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By: Katherine Schuver Garman, MD

  • Associate Professor of Medicine
  • Member of the Duke Cancer Institute
  • Affiliate of the Regeneration Next Initiative

https://medicine.duke.edu/faculty/katherine-schuver-garman-md

Abandonware is a term that is most often applied to erectile dysfunction liver cirrhosis order vigrx plus 60 caps on-line software developed under a grant erectile dysfunction 5k buy vigrx plus pills in toronto. Nobody assumes the responsibility of tying up loose ends erectile dysfunction doctors buffalo ny purchase vigrx plus amex, finding and removing bugs, distributing the software, or using the software in new projects. The original programmers scramble to find new jobs; nobody remains who can understand their code. The data in the failed resource either slips into the bit void or becomes legacy data, stored on disks, shelved, and forgotten. The identifier system and the data model for the resource are almost always lost to posterity. Here are two precautions that can salvage some of the pieces of a failed Big Data project. Software applications can be envisioned as utilities with a graphic user interface. One software application may have the functionality of three or four utilities. When a Big Data resource is built, it will usually be accessed under an umbrella application. This application will support user queries, while shielding the user from the complexities of the data and the mechanics of passing the query over multiple, networked servers. When a Big Data resource is terminated, applications with a user interface to the resource retain no value. However, the small utility programs built into the application may have enormous value to the builders of the next generation of related Big Data resources. The best applications are modularized—built from working parts that can be extracted and used as utilities. Data means nothing unless it is properly identified; hence, the data held in a Big Data resource must be preserved with its identifiers. If the data is identified and well annotated, it will be possible to reintegrate the data objects into a successor resource. Preserving legacy data is particularly important in hospital information systems, which 162 have a very high failure rate. Hospitals and medical centers should set aside money, in an escrow fund, for this purpose. Gordon Schulmeyer Some governments do an excellent job at analyzing their own failures. The world might be a better place if we, as individuals, published our own investigative reports when we disappoint our friends and coworkers or fail to meet our personal goals; but self-accountability has never been a human strength. In 2006, the Cancer Biomedical Informatics Grid was selected as a laureate in Computerworld’s Honors 185 program. Computerworld described the project as “effectively forming a World Wide Web of cancer research,” with “promises to speed progress in all aspects of cancer research and care. By 2010, the National 3 Cancer Institute had sunk at least $350 million into the effort. Though the project was ambitious, there were rumblings in the cancer informatics community that very little had been achieved. In view of past and projected costs, an ad hoc committee was assigned to review the program. In a report issued to the public in 2011, the committee found that the project had major 3 deficiencies and suggested a yearlong funding moratorium. The ad hoc committee report went into considerable detail to explain the deficiencies of the program. At the time, I thought that the project was too big, too complex, too ambitious, that it served too many interests (the intramural community at National Institutes of Health, the extramural community of academic researchers, a profusion of industry contractors, and the office of the director at the National Cancer Institute), enlisted the assistance of too many people, had too much money, was lavished with too much hype, had initiated too many projects, and that the program directors operated with insufficient accountability. In the case of the Cancer Biomedical Informatics Grid, hindsight would suggest that the project may have benefited from the following. Projects should begin with a relatively small number of highly dedicated and energetic people. Studies have shown that as more and more money and personnel are 187 added to a software project, the chances of success drop precipitously. When you stop and think about it, most of the great programming languages, some of the most important operating systems, the design of the Internet, the language of the World Wide Web, computer hardware advances, innovational corporations, and virtually all of the great algorithms in computer science were created by one individual or a small group of people (usually less than five).

