Renewable Energy free essay sample

Renewable Energy BY frappe04927 Non renewable energy sources are becoming harder to find and with that being said, these resources are more expensive. So what will we do when these resources are no longer here on earth for use to use? Many people are looking for and testing new forms of materials that we can use for energy. These sources are called renewable energy sources. Throughout the paper you will read about non renewable energy sources and the small supply that we have left, humans influences on theses non renewable resources and what some are trying to do to make new forms of energy. Energy Conservation Plan Energy conservation is becoming a great issue. We are using up the forms of non renewable energy sources that we have depended on for so long. Some types of non renewable energy resources are oil, coal, natural gas and nuclear. These forms of energy come from the ground. We will write a custom essay sample on Renewable Energy or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Many people take these forms of energy for granted, maybe thinking that these forms of energy would always be here for us to use. But since we are finding out that non renewable energy resources are becoming harder to find, we are now taking action to find or make new forms of energy. Many people take energy for granted. They do not think about running out of energy. But this is a very real problem, and running out of non renewable energy could happen. Humans are the reason that there are damages to our planet and also for the non renewable resources drying up. Over population of the human race is one of the biggest factors that are causing the disappearance of reserves and resources. James Leape, director general of WWF international stated that Reckless consumption is endangering our future prosperity. He also states that by the year 030 we will need the equivalent of two planets in order to continue to live the way we are living now. You can tell by this that energy conservation is a real issue that we need to face now. Humans are affected by this problem and things are only going to get worse. So why is it that with humans being affected by this we do not do something to make a difference? I believe it to be that most humans do not really understand what we ar e doing and the damages of what we are doing. By 2025 people will be experiencing physical scarcity and will not have enough water to live, says Morne du Plessis, CEO of WWF-SA. There are many non living things that contribute to the use of energy consumption. Many of these things are found in our households, starting with space conditioning at 44%, water heating at 13%, Lighting at 12%, Refridgeration at 8%, Home electronics at 6%, Laundry Appliances at 5%, Kitchen Appliances at 4% and other uses at 8%. These are all things that people have made to live better. But what many people do not think about is that these items that we are using are greatly affecting the conservation of energy. So, yes man made products do play a big role in the use of energy. The percents above are based on an average household usage. Now add up all ot the household usage in America, and that would snow a shocking and devastating number. Most of the humans actions that are done to this world are negative. People take too much for granted out of life. Energy conservation is one of those things. People are in the mind set that we will always have everything that we will always need. There are not enough people that fully understand the problems that we are facing or even what we can do to help with this problem. Therefore not to many people put in the ffort to make the changes needed to do this. But on the other hand, there are people that do understand the energy crisis and are working hard to find and use new means that we can use for energy. This is the positive part of the energy situation, people with the knowledge of the energy problem that are trying to make small changes, in which individuals can do and the larger corporations that are trying to find and use new renewable resources to help with the energy problem. Recycling is one of the biggest ways to help with trying to better our planet. This ives people a chance to reuse materials that otherwise would be sitting in landfills. Also there are people that are trying to use waste as a form of energy. There are also products such as bio fuel that is taken from animal oils and vegetable oils that we are now being able to use as fuel in vehicles. Tom Capehart stated in November 2008 that there are increased benefits to using biodiesel because it is made from low cost, diverse, non food feed stocks. Who knows, maybe in the future we might be able to use this form of fuel for another type of energy. I feel that by making people more ware of the problem then more people will get involved. Another way to help with sustainability is to reduce the consumption of natural resources and materials. As with anything we can maybe end up using all of the renewable materials that can make up a new form of energy. One other way would be to maximize energy efficiency. This might be a great way to help with the energy situation, as said by Rick Parks and Kip Grubb, September 2005. As for my sustainability plan, one of the first things that would need to be addressed would be that we are in an energy crisis. I would want to maybe travel the country preading the word of the damages that we are doing to our world and get people informed on the topic. I would want to try to get as many people involved in the support to conserve energy. To get this plan started, I would first start telling people and groups that I would be traveling to spread the information on energy conservation and what the future could hold for use if we do not make the much needed changes. I would want the word to get out about this issue. Second of all I would do some time of fund raiser at each stop I made to raise money for research for other forms of energy. Lastly I would travel the country talking to audiences about the damages that we have done to our planet and what we can do to help fix some of the mess that we have made. I would also offer information that people could take with them after the meetings so that they could read up on more information on the energy crisis. I would ask tor sponsors or ditterent groups to help suppo t rt ne cause and some ot the funding for materials and the traveling to get the word out on this issue. As far as when I would do these meetings, well I would contact schools and energy sellers and ny other type of large group that I could schedule a meeting with. I would try and set the meetings up two weeks apart so that I could allow time for travel and depending where the location was. I would set out at first on a six month tour and try to reach as many people as I could my state. If all went well with that, I would continue on to another state and another after that. Time would vary from place to place, but dedication plays a big part in getting something done about a very real problem. I believe that the benefits of my plan would be getting the information out to people hat do not know much about this problem or that are not aware of it at all. I think that by doing this, this might give people the push that they might need to start to help make a difference in their everyday lives. Some of the challenges that I may face could be the disregard of the information by some. People are used to living the way they have always lived. Sometimes it is hard for some people to make changes. People may also feel that this is not as bid of a problem or that it is not affecting them right now, so why worry about it. Another roblem that I could face is that maybe I might not get much funding or not enough places that would like for me to speak at. This would be hard to get information out to people and to get more people to help with energy conservation. I think that if the government, society and with global support we would start to see some big changes. The government alone has a lot of pull and influences on what people in society do. If the government did more to get information out to people about the energy crisis that we are facing and gave people ways to help with this roblem, I think that would influence many people to change the way the live to help with the energy problem. If society was more informed on the issue, then I also believe that many would try and do their part to help as well. As for globally, if the whole world were to pitch in and help get the word out about energy conservation, then I strongly feel that we would see some very good changes. Conclusion We are in an energy crisis, which is a very big problem. People need to become more aware of this problem and try to do their part to help preserve the non renewable esources that we still have left and to also help the environment by recycling and watching the energy use at home and in the car. One person can only do so much, and we may never see a difference from one person making that change. But if several people started making changes to their life styles, then there is a big possibility that we could start to see a big difference. This is an issue that everyone needs to know about and take seriously. If we do nothing, what will happen to mankind as we know it? What will we allow are childrens tutures to not take action now? ke it we do

