B. In order to collect information, the company should use more social media. Moreover, it has been recommended that the company should focus on B2C as well. The main reason is that the B2B is a small customer size segment as this will increase its revenues (Dialogue marketing, 2014). The brand image of the airline is professional but affordable. People perceive the airline as a low cost airline and customer expectations average quality service from the airline. The company to increase its brand image and to meet up the customers’ expectations, the management should advertise the qualities and services offered at the given price as well as should promote the brand image while advertising to attract more customers. Culture, Values, and Beliefs: The airline is committed to serve at the central and convenient locations, so that there is large number of passengers travelling. The mission of the company is to connect the Ireland with the world and different countries of the world with Ireland through providing quality services at competitive price. The secondary mission of the airline is to enhance the connectivity for the customers. The company is facing issues as the brand of the airline is not renowned and many people are not aware about the brand, thus it is essential the values are communicated clearly and more widely so that it reaches to a larger audience. The brand awareness of the airline is not strong in the United Kingdom. The perception of the airline is low carrier airline, however it is not the best service providers as compared to its competitors. Thus, this low price perception has been blurred as well due to the offerings of Ryanair and other low-cost airways. The company has limited locations to go and has lower customer retention rate particularly when compared with the competitors. In order to attain all these goals, it is essential to design a

Drug â€excipient Interaction of Anti-tubercular Drugs

Drug –excipient Interaction of Anti-tubercular Drugs Drug –excipient interaction of anti-tubercular drugs and its in-silico evaluation Abstract Isoniazid and Pyrazinamide are the first line anti tubercular drugs. Lactose is mainly used as the excipient in solid dosage forms of isoniazid and pyrazinamide. These drugs contains primary and secondary amino functional group which interacts with lactose by maillard reaction and form adduct. The maillard reaction adducts of isoniazid and pyrazinamide with lactose were synthesized at 60oC in alkaline borate buffer pH 9.2 and characterized by UV, FT-IR, DSC, HPLC and MS. Docking study for in-sillico evaluation of isoniazid-lactose adduct and pyrazinamide-lactose adduct was performed to study its effect on pharmacological activity. The present study shows the presence of incompatibility between isoniazid and pyazinamidewith lactose which leads to loss the therapeutic effect of isoniazid and pyrazinamide. Keywords: isoniazid, pyrazinamide, lactose, maillard reaction, excipient, incompatibility, dosage form. Introduction Excipients are traditionally better known as promoters of degradation than as stabilizers of drug substances (Crowley 1999). Physicochemical and physiological process e.g. stability, physiological pH, gastrointestinal transit time, disintegration, dissolution, permeability and bioavailability can be altered by drug excipient interaction (Jackson, Young et al. 2000). The interactions of drug with excipients can leads to changes in the chemical, physical and therapeutic properties can be termed as incompatibilities (Chadha and Bhandari 2014) and it may cause the drug degradation (Narang, Desai et al. 2012) and loss of pharmacological activity (Patil and Patil 2013). Lactose is most widely used as the excipient in the solid dosage forms. Lactose is available in different form and different grade with different physical characteristics. Lactose is very popular excipient because of low cost and inertness but in other hand lactose have interaction drug with amino functional group i.e. lact ose undergoes maillard [Monajjemzadeh, 2009]The maillard reaction is named Louis Maillard who reported over 80 years ago that some amine and reducing sugars interact each other and forms brown pigments. The first product of this reaction is simple glycosamine (Wirth, Baertschi et al. 1998). In this study, we attempted to explore the modes of interaction and energy binding of the different isomers of isoniazid adduct, pyrazinamide adduct and also study the biological activity of isoniazid adduct and pyrazinamide adduct compare with the help of various molecular modelling techniques. In treatment of tuberculosis, isoniazid and pyrazinamide are key components of first line regimen (Hemanth, Sudha et al. 2012). Isoniazid is chemically isonicotohydrazide and pyrazinamide is chemically pyrazine-2-carboxamide. Isoniazid and pyrazinamide is susceptible for hydrolysis and oxidation interact with excipient particularly carbohydrate and reducing sugars to form hydrazones. The hydrazone is mainly form by the interaction of isoniazid with lactose. There are also reported incompatibilities between lactose and other drugs containing primary and secondary amino functional group (Haywood, Mangan et al. 2005). In this study we were investigated the interaction between lactose with isoniazid and pyrazinamide for that different analytical technique were used and also done the in-sillico evaluation of isoniazid and pyrazinamide. Materials and methods Materials Isoniazid and Pyrazinamide was generously supplied as a gift sample by Macleods Pharmaceuticals Ltd., Wapi (Gujarat), India. Lactose monohydrate was purchased from Merck, Merck specialtiesPvt.Ltd. Mumbai, India. All other chemicals were of high-performance liquid chromatography (HPLC) and analytical grade. Methods Analytical methods UV-visible spectrophotometry The Ultraviolet-visible spectra of Isoniazid, Pyrazinamide and the Isoniazid–lactose adduct, Pyrazinamide-lactose adductwere recorded on a double beam UV-visible spectrophotometer (UV-1700; Shimadzu, Japan). An accurately weighed quantity of about 10 mg of isoniazid, 10 mg of pyrazinamide, 11.66 mg isoniazid-lactose adduct (equivalent to 10 mg isoniazid), 13.33 mg of pyrazinamide-lactose adduct (equivalent to 10 mg pyrazinamide) each dissolved separately in 100 ml of distilled water. From this, one ml of solution was diluted to 10.0 mL with of distilled water to obtain concentration of 10 ppm. All solutionswere scanned in UV-Visible range at 420 and 490 nm (Yates, Jones et al. 2003). Fourier-Transform infrared spectroscopy The Fourier-transform infrared spectroscopy (FTIR) spectra of isoniazid, pyrazinamide, lactose, a isoniazid–lactose physical mixture, pyrazinamide-lactose physical mixture and the isoniazid–lactose adduct, pyrazinamide-lactose were recorded. The spectra were obtained using the diffuse reflectance scan method using KBr on an FT-IR spectrophotometer (IR Affinity 1; Shimadzu, Japan). The scanning range was 400–4000 cm-1. Each sample was scanned 45 times consecutively to obtain FT-IR spectrum. HPLC analysis The HPLC (Gradient) system used for analysis consisted of Agilent Technologies 1200 series equipment, a G1315D quaternary pump, a G1315D diode array detector and a rheodyne injector fitted with a 20  µL loop. Data were recorded and evaluated using the EZChrome Elite software package. Samples were analyzed using LunaC18 column (250 Ãâ€" 4.6 mm i.d. Ãâ€" 5  µm) (Phenomenex) as stationary phase. The mobile phase was water: methanol (95:05, v/v), flow rate of 0.8 mL/min with detection at 266 nm for isoniazid and 269 nm for pyrazinamide. Differential scanning calorimetry Thermal analysis of Isoniazid, pyrazinamide, isoniazid–lactose adduct and pyrazinamide-lactose was performed by differential scanning calorimetry (DSC) using a TA 6000 Mettler toledo thermal analyzer. Individual samples as well as the Maillard adduct (about 2 mg) were weighed in the DSC aluminum pan and were scanned in the temperature range of 25–300 °C. A heating rate of 10 °C/min was used. The thermograms were reviewed for evidence of interaction. Mass Spectrometry The Mass spectrometry was performed using 410 Prostar binary LC with 500 MS with Electro spray Positive ionization and Negative Ionization mode and Mass range is 50-2000 amu. The Isoniazid-lactose, Pyrazinamide-lactose adduct solution dissolved in mobile phase to obtain concentration about 100 µg/mL. In the positive ion mode with electrospray ionization technique, the sample was analyzed. Determination of lactose in pharmaceutical tablet dosage forms The presence of lactose in DOTs tablets was initially examined according to Indian Pharmacopoeia 2007 by taking 5ml saturated solution of tablet powder and then add 5ml 1 M NaOH, Heat and cool at room temperature finally add potassium cupri tatatarate the solution becomes red color shows presence of lactose. Preparation of adduct Sample Prepared in alkaline borate buffer Accurately weighed quantity of Isoniazid 300 mg (equivalent to dose of isoniazid) and 50 mg lactose monohydrate dissolve in alkaline borate buffer pH 9.2 by stirring and ultrasound in 100 ml round bottom flask. In similar way 750 mg pyrazinamide (equivalent to dose of pyrazinamide) was dissolve with 250 mg lactose monohydrate in alkaline borate buffer pH 9.2 in 100 ml round bottom flask. The cleared solutions were refluxed at 600C for 12 hour on water bath. The reaction mixture filtered was diluted with menthol: water (1:1). The adduct was subjected to HPLC analysis (gradient and isocratic run) and Mass spectrometry (LC-MS) analysis. The intensity of brown color was determined was spectrophotometrically after dissolving weighed quantity in distilled water. Docking study The molecular docking tool, GLIDE (Schrodinger Inc., USA) (2006) was used for ligand docking study. The protein preparation was carried out using ‘protein preparation wizard’ in Maestro 9.0. Result UV-Visible spectroscopy The UV-visible absorption spectrum of the isoniazid–lactose adduct and pyrazinamide–lactose adduct had shown an increase in absorption in the visible range as compared with isoniazid and pyrazinamide in distilled water as the solvent. The increased absorption the visible region (brown color) is due to Melanoidins production as the end products of the Maillard reaction as reported earlier (Shen, Tseng et al. 2007). FT-IR spectroscopy The FT-IR absorption patterns of Isoniazid, Pyrazinamide, lactose, Isoniazid–lactose physical mixture immediately after mixing and pyrazinamide-lactose physical mixture immediately after mixing as well as Isoniazid–lactose adduct, Pyrazinamide-lactose adduct were recorded. The peak at 1678 cm−1 in the IR spectrum of Isoniazid-lactose adduct, 1614 cm−1 Pyrazinamide-lactose adduct can be attributed to the imines formation. The peak of N–H bending is present at 1552 cm−1 and 1583 cm-1 in the IR spectrum of Isonizid and Pyrazinamide and its physical mixture respectively. The peak present in spectrum of Isonizid and Pyrazinamide and its physical mixture are absent in Isoniazid-lactose adduct and Pyrazinamide-lactose adduct both these observations