At laparotomy erectile dysfunction drugs in australia discount vigrx plus online amex, do drainage and peritoneal toilet with warm saline; leave drain in situ for about 3 days and continue parenteral antibiotics postoperatively impotence yoga poses cheap vigrx plus 60 caps visa. Bartholin’s abscesses occur when the gland becomes secondarily infected with one of many common bacterial pathogens erectile dysfunction exercise buy generic vigrx plus 60caps line. Physical examination may reveal tender, fluctuant abscess lateral to and near the posterior fourchette, local swelling, erythema, labial oedema, and painful inguinal adenopathy. Most abscesses develop over 2–3 days and spontaneous rupture often occurs within 72 hours. When abscess formation is obvious, incision and drainage as follows: • Apply local anaesthesia lignocaine 1%. It is due to: Obstetrical injury: Obstructed labour usually leads to pressure necrosis of the bladder and vaginal wall and the rectum. Operative injury: A fistula may be caused during total abdominal hysterectomy and caesarean section. Extension of disease: Malignancy of the bowel or any pelvic abscess may perforate into the rectum and posterior vaginal wall. Radiotherapy: Heavy radiation of the pelvis causes ischaemic necrosis of the bladder wall and bowel, causing urinary or faecal fistula. Clinical Features the patient complains of urinary or faecal incontinence or both. Examination under anaesthesia is always mandatory for the diagnosis and definition of fistula. Under Kenyan laws rape is defined as carnal knowledge of a woman without her consent or by use of force, duress, or pretence. A girl below 18 years of age is not legally deemed to be able to give consent (Children Act). The medical personnel must approach the rape victim with great understanding, respect, and concern for her wellbeing. Careful history and medical record are important because this information will be required in court. If the patient has eaten, drunk, bathed, or douched, this may affect the outcome of laboratory tests. History must be taken to evaluate the risk of sexually transmitted disease and pregnancy. During physical examination, it is important to document location, nature, and extent of any external trauma to face, neck, breast, trunk, limbs, the genitalia, and vagina; in addition, cervical trauma must be documented. Investigations Swabs for microscopy and culture from: • Vagina • Throat 450 Levels 4–6 – Hospitals • Rectum • Urethra Swab the cervix and vagina for sperm microscopy. Treat physical injuries, noting that some tears or cuts may require surgical repair. Administer tetanus toxoid for soiled lacerations, Give prophylactic treatment to prevent pregnancy after ruling out already existing pregnancy. If the perpetrator is available for examination, document clinical evidence that may connect him/her with the victim/survivor (hair, blood, semen, scratch or teeth marks) and take specimens accordingly. Obstetrics In this section the attention turns to the care and treatment of the woman during pregnancy and before, during, and after the birth of the child, as well as on the welfare of the child. It should include age, marital status, occupation, education, ethnic origin, area of residence, drinking, smoking and any substance abuse habits, as well as past obstetric and gynaecological history. Records of each pregnancy in chronological order should include date, place, maturity, labour, delivery, weight, sex and fate of the infant, and any puerperal morbidity. Vaginal exam: this is indicated as follows: • At early pregnancy to confirm and date pregnancy. If Avoid anti-emetics (nausea & vomiting) severe with dehydration admit for hydration. If severe give Avoid strong laxatives or heartburn & constipation) mild laxative and antacid. The 4 visits are 1st by 16 weeks, 2nd at 24– 28, 3rd at 32 weeks, and 4th at 36 weeks. At each return visit antenatal care should include: Interval history of symptomatology and/or problems.

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Source of graph: the National Cancer Institute’s Surveillance Epidemiology End Results erectile dysfunction pills free trial generic vigrx plus 60 caps mastercard, available from seer erectile dysfunction books download free buy cheap vigrx plus 60caps line. Another set of black holes are supermassive erectile dysfunction drugs malaysia purchase vigrx plus 60 caps free shipping, with mass equivalents of 10 or 20 billion solar masses. When there are objects of the same type, whose masses differ by a factor of a billion, scientists infer that there is something fundamentally different in the origin or development of these two variant forms of the same object. Black hole formation is an active area of interest, but current theory suggests that lower mass black holes arise from preexisting heavy stars. The supermassive black holes presumably grow from large quantities of matter available at the center of galaxies. The observation of bimodality inspired astronomers to search for black holes whose masses are intermediate between black holes with near-solar masses and the supermassive black holes. Intermediates have been found and, not surprisingly, they come with a set of fascinating properties that distinguish them from other 122 8. Fundamental advances in our understanding of the universe may sometimes follow from simple observations of multimodal data distributions. The average behavior of a collection of objects can be applied toward calculations that would exceed computational feasibility if applied to individual objects. Years ago, I worked on a project that involved simulating cell colony growth using a Monte 98 Carlo method (see Glossary item, Monte Carlo simulation). Each simulation began with a single cell that divided, producing two cells, unless the cell happened to die prior to cell division. When you simulate colony growth, beginning with a single cell, the chance that the first cell will die on the first cell division would be about 0. If the cell survives the first cell division, the cell might go through several additional cell divisions before it dies, by chance. By that time, there are other progeny that are dividing, and these progeny cells might successfully divide, thus enlarging the size of the colony. A Monte Carlo simulation randomly assigned death or life at each cell division, for each cell in the colony (see Glossary item, Monte Carlo simulation). There was no longer any need to perform a Monte Carlo simulation on every cell in the population. I could simply multiply the total number of cells by the cell death probability (for the entire population), and this would tell me the total number of cells that survived the cycle. When dealing with large numbers, it becomes possible to dispense with the Monte Carlo simulation and to predict each generational outcome with a pencil and paper. Substituting the average behavior for a population of objects, rather than calculating the behavior of every single object, is called mean-field approximation (see Glossary item, Mean-field approximation). It uses a physical law telling us that large collections of objects can be characterized by their average behavior. Mean-field approximation has been used with great success to understand the behavior of gases, epidemics, crystals, viruses, and all manner of large population problems. At this enormous distance, light hitting the earth arrives as near-parallel rays, and the shadow produced by the earth is nearly cylindrical. This means that the shadow of the earth is approximately the same size as the earth itself. The diameter of the earth is about 8000 miles, so the diameter of the moon must be about 8000/2. Our estimate is inaccurate because the earth’s shadow is actually conical, not cylindrical. If we wanted to use a bit more trigonometry, we’d arrive at a closer approximation. Still, we arrived at a fair approximation of the moon’s size from one simple division based on a casual observation made during a lunar eclipse. In this particular case, a direct measurement of the moon’s distance was impossible. A modern-day example wherein measurements failed to help the data analyst is the calculation of deaths caused by heat waves. People suffer during heat waves, and municipalities need to determine whether people are dying from heat-related conditions. If deaths occur, then the municipality can justifiably budget for supportive services such as municipal cooling stations, the free delivery of ice, increased staffing for emergency personnel, and so on.