Free Essays on Loan Officer

Subject: Loan Officer A loan officer performs many tasks in preparing a loan. A loan officer not only helps an individual or business structure the type of loan they need, but a loan officer will analyze an applicant to decide if they are financially able to repay the loan. In this memo, I will explain some of the job duties and responsibilities, education, technology, and current events that surround my career choice. Duties and Responsibilities There are usually three types of loans 1) commercial, 2) consumer or personal, and 3) mortgage loans. Loan officers are usually specialized in only one of these. Depending on the size of the bank, a loan officer might be specialized in more than one loan category. Meaning, if you work at a small bank branch, you will be more likely to handle all three types. In a larger bank they have departments for each type of loan. There are many steps that a loan officer must take when to approve a business or a person for a loan. First, the officer must take a salesman type role and get the customer into the bank. This step can also be completed over the telephone. The next step is to help the costumer determine the right type of loan that meets their specific needs. Today, financial institutions are finding more and more ways to better serve their customers. As banks and other financial institutions begin to offer new types of loans and a growing variety of financial services, loan officers will have to keep abreast of these new product lines so that they can meet their customers’ needs (1:2). After the loan officer helps determine the correct type of loan, the application process begins. This first step is the gathering of information and it is the loan officer’s job to help the client complete the application and answer any questions. Once the application process is done, the officer w ill take all the information and compute it into a number, or â€Å"credit score†. ... Free Essays on Loan Officer Free Essays on Loan Officer Subject: Loan Officer A loan officer performs many tasks in preparing a loan. A loan officer not only helps an individual or business structure the type of loan they need, but a loan officer will analyze an applicant to decide if they are financially able to repay the loan. In this memo, I will explain some of the job duties and responsibilities, education, technology, and current events that surround my career choice. Duties and Responsibilities There are usually three types of loans 1) commercial, 2) consumer or personal, and 3) mortgage loans. Loan officers are usually specialized in only one of these. Depending on the size of the bank, a loan officer might be specialized in more than one loan category. Meaning, if you work at a small bank branch, you will be more likely to handle all three types. In a larger bank they have departments for each type of loan. There are many steps that a loan officer must take when to approve a business or a person for a loan. First, the officer must take a salesman type role and get the customer into the bank. This step can also be completed over the telephone. The next step is to help the costumer determine the right type of loan that meets their specific needs. Today, financial institutions are finding more and more ways to better serve their customers. As banks and other financial institutions begin to offer new types of loans and a growing variety of financial services, loan officers will have to keep abreast of these new product lines so that they can meet their customers’ needs (1:2). After the loan officer helps determine the correct type of loan, the application process begins. This first step is the gathering of information and it is the loan officer’s job to help the client complete the application and answer any questions. Once the application process is done, the officer w ill take all the information and compute it into a number, or â€Å"credit score†. ...