support the formation of adduct. The N–H stretching band of secondary amine appears at 3302 cm−1 and at 3292 cm-1 for Isonizid and Pyrazinamide respectively. The peak for the lactose O–H appears at 3522 cm−1 in the infrared spectra of lactose. The peaks for N–H and O–H stretching appear in the spectrum of the physical mixture, but the peak for N–H disappears in the spectrum of the adduct. This may indicate the reaction of the amine with the red ucing sugar, or it may be due overlapping of N–H stretching peak with that of O–H. The FTIR spectra of Isoniazid, Pyrazinamide, Lactose physical mixture, Isoniazid-lactose adduct and Pyrazinamide-lactose adduct shows an interaction between Isoniazid and Pyrazinamide with lactose leading to the formation of a Maillard product (Pavia et al 2009). Differential scanning calorimetry The DSC thermograms show the presence of melting points for isoniazid and pyrazinamide at 171.61ÃŽ ¿C and 189.55 ÃŽ ¿C. The DSC thermogram of lactose shows the peak at 209.83 ÃŽ ¿C. The adduct shows the disappearance of the melting point peak of isoniazid, pyrazinamide, paracetamol and vildagliptine in adduct samples confirms the formation of adduct. Gradient HPLC analysis Initially a gradient run of water and methanol was performed to obtain preliminary information regarding the unknown peaks in maillard reaction products (Shen, Tseng et al. 2007). The mobile phase was optimized to separate the Isoniazid-lactose adduct and Pyrazinamide-lactose adduct was water: methanol (95:05, v/v) with a flow rate 0.8ml/min at ambient temperature. The Isoniazid-lactose adduct and Pyrazinamide-lactose adduct elutes at 3.833min and 1.613 min respectively. The control samples for isoniazid and pyrazinamide (without lactose) were also analyzed which proves method selectivity. Isocratic HPLC analysis The optimized isocratic HPLC analysis of the Isoniazid-lactose adduct and Pyrazinamide-lactose revealed one extra peak that eluted before Isoniazid and Pyrazinamide elution respectively. Performing analysis under same chromatographic parameters, no another peak was observed in control samples. Mass spectrometry The Isoniazid-lactose and Pyrazinamide-lactose adduct dissolve in mobile phase to obtain drug concentration about 100 µg/ml. In the positive ion mode with electrospray ionization technique, the sample was analyzed. The MS spectra show the precursor ion for Isoniazid-lactose adduct and Pyrazinamide-lactose adduct was protonated molecule ([M+H]+) m/z 463.3 and 448.1 respectively. The Isoniazid-lactose adduct and Pyrazinamide-lactose adduct molecular mass was consistent with Isoniazid-lactose adduct and Pyrazinamide-lactose adduct condensation product respectively. The loss of one water molecule from parent leads to maillard-type condensation product. Docking study Isoniazid In docking study, isoniazid shows binding with ARG-38 amino acid in the selected structure of protein (PDB code: 3I6N) and isoniazid-lactose adduct shows binding with ASN-72, SER-69, SER-173, ALA-134 and PRO-132 amino acid in the selected structure of protein (PDB code: 3I6N) as shown in Table No. 1.1. Pyrazinamide Pyrazinamide shows binding with ALA-131 amino acid in the selected structure of protein (PDB code: 3PL1) and pyrazinamide-lactose adduct shows binding with ASP-133 and LEU-131 amino acid in the selected structure of protein (PDB code: 3PL1). Discussion On the above observation difficulties in the formulating a new pharmaceutical dosage form have often experienced because of the interaction between the lactose and active ingredients itself i.e. isoniazid and pyrazinamide. Although the nature and intensity of this interaction may alter the stability, dissolution rate and consequently absorption of the drug and also affect the pharmacological effect. it indicates that such interactions involving in the formation of the complexes and it studied by different analytical techniques. The UV results shows increased absorption in the visible region (brown color) is due to Melanoidins production as the end products of the Maillard reaction as reported earlier in Shen, Tseng et al. 2007. The FTIR spectra of Isoniazid, Pyrazinamide, Lactose physical mixture, Isoniazid-lactose adduct and Pyrazinamide-lactose adduct shows peak of C=N it shows that formation of a Maillard product. HPLC analysis of the Isoniazid-lactose adduct and Pyrazinamide-lactose revealed one extra peak of impurity or maillard reaction product that eluted before Isoniazid and Pyrazinamide elution respectively. The MS spectra show the precursor ion for Isoniazid-lactose adduct and Pyrazinamide-lactose adduct and it has same molecular weight related to maillard-type condensation product. In the docking study of isoniazid adduct and pyrazinamide adduct shows more binding than isoniazid and pyrazinamide but this is pseudo results because this binding present at hydroxyl group and hydroxyl group are responsible for the increase excretion of the isoniazid and pyrazinamide and it may be reduces the therapeutic effect of isoniazid and pyrazinamide. In spite of that analytical study confirm the occurrence of maillard reaction product in lactose containing solid dosage forms of amino functional group containing drugs but lactose is still preferred as excipient in the isoniazid and pyrazinamide containing anti-tubercular formulation i.e. DOT’s. Conclusion The present study reports that antitubercular drugs i.e. isoniazid and pyrazinamide undergoes maillard reaction and that confirmed by UV, FT-IR, HPLC and MS. The docking study of isoniazid adduct and pyrazinamide adduct more binding than isoniazid and pyrazinamide but it is pseudo results pharmacologically the excretion of isoniazid and pyrazinamide increase and it ultimately reduces the therapeutic activity. A drugs- excipient interaction study can be actively used to the advantage of the formulator to increase the bioavailability of the drug. By compiling the data the use of lactose in the formulation of isoniazid and pyrazinamide, secondary amines needs to reconsideration. References: Chadha, R. and S. Bhandari (2014). Drug–excipient compatibility screening—Role of thermoanalytical and spectroscopic techniques. Journal of pharmaceutical and biomedical analysis87: 82-97. Crowley, P. J. (1999). Excipients as stabilizers. Pharmaceutical science technology today2(6): 237-243. Haywood, A., et al. (2005). Extemporaneous isoniazid mixture: stability implications. Journal of Pharmacy Practice and Research35(3): 181. Hemanth, A. K., et al. (2012). Simple and rapid liquid chromatography method for simultaneous determination of isoniazid and pyrazinamide in plasma. SAARC Journal of Tuberculosis, Lung Diseases and HIV/AIDS9(1): 13-18. Indian Pharmacopoeia, (2007). Government of India, Ministry of health and family walefare, published by the Indian Pharmacopoeia Commission, Gaziabad; vol. II III, pp. 658, 478, 628, 1009, 1008. Jackson, K., et al. (2000). Drug–excipient interactions and their affect on absorption. Pharmaceutical science technology today3(10): 336-345. MONAJJEMZADEH, F., HASSANZADEH, D., VALIZADEH, H., SIAHI-SHADBAD, M. R., MOJARRAD, J. S., ROBERTSON, T. A. ROBERTS, M. S. 2009b. Compatibility studies of acyclovir and lactose in physical mixtures and commercial tablets. European Journal of Pharmaceutics and Biopharmaceutics, 73, 404-413. Narang, A. S., et al. (2012). Impact of excipient interactions on solid dosage form stability. Pharmaceutical research29(10): 2660-2683. PAVIA, D. L. 2009. Introduction to spectroscopy, CengageBrain. com Patil, D. D. and C. R. Patil (2013). Modification of pharmacological activity of nebivolol due to Maillard reaction. Pharmaceutical development and technology18(4): 844-851. Petrella, Stà ©phanie Gelus-Ziental, Nathalie Maudry, Arnaud Laurans, Caroline Boudjelloul, RachidSougakoff, Wladimir(2011).Crystal structure of the pyrazinamidase of Mycobacterium tuberculosis: insights into natural and acquired resistance to pyrazinamide.PLoS One,6(1):e15785. Singh, Amit K Kumar, Ramasamy P Pandey, Nisha Singh, Nagendra Sinha, Mau Bhushan, AshaKaur, PunitSharma, SujataSingh, Tej P (2010). Mode of Binding of the Tuberculosis Prodrug Isoniazid to Heme Peroxidases BINDING STUDIES AND CRYSTAL STRUCTURE OF BOVINE LACTOPEROXIDASE WITH ISONIAZID AT 2.7 Ã… RESOLUTION.Journal of biological chemistry, 285(2): 1569-1576. Shen, S.-C., et al. (2007). An analysis of Maillard reaction products in ethanolic glucose–glycine solution. Food chemistry102(1): 281-287. Wirth, D. D., et al. (1998). Maillard reaction of lactose and fluoxetine hydrochloride, a secondary amine. Journal of pharmaceutical sciences87(1): 31-39. Yates, E. A., et al. (2003). Microwave enhanced reaction of carbohydrates with amino-derivatised labels and glass surfaces. Journal of Materials Chemistry13(9): 2061-2063.

Men with Guns :: Films Movies Economics Feudalism Essays

Men with Guns Men With Guns is not so much a film about economic processes as it is a film about the effects of a certain economic system - feudalism. It is more a film about cultural and political processes than anything else, a film that deals in depth with the grave consequences of a country in Central or South America whose Indians are subjects to the knights - the â€Å"men with guns† - who control and terrorize their existence. Cultural processes can be defined as the creation, or transfer, of knowledge. It is the way in which the rules of an economic system are communicated. In Men with Guns, the rules of the feudal economic system are translated through the men themselves. The â€Å"sugar people† or the â€Å"corn people† know their place in society because the army or the guerrillas tell them what it is through force. Every Indian that the doctor meets tells him that they are subject to the men with guns, and that they are in control. As long as one has access to a gun, then that individual becomes a knight, no longer a feudal serf, and it does not matter if that person has began life as a white person or an Indian. Because the â€Å"men with guns† happen to be the army, the army acts as feudal knights, forcing the serfs to live in extreme poverty and fear of death, torturing who they like with no consequences, and moving entire villages. They are able to do this because of the political system in the rural part of the country. Political processes can be defined as the rules, or laws if they are established by a legitimate government, that are enforced within a political system. In the feudal system in â€Å"Men with Guns,† the rules are made by the army. In the feudal system, the rules are made legitimate purely through the ownership of firearms. It appears as though the people are helpless politically because the political system is the army. There is a feeling in the movie that two different political systems exist within the country, and that most definitely two different economic systems are present. The country can be split into two different cultures - the city and the rural areas. The city operates much like that of any other Western city, and the doctor appears to live with relative freedom and economic prosperity.