Treacher Collins syndrome

If you are a Big Data manager endowed with an overactive imagination erectile dysfunction treatment bangkok buy vigrx plus once a day, it is possible to erectile dysfunction after 80 order vigrx plus 60caps online envision all types of unlikely scenarios in which confidentiality can be breached erectile dysfunction diabetes type 2 treatment cheap 60 caps vigrx plus with visa. As an example, the privacy law that applies to hospitals and health care organi33 zations contains 390 occurrences of the string “reasonable. In addition to their use in diabetes research, the informed consent indicated the samples might be used for research on “behavioral and medical disorders,” not otherwise specified. The researchers tried but failed to make headway linking genes sampled from the Havasupai tribe with cases of diabetes. The gene samples were subsequently used for ancillary studies that included schizophrenia and for studies on the demographic trends among the Havasupai. In their opinion, these studies did not benefit the Havasupai and touched upon questions that were considered embarrassing and taboo, including the topic of consanguineous matings and the prevalence rates of mental illnesses within the tribe. In 2004, the Havasupai tribe filed a lawsuit indicating lapses in the informed consent process, violation of civil rights, violation of confidentiality, and unapproved use of the samples. The case was dismissed on procedural grounds, but was reinstated by the Arizona Court of 209 Appeals in 2008. Arizona State University agreed to pay individuals in the Havasupai tribe a total of $700,000. This award is considerably less than the legal costs already incurred by the university. If the Havasupai tribe won anything in this dispute, it must have been a Pyrrhic victory. Because the case was settled out of court, no legal decision was rendered and no clarifying precedent was established. Though I am not qualified to comment on the legal fine points, several of the general principles related to the acquisition and use of data are relevant and can be discussed as topics of general interest. Laypersons should not be put into a situation wherein they must judge the value of research goals. By signing consent, the signator indicates that he or she is aware of the potential harm from the research and agrees to accept the risk. In the case of samples or data records contributed to a Big Data resource, consenters must be warned, in writing, that the data will be used for purposes that cannot be specified in the consent form. Most consent is obtained to achieve one primary purpose, and this purpose is customarily described briefly in the consent form. The person who consents often wants to know that the risks that he or she is accepting will be compensated by some potential benefit to society. There is no ethical requirement that binds scientists to conduct their research for the sole benefit of one group of individuals. A good consent form will clearly state that research conducted cannot be expected to be of any direct value to the consenter. Finally, the consent form should include all of the potential harms that might befall the consenter as a consequence of his or her participation. It may be impossible to anticipate every possible adverse consequence to a research participant. In this case, the scientists at Arizona State University did not anticipate that the members of the Havasuapai tribe would be harmed if their gene data was used for ancillary research purposes. I would expect that the researchers at Arizona State University do not believe that their research produced any real harm. Had the original consent form listed all of the potential harms, as perceived by the Havasupai, then the incident could have been avoided. Had any members of the Havasupai tribe voiced concerns over the unspecified medical and behavioral disorders mentioned in the consent form, then the incident could have been avoided. The Havasupai did not understand how scientists use information to pursue new questions. The board of regents did not understand the harms that might occur when data is used for legitimate scientific purposes. The take-home lesson for data managers is the following: to the extent humanly possible, ensure that consent documents contain a complete listing of relevant adverse consequences.

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References:

  • http://assessingtheunderworld.org/duke-edu/Katherine-Schuver-Garman/purchase-online-penegra/
  • http://assessingtheunderworld.org/duke-edu/Katherine-Schuver-Garman/order-levitra-professional-online-no-rx/
  • https://www.nejm.org/doi/pdf/10.1056/NEJMoa2004325?listPDF=true
  • http://www.personalizedmedicinecoalition.org/Userfiles/PMC-Corporate/file/The-Personalized-Medicine-Report1.pdf
  • https://sites.duke.edu/regenerationnext/programs/

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