French Expressions Using Trouver

French Expressions Using Trouver The French verb trouver literally means to find and is also used in many idiomatic expressions. Learn how to meet ones match, find ones way, be lost for words, and more with this list of expressions with trouver. Possible Meanings of Trouver to findto come acrossto come up withto imagine Expressions with Trouver trouver boireto find something to drinktrouver se distraireto find a way to amuse oneselftrouver faireto find something to do, to manage to do somethingtrouver mangerto find something to eattrouver soccuperto find a way to keep busytrouver qui parlerto meet ones match, get more than one bargained fortrouver redire quelque choseto find fault with, criticize, have a complaint about somethingtrouver bien faireto be bound to do somethingtrouver bon de faireto see fit to do somethingtrouver le bonheurto find happinesstrouver bonne mine quelquunto think someone looks welltrouver le cheminto find ones waytrouver une consolation dans quelque choseto find consolation in somethingtrouver le courageto find the couragetrouver des difficultà ©sto come up against difficultiestrouver là ©nergieto find the energytrouver grà ¢ce auprà ¨s de quelquunto find favor with someonetrouver grà ¢ce aux yeux de quelquunto find favor with someonetrouver une idà ©eto hit on an ideatrouver la mort to meet ones deathtrouver le moyen de faireto find some way of doing, to manage to dotrouver plaisir faire quelque choseto take pleasure in doing somethingtrouver plaisir quelque choseto take pleasure in somethingtrouver un planto hit on a plantrouver preneurto find a buyer, takertrouver queto think, believe thattrouver quelque chose son goà »tto find something to ones likingtrouver quelque chose en quelquunto find something in someonetrouver quelque chose mauvais (informal)to not like something at alltrouver quelque chose trop adjto find something too adjtrouver quelquun adjto find someone adj, to think someone looks adjtrouver sa voieto find oneself, find ones life pathtrouver le sommeilto get to sleeptrouver son bonheurto find what one is looking fortrouver son maà ®treto find ones mastertrouver le tempsto find the timetrouver le temps longto find that time passes slowlyaller trouver quelquunto go see someonene pas trouver ses motsto be at a loss for wordsvenir trouver quelquunto come and see someoney trouver son compteto get something out of itComment las-tu trouvà ©(e)  ? What do you think of him (her)?Jai trouvà ©Ã‚  !Ive got it!Oà ¹ est-il allà © trouver à §a  ?Where did he get that idea from? Whatever gave him that idea?Quest-ce que tu lui trouves  ?What do you seen in him?Tu le (la) trouves sympa  ?Do you like him (her)? Do you think (s)hes nice?Tu trouves  ?Do you think so?Tu trouves à §a normal  ?Do you think thats right?bien trouvà ©well-spoken, cleverune formule bien trouvà ©eclever phrasetout trouvà ©ready-made, obviousune excuse toute trouvà ©eready-made excuseune explication toute trouvà ©eobvious explanationune solution toute trouvà ©eready-made solutionun sujet tout trouvà ©obvious topic Possible Meanings of Se Trouver to beto be foundto be situatedto feelto find oneselfto think/consider oneself adj Expressions with Se Trouver se trouver avoirto happen to havese trouver biento feel well, comfortable, happyse trouver bien davoir fait quelque choseto be glad to have done somethingse trouver daccordto happen to agreese trouver dans limpossibilità © de faireto find oneself unable to do, to not be in a position to dose trouver dans lobligation de faireto find oneself compelled to do, to have to dose trouver dans une situation dà ©licateto find oneself in a delicate situationse trouver à ªtreto happen to bese trouver malto pass out, faintse trouver mal davoir fait quelque choseto regret having done somethingse trouver mieuxto feel betterÇa ne se trouve pas sous le pas/sabot dun cheval. Thats not easy to find, not easy to come by.Ça se trouve facilement.You can find that anywhere.Il sen est mal trouvà ©.He lived to regret it.Je me suis trouvà © fin  !I looked like an idiot!Oà ¹ se trouve ...  ?Where is ...  ?Il se trouve... (impersonal)There is/are...Il se trouve que...It happens to be..., As it happens...si à §a se trouve (informal)maybe, its possibleTrouver conjugations