Diagnosis On Stomach Cancer Survival Health And Social Care Essay

Stomach Cancer is one of the 20 most common malignant neoplastic diseases in the UK. Survival from tummy malignant neoplastic disease has been increasing in the past 30 old ages, nevertheless at that place remains to be survival differences between different socio-economic categories. The endurance in more disadvantaged categories has remained lower than endurance from the more flush categories ( this difference is known as the want spread ) and more so important in males. Methods: A complete dataset of 70370 malignant neoplastic disease patients that was formed from the malignant neoplastic disease register dataset and merged with Hospital Episode Statistics ( HES ) dataset. The extra jeopardy patterning attack was used ; utilizing the construct of flexible parametric patterning with restricted three-dimensional splines was used to predict net endurance from tummy malignant neoplastic disease. Consequences: The net endurance was found to differ between different want classs, where cyberspace endurance was lower in the most disadvantaged category and the highest in the most flush category. The net endurance was found to be higher in females than males and was found to be about twice every bit much in patients who had surgery. Decision: It was found that although net endurance about doubled in patients who had surgery, the want spread still remained. However farther analysis which include phase and class of malignant neoplastic disease would assist in placing whether this want spread is in fact important after taking into history such variables. Table of Contentss Care Form 53GlossaryDCO – Death Certificate Merely EHR – Excess Hazard Ratio FP – Fractional Polynomial GOR – Government Office Region HES – Hospital Episode Statisticss IMD – Index of Multiple Deprivation MAR – Missing At Random MI – Multiple Imputation TVC – Time changing constituent DF – Degrees of freedom ONS – Office of National Statistics HES – Hospital Episode Statisticss AIC – Akaike information standard BIC – Bayesian information standard1 Introduction1.1 Biology and Symptoms of Stomach CancerCancer is a disease which causes unnatural growing of cells which start to split and reproduce uncontrollably and in some instances these cells can metastasise. This growing in cells occurs many old ages before the malignant neoplastic disease can be detected. The cancerous cells lose legion indispensable control systems due to mutant in the cistrons of normal cells. When human cells reproduce, mutant can go on by opportunity, nevertheless a figure of different mutants occur before malignant neoplastic disease cells are formed. There are three cistrons which can do malignant neoplastic disease cells ; transforming genes ( besides known as ‘cancer cistrons ‘ which are unnatural and do the cells to multiply or duplicate ) , tumour suppresser cistrons ( cistrons which stop the cells multiplying nevertheless if damaged halt working hence cells become cancerous ) and DNA fix cistrons ( cistrons which repair other damaged cistrons nevertheless if damaged so mutants can non be repaired and therefore when the cell multiplies and divides it copies the mutants ) . ( 1 ) Stomach malignant neoplastic disease is the malignant neoplastic disease that occurs in the tummy and is besides known as stomachic malignant neoplastic disease. There are a figure of different types of tummy malignant neoplastic diseases. The most common type of tummy malignant neoplastic disease is known as glandular cancer of the tummy which starts in the secretory organ cells of the tummy liner, the secretory organ cells so produce stomach fluids and mucous secretion. Other types of tummy malignant neoplastic disease include ; Squamous cell malignant neoplastic diseases ; formed in the squamous cells ( skin cells that are between the secretory organ cells which form the tummy liner ) ( 2 ) . Lymphoma of the tummy ; really rare and is a different type of malignant neoplastic disease in which white blood cells ( lymph cells ) become cancerous cells and can non assist support the organic structure like normal white blood cells ( 2 ) . Gastrointestinal tummy tumor ( GIST ) ; a rare tumor which grows from the cells of the connective tissue which uphold the variety meats of the digestive ( GI ) piece of land and can be both cancerous and non-cancerous ) ( 2 ) . Neuroendocrine tumor ; are rare tumour which grows in the tissues that produce endocrines in the digestive system and can be cancerous and non-cancerous ( 2 ) . The early symptoms of tummy malignant neoplastic disease are non-specific and include dyspepsia, sourness and belch, experiencing full Oklahoman and hence ensuing in loss of weight, shed blooding in the tummy which can do anemia and hence doing fatigue and paler tegument. Other symptoms include purging, blood coagulums, hurting in the upper venters or hurting under the chest bone and trouble in get downing. Symptoms of the advanced phase of the malignant neoplastic disease, include blood in the stool and development of fluid in the venters ( 3 ) . There are no testing programme for tummy malignant neoplastic disease in the UK, nevertheless tummy malignant neoplastic disease is the most common malignant neoplastic disease in Japan and hence a showing programme is used which involves a Ba repast x-ray followed by endoscopy.1.2 Stomach Cancer Incidence, Survival & A ; MortalityCancer is a cardinal wellness issue in the UK, where a one-fourth of all deceases are due to malignant neoplastic disease and one in three people develop malignant neoplastic disease at any point in their lives. Cancer is more common in older people where more than 75 % of deceases occur in people over 65, nevertheless it can develop at any age. The incidence rate of malignant neoplastic disease has increased by 20 % in males and 40 % in females since the mid-1970 ‘s ( 4 ) . Stomach malignant neoplastic disease was found to be the 9th most common malignant neoplastic disease amongst work forces and the 14th most common amongst adult females in the UK in 2008 ( 5 ) . Around 7610 new instances of tummy malignant neoplastic disease were diagnosed in the UK in 2008, 4923 instances among work forces and 2687 in adult females with an overall incident rate of 8.6 per 100,000 individuals. In Britain the incidence rates for both males and females have more than halved ; from about 30 per 100,000 in 1975-1977 to about 13 per 100,000 in 2006-2008 in males, and from about 14 per 100,000 in 1975-1977 to about 5 per 100,000 in 2006-2008 ( 5 ) . The rate increased quickly for people above 60 old ages to about 140 per 100,000 in work forces and 67 per 100,000 in adult females aged 85 and over in 2008 ( 5 ) . Survival from tummy malignant neoplastic disease progressively progressed in patients diagnosed in 1996-1999 compared to patients diagnosed in 1971-1975, peculiarly due to quicker and earlier sensing and diagnosing, and betterment in intervention ( 6 ) . In England and Wales ; the one twelvemonth endurance more than doubled in patients diagnosed in 1996-1999 compared to 1971-1975. The 5 twelvemonth endurance were about three times higher in patients diagnosed in 1996-1999 compared to patients diagnosed in 1971-1975 ( 6 ) . The mortality rate of tummy malignant neoplastic disease decreased by about 70 % in both males and females over the last 30 old ages in the UK. The tendency of mortality was similar to the tendency of incidence as the mortality rate was found to be higher in males than females across the UK in 2008 ( 7 ) . The different types of intervention for tummy malignant neoplastic disease include surgery, radiation therapy, chemotherapy and biological therapy. Combinations of the interventions are besides normally used such as chemotherapy and surgery in state of affairss where it is non possible to take a localized malignant neoplastic disease wholly as it has spread and hence chemotherapy is used to first shrivel the malignant neoplastic disease plenty to surgically take it ( 8 ) .1.3 Hazard FactorsMore than 70 % of all tummy malignant neoplastic disease instances are diagnosed in developing states ( 9 ) . Older people, males and people belonging to the most disadvantaged socio-economic position have a higher hazard of tummy malignant neoplastic disease ( 10 ) . Other hazard factors include ; smoke, intoxicant, weight, household history, exposure to radiation, business and Helicobacter Pylori ( 10 ) . Helicobacter Pylori is a bacterial infection that has higher prevalence in developing states and in people who have a low socio-economic position. In a survey of instances in 2010, it was found that 32 % of tummy malignant neoplastic disease instances were associated with infection of the bacteria. In other surveies it has besides been found that get rid ofing Helicobacter pylori may help in forestalling tummy malignant neoplastic disease ( 10 ) . There is uncertainness about the association of holding tummy malignant neoplastic disease and an unhealthy diet. A few surveies have found that a higher consumption of fruits and veggies is associated with cut downing the hazard of tummy malignant neoplastic disease, nevertheless other surveies such as the EPIC survey found that a Mediterranean diet reduces the hazard of tummy malignant neoplastic disease. Another survey found that pickled veggies increase the hazard of tummy malignant neoplastic disease in Nipponese and Koreans ( 10 ) . Family history of tummy malignant neoplastic disease increases the hazard of acquiring the disease, nevertheless some of this addition may be environmental, as some surveies showed grounds of increased hazard in partners of patients ( 10 ) . The EPIC survey found that physical activity reduced the hazard of tummy malignant neoplastic disease and have a protective consequence, nevertheless other surveies provide no grounds of such and hence farther research needs to be carried out to supply important grounds ( 10 ) .1.4 Socio-economic InequalityThe endurance between want classs varies well for tummy malignant neoplastic disease ; with flush patients holding higher endurance rates compared to strip patients as shown from a figure of surveies worldwide. Mitry et Al. ( 11 ) analysed tummy malignant neoplastic disease informations from England and Wales malignant neoplastic disease registers and found a statistically important ‘deprivation spread ‘ ( i.e. the difference in endurance between flush and disadvantaged categories of patients ) in survival analysis in work forces diagnosed between1986-1999. Another survey carried out in the Netherlands found that the hazard of deceasing was lower after seting for possib le confounders in flush patients compared to deprived patients ( 12 ) . A survey in Japan besides looked at the association between socio-economic position and tummy malignant neoplastic disease endurance by analyzing the endurance of patients by their business. There was grounds of disparity in endurance by business after seting for possible confounders and this was chiefly due to ulterior diagnosing of tummy malignant neoplastic disease amongst the lower businesss ( 13 ) . The want spread in endurance has widened for male patients diagnosed in the 1996-1999 compared to those diagnosed in 1986-1990. Mitry et Al. ( 11 ) showed that the want spread for both annual endurance and five-year endurance has widened steadily and significantly from 1986 to 1999 for tummy malignant neoplastic disease and that that the want spread in work forces is likely to go on broadening. In England There were grounds of socioeconomic inequality in tummy malignant neoplastic disease incidence, it was reported that incidence remained unchanged in the flush groups, nevertheless incidence decreased by 31 % in deprived work forces and by 47 % in disadvantaged adult females higher in West Midlands, England between 1986-2000 ( 14 ) . Many suggestions were put frontward to explicate the beginning of the want spread in malignant neoplastic disease endurance, and three chief factors were suggested ; phase of diagnosing, biological features of the malignant neoplastic disease, host factors and consequence of intervention, psychosocial factors, and intervention received, medical expertness and malignant neoplastic disease showing ( 15 ) .1.5 Aims & A ; AimsThe net ( comparative ) endurance in a population of malignant neoplastic disease patients is their endurance from the malignant neoplastic disease of involvement in the absence of other causes of decease. The comparing of net endurance