Psychology Essay Example | Topics and Well Written Essays - 250 words - 4

Psychology - Essay Example Piaget divided development into a Sensiormotor Stage (birth to age 2), a Preoperational Stage (ages 2-7), a Concrete Operational Stage (ages 7-11), and a Formal Operational Stage (ages 11- adult). Each stage is marked by certain abilities, such as the ability to understand conservation of mater or the ability for hypothetical thinking. Erikson’s work closely resembles Piaget’s, but it is showing the development of a person’s social intelligence and self-awareness, not cognitive ability. Erikson believed that we went through eight different levels of psychosocial development, each one possessing a unique crisis for the individual’s understanding of who they are and where they fit into society. Stage 1 is Trust v. Mistrust, Stage 2 is Autonomy v. Doubt, Stage 3 is Initiative v. Guilt, Stage 4 is Industry v. Inferiority, Stage 5 is Identity v. Role Confusion, Stage 6 is Intimacy v. Isolation, Stage 7 is Generativity v. Self-absorption and Stage 8 is Integrity v. Despair. Erikson suggests that if the conflict of each stage is not successfully resolved, the final adult will be a person that has emotional baggage. They will have a difficult time reconciling conflicting feelings that should have been resolved at an earlier stage. Both of these theories are as relevant today as they have ever been. Students may use different technology and have a different social environment than they once did, but they still must follow these stages of development in order to be fully functional human

EC3--Movie, book, TV show, or song Essay Example | Topics and Well Written Essays - 250 words

EC3--Movie, book, TV show, or song - Essay Example Hunt Stevenson, the plants now former foreman, travels all the way to Tokyo in an attempt to convince the corporation to restart operations on the Hadleyville Plant. Owing to the desperate nature of the laborers, the corporation agrees to reopen the plant, but institutes changes that drastically affect the workers. The new contracts that the workers are issued clearly contradict the law. This movie is relevant to the topic, contract law, by virtue of highlighting the various issues that are associated with contract law. In the movie, the corporation’s management decided to change elements of their contracts with their workers, making the working conditions literally unbearable. The workers are denied the right to a union, receive lower pay rates than before, each have to learn all the jobs within the factory and are supposed to meet quality standards that are virtually impossible. The management later on decides to loosen up on the standards and harsh regulations that govern the workers on a day-to-day

Chronic Opiod Use after Hysterectomy

Chronic Opiod Use after Hysterectomy Specific Aims The rapid increase in the incidence of opioid-related overdoses and deaths has become a big public health threat in the United States. This opioid epidemic affects more women than men due to higher opioid prescribing and dose, longer period use, and more opioid dependence in women.1 From 1999 to 2010, the rate of opioid overdose caused death increased 5-fold among women.2 Besides the illicit purchase for some women, the initial exposure to opioids for many others may likewise come from the regular medical treatment as prescription opioids are widely used for pain management after surgery.3 As such, the critical research gap on opioids use is that the evidence is insufficient to draw conclusions about optimal strategies for initiation and titration of opioid therapy.4 Several observational studies have investigated the patterns of opioid use for noncancer pain in patients pre and post-surgery, and identified the risk factors of chronic opioid use post-surgery.5-11 Most of these studie s examined the prediction of baseline demographic and clinical characteristics of patients for prolonged opioid postoperative use and suggested that surgery is a risk factor for chronic opioid postoperative use.5-9 Only two studies examined the initial opioid exposure within 6 or 7 days of the surgery date and results are controversial.10,11 One study reported that initial exposure of opioid poses 44% increase risk of chronic postoperative opioid use and another one suggested that this risk would be low and statistically insignificant.10,11 Similar investigation has not been done specifically for hysterectomy, the most frequently performed non-obstetric surgeries in the United States for women of reproductive age.3,12 Pain has been demonstrated as a common symptom before and after hysterectomy.13,14 A small cross-sectional study has examined the predictors for opioid prescription in women of productive age and identified that opioid use was significantly associated with hysterectomy status and pain-related dysfunction.15 Another cross-sectional survey study reported that 32% patients had chronic pain after hysterectomy.14 Neither chronic opioid postoperative use nor initial opioid exposure for acute surgery pain was examined in these two studies.14,15 Filling this gap in knowledge is critical since identifying the risk factors of chronic opioid postoperative use could lead to optimized initial opioid prescribing for acute pain management and reduced chronic opioid postoperative use and improved women health. Our long-term goal is to help reduce chronic use of opioids and optimize the pain management in women after obstetric and gynecologic surgery through identification and dissemination the safer initial opioid prescribing for acute post-operative pain. Our objective here, which is the next step in our long-term goal, is to compare the patters of opioid use pre and post hysterectomy and determine the important risk factors that associate with chronic use of opioids in women post hysterectomy. The national OptumInsight Clinformatics data offers an essential resource to investigate these aims. The availability of clinical diagnoses and pharmacy medical dispensing offers a significant advantage for investigating drug utilization with corresponding clinical conditions in large population. Our team is well suited to conduct this research given extensive expertise in contemporary pharmacoepidemiology, many years of experience on opioid abuse research, prior drug utilization studies using large claims data, and clinical expertise from obstetric and gynecologic physicians. Our specific aims are to investigate patterns and predictors of chronic opioid use in women pre and post hysterectomy with the following analyses: Aim 1: To characterize the patterns of chronic opioid use in women after hysterectomy. Aim 2: To determine the significant risk factors for chronic use of opioids in women after hysterectomy. The first specific aim for this study is to identify patients who chronically take opioids during six months post hysterectomy, and investigate the time and geographical patterns of chronic opioid use in women after hysterectomy. The pattern of chronic opioid use pre- and post-surgery will also be compared in women with varied age, comorbidities, co-medications, as well as types and doses of initial opioid prescribing. The second specific aim is to determine the risk factors that significantly relate to chronic opioid use, and determine if characteristics of initial filled opioid prescriptions significantly associate with the chronic use of opioids after adjusting for other potential risk factors. Many pain related studies have demonstrated that long term opioid prescribing was significantly predicted by patients clinical characteristics and psychosocial factors, including pain conditions, psychiatric disorders, frequency of medical visits, smoking, and pain-related dysfunction.16-18 Therefore, the adjusted covariates in this study would include both demographic and clinical characteristics. B. Significance and Innovation Currently the United States is experiencing an unprecedented opioid epidemic. According to the Centers for Disease Control and Prevention (CDC), opioid-related deaths increased 200% overall from 2000 to 2014.19 During 2014, about 1.9 million people had an addiction of opioids, with overall 47,055 overdose deaths, 18,243 overdose deaths in women, and 18,893 overdose deaths related to prescription pain relievers.20,21 Based on the data reported by the CDC, women are more likely to have chronic pain, be prescribed opioids with higher dose and longer period, and hence progress to dependence.22 Although opioid abuse is a public health crisis, opioid analgesics are still the mainstay for treatment for acute pain after major surgery. In 2014, total 245 million prescriptions for opioids were dispensed from U.S. retail pharmacies.23,24 During 1998-2010, approximately 7.4 million hysterectomies were performed, making hysterectomy one of the most frequently performed surgeries for women in the United States.25 With over 60% of hysterectomies performed abdominally and up to 85% of patients experiencing moderate-to-severe pain after hysterectomy, postoperative pain management becomes very important.26,27 Evidence suggests that intense and long-lasting postsurgical pain can increase postsurgical morbidity, delay recovery, and lead to chronic pain.28 Opioids such as morphine, meperidine, and oxycodone are widely used postoperatively to reduce and manage pain in patients after hysterectomy.29 Women with hysterectomy and high levels of pain-related dysfunction were almost twice as likely to have opioid prescription. More than 85% of women with hysterectomy and a high level of pain-related dysfunction were found to use opioid.15 Hormonal disturbance, hyperalgesia, and iatrogenic effects are potential adverse effects from op ioid use in women after hysterectomy.14,15 The interaction of opioid-induced