in the UK by want class suggests a important broadening want spread in males ( 11 ) . The purpose of this undertaking is to look into whether the widening want spread in work forces was due to work forces in the deprived group non profiting from healing surgery. The phase at diagnosing will besides be studied to look into the possibility of deprived work forces diagnosed at a ulterior phase compared to affluent work forces. Datas from the eight regional malignant neoplastic disease Registries of England over the period 1997-2006 will be examined. This dataset will be linked to the Hospital Episode Statistics from which information on intervention will be derived, to analyze survival tendencies and estimate net endurance of patients with tummy malignant neoplastic disease after seting for sex, age, want spread, intervention and phase of disease at diagnosing. Net endurance will be estimated utilizing an extra jeopardy theoretical account. From the extra jeopardy theoretical account, all cause mortality will be modelled as the amount of the extra ( cancer-related ) mortality jeopardy and the expected ( background ) mortality. Net endurance will hence be calculated as the ratio of the observed ( all cause ) endurance to the expected ( background ) endurance. The background mortality/survival will be defined utilizing life tabular arraies from the general population. The life tabular arraies will be merged utilizing age, sex, twelvemonth of issue, GOR ( Government Office Regions ) and want class to the malignant neoplastic disease dataset. Net endurance by want class will foremost be estimated to find if there is any grounds of socio-economic inequality in malignant neoplastic disease endurance in the analysed period 1997-2006. An analysis will so be carried out, seting for confounders such as age, sex, intervention, and phase of malignant neoplastic disease.2 Materials and methodsThis chapter will supply description of the informations used in the undertaking and the statistical methods applied to predict net endurance from tummy malignant neoplastic disease by want category. The construct of flexible parametric patterning with restricted three-dimensional splines will be used to take into history differences in mortality by age, sex and intervention are discussed in item. All statistical analysis was carried out utilizing STATA 12.1 ( 16 ) .2.1 DatasThe UK is known to hold the most extensive/complete malignant neoplastic disease enrollment systems in the universe ( 17 ) . Presently there are eight malignant neoplastic disease registers in England. The malignant neoplastic disease registers in England collect information on clinical informations such as phase and type of malignant neoplastic disease, decease certifications which are forwarded by the Office of National Statistics ( ONS ) and demographic information such as day of the month of birth, day of the month of diagnosing, sex ( 18 ) . Information such as the malignant neoplastic disease class, phase and intervention are largely uncomplete. furthermore information on infirmary admittances and co-morbidity is frequently unavailable. Further information on malignant neoplastic disease patients can be obtained from the Hospital Episode Statistics ( HES ) . The HES is a database apparatus to include informations and information on all admittances in NHS infirmaries since 1989. Since 2003, the HES database has besides included and stored information on outpatients. The information in the HES are extracted from clinical instance notes. clinical instance notes include more elaborate descriptions of the clinical informations such as class and phase of malignant neoplastic disease at diagnosing, intervention received and co-morbidity. The malignant neoplastic disease register and HES database can be merged ( 19 ) utilizing the patients NHS figure and cardinal information day of the month of birth. Once the malignant neoplastic disease register and the HES database are combined, an independent cheque on the quality of the information is carried out every bit good as betterment in the completeness of the informations aggregation ( 19 ) . The patients acknowledged through decease certifications are followed up by their enrollment officers from their several regional malignant neoplastic disease registers to happen out the topographic point of intervention and therefore the patients ‘ infirmary & A ; instance notes. However this is non equal for some patients as they may non hold been provided any secondary attention ( hospitalization/clinics ) and therefore these patients are referred as decease certification merely ( DCO ) ( 20, 21 ) . Analysiss will be carried out on anon. informations from the eight malignant neoplastic disease registers in England on tummy malignant neoplastic disease diagnosed during 1997-2006. The patients identified suited for the analyses were merged in progress with their several patient records from the HES database from which information on intervention was extracted. Demographic information which included day of the month of birth, sex, Government Office Region ( GOR ) , day of the month of malignant neoplastic disease diagnosing and morphology were given for each patient. Information on the abode ZIP code at diagnosing and critical position ( dead, alive or emigrated ) were found from the Office of National Statistics for each patient. However as there was no information available the socio-economic position of each malignant neoplastic disease patient, utilizing the ZIP code ; the abode at diagnosing of each malignant neoplastic disease patients was identified and hence a want mark based on the abode was allocated to each patient. Five want classs ( from 1 ‘most affluent ‘ to 5 ‘most deprived ‘ ) were classified utilizing the income sphere mark of the 2004 Index of Multiple want ( IMD2004 ) and each patient was hence assigned to their several class based on their want mark. The IMD is based on everyday administrative informations of the 34,378 Lower Super-Output Areas ( LSOAs ) in England. Carstairs index ( 22 ) was the index used antecedently. Comparing the IMD mark to the Carstairs mark, the IMD is based on a smaller geographical country and is non based the nose count informations and therefore can be updated on a regular basis without transporting out a new nose count. The IMD is normally updated every 3-4 old ages.2.2 Statistical Methods2.2.1 Relative Survival and Excess MortalityNet endurance can be used to mensurate malignant neoplastic disease mortality straight. It can besides be used to mensurate extra mortality of malignant neoplastic disease patients compared to the general population. Net endurance can be estimated utilizing cause specific or extra mortality. Net endurance utilizing the cause-specific attack can be used by measuring the cause of each decease, merely the deceases attributed to the malignant neoplastic disease are considered and all other causes of deceases are censored. The major disadvantage is that there is a strong dependance on the quality of decease records. Cause-specific endurance can be used to mensurate malignant neoplastic disease mortality straight and uses inside informations of all deceases, nevertheless the cause of decease in this instance is malignant neoplastic disease and is used in the malignant neoplastic disease mortality. This method requires the cause of decease to be accurate and exactly specified, nevertheless the cause of decease is non given in most instances. Indirect deceases such as deceases due to route accidents or deceases due to side-effects of medications/treatment alongside deceases due to malignant neoplastic disease are hard to sort. Furthermore, different diagnosticians will specify cause of decease otherwise depending on the state of affairs at clip of decease hence cause of decease may non be right defined. There are two methods of appraisal of the cause specific attack are Kaplan-Meier method and the Acturial method. Excess mortality is a method which accounts for malignant neoplastic disease mortality straight and indirectly without necessitating an accurate and precise specification of the cause of decease ( 23 ) . The extra mortality is derived as the difference in the ascertained mortality ( mortality due to all causes ) and expected mortality ( mortality due to non-cancer-related causes ) . Both extra mortality methods estimation malignant neoplastic disease mortality after seting for background mortality from assorted other causes and hence presumptively should give similar values. In world nevertheless this depends on how suitably premises are fulfilled for each several method, chiefly accurately documenting and stipulating the cause of decease for the cause-specific method and the truth of gauging the expected mortality for the extra mortality method ( 23 ) . Excess mortality is classified mathematically utilizing the jeopardy map at clip since diagnosing as. The jeopardy map is equal to the amount of the extra jeopardy due to stomach malignant neoplastic disease diagnosing and the expected jeopardy ( sometimes known as the baseline jeopardy, estimated utilizing external informations from the general population ) where is the covariates vector ( 24 ) . Equation ( 1 ) Net endurance ( Relative endurance ) is the survival corresponding to extra mortality, and is derived as the ratio of the ascertained endurance of the malignant neoplastic disease patients to the expected endurance estimated from the general population utilizing life tabular arraies. Equation ( 1 ) may therefore equivalently be written in footings of net/relative endurance as Equation ( 2 ) where and are the cumulative observed and expected endurance severally. The relation between the jeopardy map and expected jeopardy and cumulative observed and expected endurance severally, is given by and, and the net/relative endurance is so given as. ( 24 ) The jeopardy is assumed to be piecewise changeless over of follow-up clip ( changeless over little clip intervals ) in pattern and hence a short period such as a twelvemonth or less might be used at the start of the followup. If a longer period is used so the changeless jeopardy premise is violated and clip since diagnosing is non automatically adjusted for and is hence the uninterrupted map may be modelled as a measure map. A new covariate vector is derived by adding the covariate vector with the index variables where the index variables are generated for all intervals apart from the mention interval. A multiplicative map of the covariates in the signifier of is assumed to be the extra jeopardy and therefore equation ( 1 ) becomes Equation ( 3 ) or instead Equation ( 4 ) where the parametric quantity estimates when exponentiated can be inferred as extra jeopardy ratios ( EHRs ) . The jeopardies are assumed to be relative implicitly in equation ( 3 ) . By Introducing interaction footings of the follow-up clip and covariates in the theoretical account can be used for patterning non-proportional jeopardies. Excess mortality can be estimated utilizing assorted different methods, Different methods exist for gauging extra mortality, either utilizing a full likeliness attack ( 25 ) , or based on sorted informations incorporating one observation for each life table interval within a generalised additive theoretical account ( 25, 26 ) . Life tabular arraies provide information on endurance and give the chance of decease in the general population stratified by age, calendar twelvemonth, sex, want and authorities office part ( GOR ) . The life tabular arraies in England are based on the nose count informations and are hence updated every 10 old ages to demo alterations in life anticipation. In the analysis carried out for this undertaking the life tabular array used is stratified by sex, age, GOR, twelvemonth of issue, and IMD quintile. The Life tabular arraies from 1981-2010 were used. Life tabular arraies are based on mortality in the general population, which include the mortality due to stomach malignant neoplastic disease, but because decease due to malignant neoplastic disease is little compared to the general population, it does non impact net/relative endurance estimations in pattern Ederee et Al. ( 27 ) . The stpm2 bid in STATA was used to foretell comparative endurance. The timescale and failure were declared utilizing the stset bid, and the clip beginning for the analysis was taken to be the day of the month of diagnosing of each topic. The timescale was calculated in old ages and the extra mortality was modelled as the primary result of involvement as suggested in ( 23 ) .2.2.2 SplinesFrequently complex non-linear effects from uninterrupted variables e.g. age are modelled in arrested development theoretical accounts. There are many improved methods of patterning complex and non-linear effects. Splines is an easy manner of including an explanatory variable in a smooth non-linear manner. Mathematical maps which are sections of multinomials and joined together at points called knots are known as splines. To do the spline smooth, A figure of restraints which include limitations on the mathematical derived functions of the spline map are applied between next multinomial sections so that the curve is smooth at the knot. In general, splines can be generated utilizing multinomials of any grade. However three-dimensional splines are frequently used, in which each section can be written as a three-dimensional multinomial as three-dimensional multinomials normally model most curves right and are computationally easy to obtain. The smoothness status for a three-dimensional spline means that the spline map is uninterrupted i.e. the first and 2nd derived functions are uninterrupted everyplace and there are no leaps or interruptions in the spline. A three-dimensional spline with K knots may be derived mathematically in footings of K+4 parametric quantities in general as ( 28 ) : where the notation classifies the incline map, where if, and if and the knots are at places severally. Cubic splines behave ill at the dress suits when fitted to informations is less and the spline map may be susceptible to extreme value. A subset of three-dimensional splines where the spline map is additive before the first knot and after the last knot are known as restricted splines ( 28 ) . A restricted three-dimensional spline can be specified by K-1 parametric quantities for K figure of knots which is 5 less than a general three-dimensional spline. where the is defined as: With a logarithmically transformed clip variable, restricted splines are normally used to pattern the extra jeopardy. Knots can be anyplace on the log-outcome clip distribution, where the boundary knots at the first and last log-outcome clip.2.2.3 Flexible Parametric Survival ModelsRoyston and Parmar ( 29 ) foremost introduced flexible parametric theoretical accounts in the position of censored endurance informations. This method of patterning informations gave more flexibleness to the form of the jeopardy map in comparing to other parametric theoretical accounts e.g. the Weibull theoretical account for which the signifiers of the jeopardy map are limited. The flexible parametric theoretical accounts do non necessitate numerical incorporation and hence a cardinal advantage of such theoretical accounts is comparatively fast calculations. ( 30 ) The Cox theoretical account is the most common method of covering with censored informations, nevertheless flexible parametric theoretical accounts can cover with non-proportional jeopardies more expeditiously. In flexible parametric endurance theoretical accounts, clip is treated as a uninterrupted variable and hence unlike piecewise approaches the demand of dividing the time-scale is non needed ( 24, 26 ) . The big Numberss of excess parametric quantities which are required to be created so that time-dependent effects are incorporated in the piecewise attack are hence non required in this modeling attack and hence this reduces the computational clip and uses less computing machine memory particularly for big datasets. Alteration of the flexible parametric theoretical accounts have since been done for comparative endurance theoretical accounts ( 30, 31 ) A parametric theoretical account is defined as a theoretical account which can be identified in footings of a fixed set of parametric quantities ( , , †¦ ) . Restricted three-dimensional splines are fitted to the estimations of the log baseline jeopardy in a flexible parametric net/relative endurance theoretical account ( 30 ) . Equation ( 6 ) Transforming to the endurance graduated table Equation ( 7 ) where is the restricted three-dimensional spline map of with knots, and is the cumulative overall jeopardy. The log-likelihood map is obtained utilizing equation ( 6 ) and numerical methods are used to gauge the parametric quantities which give upper limit likeliness utilizing equation. Thus the endurance and hazard maps can be analytically estimated.2.2.4 Evitable DeathsA manner of infering extra hazard ratios is by ciphering evitable deceases ( 32-34 ) . The figure of evitable deceases is the figure of deceases due to stomach malignant neoplastic disease which could be avoided if the net endurance in all socio-economic classs would be the same as that of the most flush class after seting for the different features of each class. The expected figure of deceases due to all causes amongst a specific group of patients utilizing equation ( 2 ) is: where N is the size of the population, is the expected endurance at clip T and is the net endurance of the concerned group at clip T. In the general population, the predicted figure of all-cause deceases in a matched group is:.The premise of net endurance being the same as in a population being compared to is made ( in this instance the least disadvantaged ( flush ) category ) to deduce evitable deceases. The figure of evitable deceases are calculated by deducting the predicted figure of deceases due to all causes given the new comparative endurance from the predicted figure of deceases due to all causes given the original comparative endurance. The figure of â€Å" evitable † deceases represents postponed deceases which will happen subsequently and hence are really variable with the follow-up clip.2.3 Statistical AnalysisTo transport out the statistical analysis, informations were examined to vouch it ‘s dependability. Consistency cheques were besides carried to do certain informations was placed in the needed scopes. Datas from the Hospital Episode Statistics ( HES ) database were merged with the malignant neoplastic disease register informations, and information on intervention was obtained. patients whose records could non be matched to the HES database were excluded. Patients who had losing informations on variables such as GOR or IMD mark ( used to deduce want classs ) , which were used in unifying with the general population life tabular array to gauge the net endurance were besides excluded from the analysis. The patient distributions were examined by the chief explanatory variables on the information. To happen differences in want class, cross-tabulations of other variables ( such as intervention, GOR and malignant neoplastic disease registers etc. ) by want category were carried out. Net endurance by want category was estimated utilizing a flexible parametric theoretical account. This theoretical account did non affect any variables with losing informations and the stpm2 bid in STATA was used to cipher predicted net endurance. Expected chances of decease were estimated by unifying the life tabular arraies stratified by age, sex, want and GOR and twelvemonth of issue, to the malignant neoplastic disease dataset ( formed of HES merged with the malignant neoplastic disease register informations ) . The method of flexible parametric theoretical accounts utilizing restricted three-dimensional splines was used, as this method was computationally less ambitious and less clip consuming and a more accurate method of analysis. Using flexible parametric patterning with splines, interaction footings were fitted in the theoretical account. As extra mortality was predicted to differ non-linearly with age, hence interaction footings for age with splines were besides introduced. To prove the rightness of this method of analysis, both in footings of the procedure of utilizing splines and besides presenting the interaction footings of the theoretical account. Net endurance for up to 10 old ages was estimated and predicted by want category, seting for sex, intervention and age group. A new variable dividing the age with 5 splines was so created and used to do dummy variables for the restricted three-dimensional age splines variables. A restricted three-dimensional spline with 5 knots was used. To let for non-proportionality in the extra jeopardy for both twelvemonth ( twelvemonth of diagnosing ) spline and age spline variables, dummy variables for the interaction between both variables were generated. A figure of flexible parametric theoretical accounts were fitted for males and females individually. The first theoretical account was fitted with want and chief confounders such as the age splines and twelvemonth ( twelvemonth of diagnosing ) splines. A 2nd theoretical account with interactions between age splines and twelvemonth ( twelvemonth of diagnosing ) splines every bit good as utilizing all the variables from the first theoretical account. The 3rd theoretical account was fitted by including intervention ( as the association between intervention and want class was to be examined particularly in patients who had surgery ) in the best adjustment theoretical account out of the first two theoretical accounts. The theoretical accounts were re-fitted with clip changing effects with age merely and so with both age and clip of diagnosing. These theoretical accounts were compared for the best of tantrum utilizing the likeliness ratio trial. To happen out which grades of freedom ( DF ) for the baseline jeopardy produced the better adjustment theoretical account, the best adjustment theoretical account without the clip changing effects was fitted with 1 to 5 DF and so compared utilizing Akaike information standard ( AIC ) and Bayesian information standard ( BIC ) . The best fitting theoretical account with the DF for the baseline jeopardy was chosen to be the 1 with the smallest AIC and BIC. The same method was used to make up one's mind which DF for the varying effects was best used for the best fitting clip changing effects theoretical account. The scrutiny of evitable deceases was carried out to gauge and foretell the figure of evitable deceases at 1 and 5 old ages if endurance was the same in all want classs as the most flush class.3 Consequences3.1 Description of the malignant neoplastic disease register informationsFor the analyses to be carried out, a sum of 70,370 patients who were diagnosed with tummy malignant neoplastic disease during the period of 1997-2006, and were linked to the HES database. From the entire figure of patients, 1729 ( 2.46 % ) patients were registered via their decease certification merely ( DCO ) or had zero endurance ( day of the month of decease was the same as the day of the month of diagnosing ) . Zero endurances were included in the analysis by adding one twenty-four hours to the day of the month of decease, as excepting them would overrate the endurance, nevertheless it is known that DCOs seldom have a confirmed day of the month of diagnosing ( 21 ) . Of the entire figure of tummy malignant neoplastic disease patients, 45,580 ( 64.77 % ) were work forces and 24,790 ( 35.23 % ) of the patients were adult females. Table shows the figure of tummy malignant neoplastic disease instances by GOR. The largest absolute figure of tummy malignant neoplastic disease patients was in the North-West part and the smallest being in the North East part. Table: Proportion of tummy malignant neoplastic disease patients by Government Office Region Government office part Number ( % ) of patients North East ( A ) 5,157 ( 7.33 ) North West ( B ) 11,615 ( 16.51 ) Yorkshire and The Humber ( D ) 8,710 ( 12.38 ) East Midlands ( E ) 6,278 ( 8.92 ) West Midlands ( F ) 8,461 ( 12.02 ) East of England ( G ) 7,027 ( 9.99 ) London ( H ) 7,508 ( 10.67 ) South East ( J ) 8,878 ( 12.62 ) South West ( K ) 6,736 ( 9.57 ) The proportion of males to females and average age of tummy malignant neoplastic disease diagnosing were similar across all want categories, the highest mean age at diagnosing in the in-between want class ( 73.3 old ages ) and the lowest amongst the most disadvantaged group and the flush group ( 72.4 old ages ) , nevertheless this difference in mean age at diagnosing was non that large amongst want categories. The spread for age amongst all want categories was found to be similar due to the lopsidedness and standard divergence. The proportions of topics coming from each GOR by want category differed mostly. Figure: Percentage of patients by want categoryA clear monotonically increasing form was found in the per centum of people by want category, where there was a lower per centum of patients from the flush category and a higher per centum of patients from the disadvantaged category as shown in Figure 1. Figure: Percentage of patients having no intervention A tendency was seen in intervention. Figure 2 shows that the most disadvantaged group were less likely to have any signifier of intervention. The tendency in the per centum of patients having any intervention including surgery was found to back up the consequences from Figure 2, where the per centum of patients from flush to the most disadvantaged were 34.63 % , 34.30 % , 33.74 % , 33.02 % and 32.79 % severally. Table: Distribution of patients by Sexual activity Males Females Entire VariablesNitrogen%Nitrogen%Nitrogen%45,580 64.77 24,790 35.23 70370 100 Age group ( old ages ) 15-44 1,020 2.24 706 2.85 1,726 2.45 45-54 2,760 6.06 1,072 4.32 3,832 5.45 55-64 7,277 15.97 2,663 10.74 9,940 14.13 65-74 14,990 32.89 6,087 24.55 21,077 29.95 75-84 14,992 32.89 9,031 36.43 24,023 34.14 85-100 4,541 9.96 5,231 21.10 9,772 13.89 Want 1-least deprived 7,033 15.43 3,497 14.11 10,530 14.96 2 8,169 17.92 4,226 17.05 12,395 17.61 3 9,241 20.27 5,160 20.81 14,401 20.46 4 10,399 22.81 5,723 23.09 16,122 22.91 5-most deprived 10,738 23.56 6,184 24.95 16,922 24.05 Treatment Surgery merely 7,718 16.93 4,347 17.54 12,065 17.15 Chemo merely 6,266 13.75 2,114 8.53 8,380 11.91 Radio merely 233 0.51 112 0.45 345 0.49 Surgery, wireless 135 0.30 77 0.31 212 0.30 Surgery, chemo 1,688 3.70 731 2.95 2,419 3.44 Chemo, wireless 114 0.25 37 0.15 151 0.21 Surgery, chemo, wireless 45 0.10 13 0.05 58 0.08 No intervention 29,381 64.46 17,359 70.02 46,740 66.42 Site C160 13,932 30.57 4,520 18.23 18,452 26.22 C161 643 1.41 290 1.17 933 1.33 C162 1,133 2.49 600 2.42 1,733 2.46 C163 2,276 4.99 1,746 7.04 4,022 5.72 C164 1,059 2.32 812 3.28 1,871 2.66 C165 3,268 7.17 1,688 6.81 4,956 7.04 C166 1,227 2.69 686 2.77 1,913 2.72 C168 460 1.01 250 1.01 710 1.01 C169 21,582 47.35 14,198 57.27 35,780 50.85 Government Office Region ( GOR ) A 3,223 7.07 1,934 7.80 5,157 7.33 Bacillus 7,367 16.16 4,248 17.14 11,615 16.51 Calciferol 5,466 11.99 3,244 13.09 8,710 12.38 Tocopherol 4,182 9.18 2,096 8.46 6,278 8.92 F 5,669 12.44 2,792 11.26 8,461 12.02 Gram 4,746 10.41 2,281 9.20 7,027 9.99 Hydrogen 4,745 10.41 2,763 11.15 7,508 10.67 Joule 5,802 12.73 3,076 12.41 8,878 12.62 K 4,380 9.61 2,356 9.50 6,736 9.57 Cancer Registry North & A ; York 7,455 16.36 4,431 17.87 11,886 16.89 Trent 5,277 11.58 2,799 11.29 8,076 11.48 East Anglia 3,148 6.91 1,474 5.95 4,622 6.57 Thames 9,368 20.55 5,202 20.98 14,570 20.70 Oxford 1,815 3.98 1,002 4.04 2,817 4.00 South & A ; West 5,876 12.89 3,063 12.36 8,939 12.70 West Midlands 5,975 12.43 2,790 11.25 8,456 12.02 North West & A ; Mersey 6,975 15.30 4,029 4.029 11,004 15.64 From Table 2, it can be clearly seen that the proportion of males and females were similar in the two youngest age group classs, nevertheless the proportion of males was more in the in-between two classs and the proportion of females was more in the oldest two classs. The distribution of the proportion of males and females was similar for all want, intervention, GOR and malignant neoplastic disease register classs. The proportion of males was about twice every bit many as females for site C160 and the proportion of females was more compared to males for site C169, nevertheless the proportion of males and females were similar for all other sites. A important factor in finding endurance is intervention, hence a trial was carried out to see if there was any difference between want classs in the proportion having any intervention compared to those non having intervention, and in the proportion having intervention affecting surgery compared to those undergoing no surgical intervention. Two logistic arrested development theoretical accounts were hence carried out, one for the proportion having any intervention and the other for the proportion having surgical intervention by want class, seting for age and twelvemonth of diagnosing, individually for males and females. After seting for confounder, the odds of acquiring any intervention for females in the most disadvantaged class were 0.88 times less than in the flush class ( p-value 0.009 ) . There was no difference in the odds of intervention in males between want classs. After seting for confounders, the odds having surgical intervention in males from the more disadvantaged classs was 1.18 times more than in the flush class ( p-value & lt ; 0.001 ) and no difference in the odds of having surgical intervention in females between want classs. The average age at diagnosing was 72.92 old ages. The mean overall follow-up clip of 1.57 old ages as shown in table 3. The per centum of patients who died by the terminal of the follow-up period was found to be 91.64 % of patients. Table 3 shows the average follow-up clip ( the norm clip until stomach malignant neoplastic disease patients are dead or censored ) and the per centum of those who died stratified by age group, want category and intervention. A really little difference was found in both overall mean follow-up clip and the proportion dead by the terminal of followup between males and females. The average follow-up clip was longer and the proportion of patients deceasing by the terminal of the followup was lower in younger topics. The average follow-up clip was longer and the proportion of patients deceasing was lower in the patients belonging to the most flush class, with both results demoing an diminishing tendency by diminishing want category. The average follow-up clip of patients having surgery, with either or both radiation therapy and chemotherapy, was longer than those patients who did non have surgery and the proportion death by the terminal of followup was smaller. This was chiefly due to the fact that chemotherapy and radiation therapy interventions were carried out on patients at the ulterior phases of the malignant neoplastic disease, whereas surgery was carried out earlier phase, nevertheless this may propose that patients who underwent surgery had a better endurance. Variable Average followup ( old ages ) % dead by the terminal of followupMaleFemaleOverallMaleFemaleOverall1.58 1.56 1.57 91.74 91.45 91.64 Age group ( old ages ) 15-44 2.63 2.95 2.76 80.39 74.50 77.98 45-54 2.47 2.55 2.49 83.62 80.78 82.83 55-64 2.25 2.51 2.32 85.83 82.58 84.96 65-74 1.76 1.99 1.83 90.43 97.93 89.70 75-84 1.13 1.29 1.19 95.96 94.59 95.44 85-100 0.62 0.64 0.63 99.10 99.14 99.12 Want 1-least deprived 1.76 1.80 1.77 89.95 89.33 89.74 2 1.65 1.58 1.63 91.46 90.91 91.27 3 1.56 1.52 1.54 92.14 91.98 92.08 4 1.48 1.50 1.49 92.36 91.94 92.22 5-most deprived 1.53 1.48 1.51 92.18 92.12 92.16 Treatment Surgery merely 3.41 3.70 3.52 77.52 74.76 76.53 Chemo merely 1.58 1.48 1.55 94.14 94.80 94.31 Radio merely 1.70 1.40 1.60 90.56 91.07 90.72 Surgery, wireless 3.82 4.67 4.13 76.30 61.04 70.75 Surgery, chemo 3.26 3.25 3.26 81.46 80.85 81.27 Chemo, wireless 1.84 2.02 1.89 92.11 89.19 91.39 Surgery, chemo, wireless 3.13 3.27 3.16 86.67 84.62 86.21 No intervention 0.99 0.94 0.97 95.64 95.82 95.71 Table 3: Average follow-up clip and % of patients who were recorded as holding died by the terminal of the follow-up period by sex3.2 Consequences from the more complex analysisThe simple flexible parametric theoretical account was fitted with want, age splines and twelvemonth splines variables. The grades of freedom for the baseline jeopardy were chosen utilizing the AIC and BIC consequences from Table 4. Table 4: Degrees of freedom for Baseline jeopardy and their AIC/BIC Baseline Hazard DF Model DF AIC BIC Male 1 16 92327.50 92467.13 2 17 87329.59 87477.95 3 18 86419.88 86576.97 4 19 86097.21 86263.03 5 20 85890.83 86065.38 Female 1 16 44135.45 44265.34 2 17 41201.07 41339.08 3 18 40783.54 40929.67 4 19 40686.45 40840.69 5 20 40568.31 40730.67 From Table 4, it can clearly be seen that the theoretical accounts fitted with 5 grades of freedom for the baseline jeopardy give the smallest AIC and BIC for both males and females and hence provide a better tantrum for the theoretical account. Although it seems best to utilize 5 DF for the baseline jeopardy, 3 DF will be used as the theoretical accounts with 5 DF are computationally intensive when clip changing effects are included. Table 5: Net endurance by want class at 1, 5 and 10 old ages unadjusted for intervention for males and females individually Net enduranceMalesFemales1-year endurance Most flush 0.36 0.38 2 0.34 0.35 3 0.33 0.34 4 0.32 0.33 Most disadvantaged 0.32 0.33 5-year endurance Most flush 0.16 0.19 2 0.14 0.16 3 0.13 0.16 4 0.12 0.15 Most disadvantaged 0.12 0.15 10-year endurance Most flush 0.12 0.15 2 0.10 0.12 3 0.10 0.12 4 0.09 0.11 Most disadvantaged 0.09 0.11 Consequences from the estimation of cyberspace endurance up to 1, 5, and 10 old ages after diagnosing, unadjusted for intervention, are shown in Figures 3-8 for males and females individually, and showed that there was a suggestion of a additive tendency across the want groups. Between the five want groups, 1-year predicted net endurance ranged from 0.32 to 0.36 for males and 0.33 to 0.38 for females. The 5-year predicted net endurance ranged from 0.12 to 0.16 for males and 0.15 to 0.19 in females. The 10- twelvemonth predicted net endurance ranged from 0.09 and 0.12 for males and 0.11 to 0.15 for females ( Table 5 ) . In general, the predicted cyberspace endurance scope had a somewhat higher lower limit and upper limit for females than males bespeaking that the predicted cyberspace endurance was overall better/higher in females than males. The estimated difference in endurance was 0.04 in males and 0.05 in females between the most flush and the most disadvantaged groups at one twelvemonth after diagnosing. At five old ages after diagnosing the estimated difference in endurance between the two groups was the same for males but decreased to 0.04 for females. A clear additive tendency was seen between one and five old ages after diagnosing. The tendency between the least disadvantaged and most disadvantaged classs remained up to ten old ages after diagnosing, although at ten old ages the endurance of the two most disadvantaged classs was the same. Table 6: Excess jeopardy ratio ( EHR ) of decease, adjusted for age and twelvemonth of diagnosing for males and females individually without seting for intervention and clip varying effects for patients diagnosed with tummy malignant neoplastic disease during 1997-2006 in England Males FemalesEHRP-value95 % CIEHRP-value95 % CIWant 1-Least deprived Baseline––Baseline––2 1.046 0.014 ( 1.009, 1.084 ) 1.072 0.006 ( 1.020, 1.128 ) 3 1.076 & lt ; 0.001 ( 1.039, 1.114 ) 1.082 0.001 ( 1.031, 1.136 ) 4 1.117 & lt ; 0.001 ( 1.079, 1.155 ) 1.118 & lt ; 0.001 ( 1.066, 1.172 ) 5-most deprived 1.142 & lt ; 0.001 ( 1.103, 1.181 ) 1.143 & lt ; 0.001 ( 1.091, 1.197 ) Splines 1 3.389 & lt ; 0.001 ( 3.349, 3.428 ) 3.383 & lt ; 0.001 ( 3.331, 3.436 ) 2 1.242 & lt ; 0.001 ( 1.230, 1.254 ) 1.262 & lt ; 0.001 ( 1.246, 1.278 ) 3 1.107 & lt ; 0.001 ( 1.101, 1.113 ) 1.098 & lt ; 0.001 ( 1.090, 1.106 ) Table 6 shows a comparing of the consequences of the flexible theoretical accounts for males and females individually. Comparing the consequences of males and females, the extra jeopardy ratio ( EHR ) of decease by want class was higher in general for females, although both analyses gave a additive tendency in EHR by want. For both males and females, the EHR of decease by want was statistically important indicating that the EHR differed for each want class compared to the most flush class. Therefore more disadvantaged groups had a higher extra mortality due to malignant neoplastic disease compared to the less disadvantaged groups. Age and twelvemonth of diagnosing were modelled as a non-linear effects, and were important in for the first three age splines for both males and females and were important for twelvemonth spline 1 and 4 in males and twelvemonth splines 1 & A ; 2 in females. Figure: Internet endurance up to 1 twelvemonth after diagnosing, by want class at diagnosing for males diagnosed with tummy malignant neoplastic disease during 1997-2006 in England. Figure: Internet endurance up to 1 twelvemonth after diagnosing, by want class at diagnosing for females diagnosed with tummy malignant neoplastic disease during 1997-2006 in England. Figure: Internet endurance up to 5 old ages after diagnosing, by want class at diagnosing for males diagnosed with tummy malignant neoplastic disease during 1997-2006 in England. Figure: Internet endurance up to 5 old ages after diagnosing, by want class at diagnosing for females diagnosed with tummy malignant neoplastic disease during 1997-2006 in England. Figure: Internet endurance up to 10 old ages after diagnosing, by want class at diagnosing for males diagnosed with tummy malignant neoplastic disease during 1997-2006 in England. Figure: Relative endurance up to 10 old ages after diagnosing, by want class at diagnosing for females diagnosed with tummy malignant neoplastic disease during 1997-2006 in England. Table 7: Degrees of freedom for Time Varying Component ( TVC ) and their AIC/BIC with baseline jeopardy of 3 DF. TVC DF Model DF AIC BIC Male 1 23 86047.89 86248.62 2 28 86035.85 86280.22 4 38 85727.08 86058.72 5 43 85660.87 86036.14 Female 1 23 40628.06 40814.77 2 28 40590.59 40817.9 4 38 40504.96 40813.45 5 43 40515.35 40864.43 The flexible parametric theoretical account was fitted with want, age splines and twelvemonth splines variables and age splines as the clip changing consequence. The grades of freedom for the baseline jeopardy were chosen utilizing the AIC and BIC consequences from Table 4. From Table 7, it can clearly be seen that the theoretical account fitted for males with 5 DF for the clip variable consequence gives the smallest AIC and BIC, nevertheless the theoretical account fitted for females with 4 DF has the smallest AIC and BIC. Therefore either 4 DF or 5 DF can be used run the analysis for the clip changing effects and intervention. Further analysis was carried out utilizing 4 DF. Table 8: Adjusted extra jeopardy ratio ( EHR ) of decease for males and females individually seting for intervention and clip changing effects of age and twelvemonth of diagnosing for patients diagnosed with tummy malignant neoplastic disease during 1997-2006 in England Males FemalesEHRP-value95 % CIEHRP-value95 % CIWant 1-Least deprived Baseline––Baseline––2 1.080 & lt ; 0.001 ( 1.042, 1.120 ) 1.056 0.036 ( 1.004, 1.110 ) 3 1.111 & lt ; 0.001 ( 1.073, 1.150 ) 1.095 & lt ; 0.001 ( 1.043, 1.149 ) 4 1.167 & lt ; 0.001 ( 1.128, 1.208 ) 1.124 & lt ; 0.001 ( 1.072,1.179 ) 5-most deprived 1.195 & lt ; 0.001 ( 1.155, 1.236 ) 1.162 & lt ; 0.001 ( 1.109, 1.217 ) Splines 1 3.639 & lt ; 0.001 ( 3.593, 3.686 ) 3.783 & lt ; 0.001 ( 3.709, 3.859 ) 2 1.219 & lt ; 0.001 ( 1.206, 1.232 ) 1.243 & lt ; 0.001 ( 1.223, 1.264 ) 3 1.100 & lt ; 0.001 ( 1.093, 1.108 ) 1.112 & lt ; 0.001 ( 1.102, 1.122 ) Treatment No Surgery Baseline––Baseline––Surgery 0.327 & lt ; 0.001 ( 0.317, 0.337 ) 0.311 & lt ; 0.001 ( 0.298, 0.325 ) No Chemo Baseline––Baseline––Chemo 0.732 & lt ; 0.001 ( 0.711, 0.754 ) 0.826 & lt ; 0.001 ( 0.788, 0.865 ) No Radio Baseline––Baseline––Radio 0.755 & lt ; 0.001 ( 0.679, 0.839 ) 0.764 0.001 ( 0.653, 0.894 ) Age splines Age spline1 1.304 & lt ; 0.001 ( 1.285, 1.323 ) 1.295 & lt ; 0.001 ( 1.269, 1.322 ) Age spline 2 0.945 & lt ; 0.001 ( 0.931, 0.959 ) 0.938 & lt ; 0.001 ( 0.922, 0.956 ) Age spline 3 1.014 0.063 ( 0.999, 1.028 ) 1.019 0.048 ( 1.000, 1.039 ) Age spline 4 0.993 0.286 ( 0.980, 1.006 ) 0.980 0.028 ( 0.963, 0.998 ) Age spline 5 0.987 0.044 ( 0.975, 1.000 ) 0.999 0.896 ( 0.985, 1.014 ) Year of diagnosing splines Year spline1 0.923 & lt ; 0.001 ( 0.912, 0.935 ) 0.929 & lt ; 0.001 ( 0.914, 0.944 ) Year spline 2 1.016 0.012 ( 1.003, 1.028 ) 1.005 0.567 ( 0.989, 1.021 ) Year spline 3 0.988 0.041 ( 0.976, 0.999 ) 0.996 0.622 ( 0.980, 1.012 ) Year spline 4 1.025 & lt ; 0.001 ( 1.013, 1.038 ) 1.012 0.140 ( 0.996, 1.029 ) Year spline 5 1.003 0.630 ( 0.991, 1.015 ) 1.005 0.592 ( 0.988, 1.021 ) Table 8 shows a comparing of the consequences of the clip changing effects theoretical account seting for want, age at diagnosing, twelvemonth of diagnosing and intervention for males and females individually. Comparing the consequences from the male analysis with the female, the extra jeopardy ratio ( EHR ) for decease by want was lower in females in general, although both analyses gave a additive tendency in EHR by want. Comparing the EHR for both analyses to consequences from Table 6, it is clear that the EHR is lower when intervention and clip changing effects such as age and twelvemonth of diagnosing are taken into history. There was besides lessening in EHR for any intervention compared to no intervention ; nevertheless there was a big lessening in EHR of surgery compared to no surgery for both males and females. In both analyses, intervention with surgery was associated with increased net endurance compared to non-surgical intervention or no intervention. Age and twelvemonth of diagnosing were modelled as a time-dependent non-linear consequence, and were important for peculiar splines in both theoretical accounts. The additive tendency in want category remained and became more important, since the EHR in want classs for both males and females differed in comparing to the most flush group at the 5 % significance degree, as in the instance of the simpler analyses. Therefore more disadvantaged groups had a higher extra mortality due to malignant neoplastic disease compared to the less disadvantaged groups. The deficiency of an interaction term between want classs and splines in the concluding theoretical account suggests that the difference in comparative endurance between want groups did non alteration over the clip period of the survey. Figure: Internet endurance up to 1 twelvemonth after diagnosing, by want class at diagnosing for males seting for intervention and clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 1 twelvemonth after diagnosing, by want class at diagnosing for females seting for intervention and clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 5 old ages after diagnosing, by want class at diagnosing for males seting for intervention and clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 5 old ages after diagnosing, by want class at diagnosing for females seting for intervention and clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 10 old ages after diagnosing, by want class at diagnosing for males seting for intervention and clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 10 old ages after diagnosing, by want class at diagnosing for females seting for intervention and clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 10 old ages after diagnosing, by want class at diagnosing for males who had intervention affecting surgery, seting for clip changing effects and diagnosed during 1997-2006 in England. Figure: Internet endurance up to 10 old ages after diagnosing, by want class at diagnosing for males who had intervention affecting surgery, seting for clip changing effects and diagnosed during 1997-2006 in England. Table 9: Net endurance by want class at 1, 5 and 10 old ages adjusted for intervention and surgery for males and females individually. Males FemalesNet enduranceNet endurance from tummy surgeryNet enduranceNet endurance from tummy surgery1-year endurance Most flush 0.37 0.65 0.36 0.67 2 0.34 0.63 0.34 0.65 3 0.33 0.62 0.33 0.64 4 0.32 0.61 0.32 0.63 Most disadvantaged 0.31 0.60 0.32 0.63 5-year endurance Most flush 0.16 0.42 0.17 0.46 2 0.14 0.39 0.16 0.44 3 0.14 0.38 0.15 0.42 4 0.13 0.37 0.14 0.42 Most disadvantaged 0.13 0.36 0.14 0.41 10-year endurance Most flush 0.12 0.36 0.13 0.40 2 0.11 0.32 0.12 0.37 3 0.10 0.32 0.11 0.36 4 0.10 0.30 0.11 0.35 Most disadvantaged 0.10 0.30 0.11 0.35 Consequences from the estimation of cyberspace endurance up to 1, 5 and 10 old ages after diagnosing, adjusted for intervention and clip changing affects, are shown in Figures 9-14 for males and females individually, and showed that there was a sug

Analysis of “The Lorax” Essay

The story, â€Å"The Giving Tree,† is a book written by Shel Silverstein that is about the relationship between a tree and a boy. In the beginning of the story, the boy and the tree spend a lot of time together having fun. For example, they would play hide and seek, the boy would play on the branches, and the boy would play king of the forest with the leaves of the tree. The tree would be very happy because she was interacting with the boy. Throughout the story, the boy would spend less and less time with the tree. As a result, the tree would become sad. Once in a while the boy would come back, asking for certain things, and the tree would be happy to help the boy because she loved the boy so much. Through the story, â€Å"The Giving Tree,† Shel Silverstein relates a lesson of how giving is more important than taking. In the story, the boy takes advantage of the tree by taking everything that the tree has. The tree gives freely without complaining because the tree loves the boy, and wants him to be happy. In the end, all the boy wanted to do was to spend time with the tree once again. If the boy did not continuously take advantage of the tree, the boy did not have to miss, and become unhappy about the old tree that loved him so much. The tree’s love for the boy is a perfect example of what people should be like: giving freely, and unconditionally. If everyone was like the tree, there would be very little unhappiness in the world, and the world would be a better place. If countries started to give freely to one another, there would be fewer wars, there would be no more sadness and devastation, and there would be world happiness and peace. The message from Shel Silverstein is to not be like the boy who ultimately becomes unhappy by taking from the tree. In summary, Silverstein uses the story to expound on the idea that giving is more important than receiving. The story also has a slight reference to the relationship between mother and child. The tree (the mom) was willing to give anything to the boy (the son). The tree sacrifices herself in order to make the boy happy, which any mom would probably do for her son. In the beginning, the tree wanted to sacrifice its time just to play with the boy. This is similar to a parent, which sacrifices time to interact with and provide for their kids. Towards the teenage years, the tree gives up her apples so that the boy could have money. Likewise, many parents sacrifice money to have their children enjoy their teenage years: movies, cars, trips, etc. When the boy becomes an adult, he takes the branches and trunk of the tree away to build a house, and a boat. All of these examples exemplify the ways in which moms make so many sacrifices to make their children happy, but some kids just take them, run with them, and never think about how much it cost their moms. As depicted in the story, the boy never expressed any gratitude to the tree. The boy rarely went back to visit the tree, but only visited the tree to take something away for his own personal benefit. Furthermore, moms also show sadness when their children leave them for college, and adulthood. When the boy does not come back to see the tree for years at a time because of his own issues, the tree becomes sad. In short, Silverstein illustrates the interaction between mother and child by showing the selfless acts of parents and the selfishness of children. The book, â€Å"The Giving Tree,† can strongly connect to our relationship between the environment and humans. Currently, there is an evident problem of global warming. This recent dilemma is caused because of our selfish taking from the environment. The tree can strongly resemble the earth on which we live, and the boy can resemble humans. We constantly take from the Earth, and rarely give back to the environment. For example, during the 20th century, industries took advantage of the Earth without replenishing resources: deforestation, driving animals to extinction, and over-fishing. Furthermore, since global warming has become such a big problem now, we want to go back to live on the lush, non-polluted earth. Likewise, after the boy takes everything away from the tree, the boy wanted the tree to be like it was before. Ultimately, the book elucidates the way in which humans abuse the environment just like how the boy misused the tree. A question that can come to mind when reading Shel Silverstein’s story is, what is the reason for writing the story. Silverstein might have written the book for young children, but it was to teach everyone of the â€Å"give not take,† principle. Moreover, another question can be what is the reason for allowing the boy not to think about his selfishness? Perhaps Silverstein wanted to portray the fact that people are sometimes selfish. Finally, throughout the story, why is the boy referred to as a boy even though he becomes a man. Maybe Silverstein was writing in the perspective of a mother because a mom always calls his son her boy.

Essay Sample on American Reforms Between 1825 and 1850

Essay Sample on American Reforms Between 1825 and 1850 Example essay on American Reforms: America experienced many kinds of reforms during the time period between 1825 and 1850. The different types of reform movements in the United States during this time period sought to expand democratic ideals through religious, women’s, and social reforms. The era’s reformers were portrayed as idealistic altruistic crusaders who intended to improve American society. Church attendance was still a regular ritual for about three-fourths of Americans. In fact, Alexis de Tocqueville declared that there was, â€Å"no country in the world where the Christian religion retains a greater influence over the souls of men than in America.† Hence, it was very easy to bring reform to America through religion. One of the reformers was Charles Finney. He denounced both alcohol and slavery and encouraged women to pray aloud in public. This brought a democratic principle in which women are equal to men and slaves are also free people. In Document B, he declares that through such type of reforms harlots, drunkards, infidels and all kinds of abandoned characters are awakened and connected. This provides the people in the community a well rounded life and expanded democratic ideals as it included more people through participation in the community. The author of Document E foretells that if people are happy with what they have and know that God is in control, j ust like the good boy, they will be happier in their lives and will have the capacity to govern themselves. This will contribute to the society, which is one of the key facts in democracy. Women’s higher education was frowned upon in the early decades of the nineteenth century. Prejudices also prevailed that too much learning injured the feminine brain. But later on women became one of the reformers that expanded democracy through their involvement and petition to legislatures. Dorothea Dix was one of the tireless reformers who worked mightily to improve the treatment of the mentally ill and finally made a petition to the Massachusetts legislature in 1843. She was also appointed superintendent of women nurses for the union forces at the outbreak of the civil war. The lady that is portrayed in Document C also shows that women need to be treated equally as people and not as slaves. The author of Document I also mentions that women have also part in democratic government as they are members of the governed and no favor of laws must be shown to anyone. America was being changed in a way that would affect the future generations. Temperance society was founded, Harmony and Brook farm communes were also established. In fact, as in Document A, Americans were starting to feel proud as America was the first to adopt the penitentiary system of prison discipline and attempted to prevent crimes by imparting knowledge. People were also uniting and forming voluntary association to promote the great purposes of human culture as in Document F. The people also wanted to guarantee each other spiritual progress and physical support which is one of the main facts of democratic principles as the people, the governed, have a say in their government. Some of the reformers also believed that the government by that time was biased and that a new one in which the people participate, as the author says in Document G, was needed. Some of the people in this reformation era were mostly morally ethical. Some believed that who get involved in drinking end up b eing poor or dead. These people started to have the right to say what they believed in. This can be seen in Document H. Many of the reformers in this era believed to take the American Society to a higher level. However, all did not believe in the same path to that level. Some, like Samuel Morse in Document D, believed that America should not give foreigners a lot of rights. Everyone having the right to say what they believed in is the main democratic principle that came forth from the reforms and the reformers during this era to direct America in a new path its people never knew.

stereotypes in ancient east essays

stereotypes in ancient east essays Social, religious and ethnic stereotypes in the ancient Near East and the lessons to be gained from that for our modern world: 2. The Ancient Near East; Explain the culture and define the stereotypes. 3. Draw paralells between The ancient Near East and The modern world and what lessons we have learnt. Would one be able to link stereotypes to an exact science of numbers, figures and statistics? Or do stereotypes evolve socially through the the general mindset and identification of peoples perception of popular and recognisable behaviour in more than one individual? Defining the word itself is easy, one could find an abundance of information leading to the answer right through from the Greek deriviation from stereos; meaning solid and typos; meaning the mark of a blow, impression, or model, to a modern dictionarys definition as; A relatively rigid and oversimplified or baised perception or conception of an aspect of reality, especially of persons or social groups. But dictionarys does not lead to the true meaning and social explanation of the term. We need to view the definition as a blank space which we colour in with meaning as we gather our paints. To start of with we are placed in an eviroment; a physical and phsycological plain in which humans create real and psuedo based experiences on which they base their own behaviour and those of the people around them. In that enviroment it then becomes very important for the basic survival of the species and the individual that social life demands that we know and try to understand the why of behaviour. Why in the sense of control, of order, of predictabality, of stability and of meaning. Through that people build up a preconception of what survival is to them, by adding the creative mind to social enviroments known to them. They can therefore try and predict the outcome of situations within that known enviroment by adding their own experi...

Business Research Methods Essay Example for Free

Business Research Methods Essay Starbucks (158) , Research methods (28) company About StudyMoose Contact Careers Help Center Donate a Paper Legal Terms & Conditions Privacy Policy Complaints Starbucks grew as it attracted many people, leading to tripling its stores worldwide. It became part of every neighborhood, appearing on every street, in airports, supermarkets, and roadside rest stops all over America. This is when complaints began to surface that Starbucks is transforming into a fast-food restaurant and not a coffee house. The coffee industry was no longer dominated by Starbucks, for competitors began to put pressure on the business. In addition, the biggest dilemma to hit Starbucks was the 2008 economic crisis. This took a toll on the consumer who saw Starbucks as a luxury and searched for more affordable alternatives. As a result, Starbucks’ management was faced with the need to generate the right management question that would be the thread to making the best decision through its research design. An organizational dilemma can spark a research question. Once an organization determines a situation exists, research methods start to devise and eventually sample designs are implemented. When people think of Starbucks, do they think of great customer service, quality products, clean store, or great coffee? The organizational dilemma is: how should Starbucks go about keeping loyal customers while overcoming the old perceptions and changing with the times. According to Howard Schultz, â€Å"We are not in the coffee business serving people; we are in the people business serving coffee† (Starbucks Board of Directors, 2008). Marius Pretorius (2008) research infers Starbuck’s organizational dilemma, whether strategic or operational is not diminished when using Michael Porter’s (1985) generic strategies for competitive advantage. Declining sales require a turnaround solution that address strategic causes and cost relationship pressures that govern demand determinants. Which are â€Å"highly susceptible to external influences that are not clearly visible to the decision-makers† (Pretorius, 2008, pg. 21). Designing a two-stage exploratory study to identify the basis of distress and the key determinants is essential to a turnaround strategic plan. An exploratory study provides sufficient flexibility to address research costs, timelines, and development of clear constructs to address priorities and operational definitions (Cooper & Schindler, 2011). The first stage of the study will look to ascertain the causation of the organizational dilemma and postulate the asymmetrical relationships in declining sales by examining both internal and external independent and dependent variables. This research will categorize findings into four relationship types as stimulus-response, property-disposition, disposition-behavior, or property-behavior. This will refine the second stage of research and explore influencing factors in depth. Characteristics and Operational Definitions The research design will produce casual inferences upon which a complementary strategy will result. â€Å"Although they may be neither permanent nor universal, these inferences allow us to build knowledge of presumed causes over time† (Cooper & Schindler, 2011, pg. 154). Therefore, it is important to identify moderating or interactive variable dependencies. To ensure data validity operational definitions will challenge data to meet specific standards. These definitions may not exhibit the organization’s use but will establish a means to classify clearly an event. The main concern is to establish actionable information in which contributory or contingent effects on the original independent to dependent variable (IV–DV) relationship will provide empirical conclusions. References Cooper, D.R. & Schindler, P.S. (2011). Business research methods (11th ed.). New York, NY: McGraw-Hill/Irwin. Porter, M.E., (1985). Competitive advantage: Creating and sustaining superior performance. New York, NY: The Free Press Pretorius, M., (2008). When Porter’s generic strategies are not enough: Complementary strategies for turnaround situations. Journal of Business Strategy 29(6): 19–28. Starbucks Board of Directors. (2008). Retrieved 2 2013, February, from Starbucks.com: www.starbucks.com/aboutus/environment.asp Starbucks, (2011) Our Company: Mission Statement. We have essays on the following topics that may be of interest to you