adverse effects and post-hysterectomy hormonal dysregulation may intensify pain and promote continued use of opioids.15 There are no known studies that evaluate the connection between acute and chronic postsurgical opiate prescription in women experienced hysterectomy. In consideration of the current opioid epidemic it is important to understand how post-surgical pain is managed, and if this setting presents increased risk of opioid addiction among certain groups, or related to particular prescribing practices. The goal of this proposed study is to examine whether opioids prescribed in women following hysterectomy is associated with chronic use of opioids, and to evaluate which factors may predict patterns of opioid use that indicate overuse or addiction. Accordingly, this study first aims to describe the incidence pattern of chronic opioid use in women post hysterectomy. The second aim is to explore the significant risk factors and determine if the characteristics of initial opioid prescribing significantly associate with chronic opioid use after adjusting for other potential risk factors. This study will reveal important insights regarding post-surgical pain management for a common procedure, and determine if certain patient or treatment characteristics increase the risk of chronic opioid use in this setting. We expect that this research will provide evidence for the need to improve clinical practice towards optimized pain management and reduced chronic opioid use in women after hysterectomy through identification the specific opioid, drug type (short-acting or long-acting), and doses that significantly associate with chronic opioid use in women after hysterectomy. Our study will provide sufficient evidence to draw conclusion about optimal strategies for initiation and titration of post-surgery opioid therapy, and enhance evidence-based medicine for opioid use in Rhode Island, and also the United State. This award would enhance my capabilities on handling interdisciplinary studies and further help me to develop my own research projects and seek for external funding. Innovation Our proposed observational studies based on the administrative claims data will allow for investigation of time trends and geographic variation of drug use in large population and address for well-characterized clinical conditions. Our approach will employ state of the art, innovative pharmacoepidemiologic study designs and statistical models, to improve the precision of outcome definition and minimize measured and unmeasured confounding and bias in our estimation of significant predictors for chronic opioid use after hysterectomy. The unintended outcomes from adverse drug effects make the prospective trials unethical. In this circumstance, a well-designed, retrospective observational study with sufficient sample size offers an efficient design to determine if there is an adequate signal for impropriate opioid prescribing to women post obstetrics and Gynecology surgery. The generalizability of study results are guaranteed due to the nationwide large health plan data that the analyses are based upon. C. Approach Data Sources Study data will be derived from the national OptumInsight Clinformatics Data MartTM, a research database spanning January 01, 2010 through December 31, 2013. The Optum Research Database includes about 23 million beneficiaries from the nationwide commercial health insurer, United Healthcare. The data contains health care utilization with transactional reimbursement data from outpatient pharmacy dispensing, inpatient and outpatient services.30 It links administrative enrollment data with the important medical codes including the national drug code (NDC) for pharmacy dispensing, the Current Procedural Terminology (CPT) code for medical procedure, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for diagnosis. The claims data in this database have been adjudicated, ascertained, and deidentified for research purpose. The University of Rhode Island (URI) and OptumInsight Inc have approved utilization of these data. URI already licenses thi s database that it is freely available for faculties to use. Study Population This study will include adult women who receive the hysterectomy surgery between July 01 2010 and June 31 2013 and have at least 6 months of continuous prior coverage under this health insurance plan. This continuous 6-month coverage provides a baseline for defining new drug users, as well as baseline clinical characteristics, such as comorbidities and co-medications. The hysterectomy procedures will be derived from the ICD-9-CM diagnostic codes 68.3x-68.7x, and 68.9x, where 68.3x indicates a subtotal abdominal hysterectomy, 68.4x indicates a total abdominal hysterectomy, 68.5x indicates a vaginal hysterectomy, 68.6x indicates a radical abdominal hysterectomy, 68.7x indicates a radical vaginal hysterectomy, and 68.9x indicates other and unspecified hysterectomy.13,31 Patients with pelvic evisceration (ICD-9-CM: 68.8x) will be excluded. We also will exclude patients with any cancer diagnoses, including malignant neoplasm of the female genitourinary organs-cancer (ICD-9-CM: 179-184), a nd carcinoma in situ of female genitourinary system (ICD-9-CM: 233). Exposure Assessment Opioids in this study include the following medications: codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone. Tramadol and propoxyphene, considered as weak opioids or already off market, will not be included.11,15 The exposure group involves adult women who receive the hysterectomy surgery and fill more than one prescription for opioids on the day of hospital discharge or within 7 days after hysterectomy surgery, provided that they have no exposure to opioids for at least 6 months prior to hysterectomy.11 The 7 days of window is based on the assumption that a filled prescription during this period would likely to treat acute postoperative pain caused by hysterectomy. A comparison group, defined as the patients with no opioids use on the day of hospital discharge or within 7 days after hysterectomy surgery, will serve as a control to make a comparison of risks for chronic use of opioids. The control patients also have no exposure to opioids for at least 6 months prior to hysterectomy. The exposure of opioids will be identified using NDC codes from pharmacy claims data. In this study, exposure assessment includes all characteristics of the initial filled opioid prescription at the day of hospital discharge from hysterectomy or during 7 days post-hysterectomy. The different type of opioids (classified as long or short acting), number of supply days, and oral morphine equivalent daily dose (milligrams) will be assessed and analyzed. Outcome Assessment Since the study focuses on the risk of chronic opioid use after initial exposure to opioids following hysterectomy, patients were followed from the 8th day after hysterectomy to the first day of outcome occurrence. The outcome, chronic use of opioids after hysterectomy, will be defined using trajectory models.11 in which patients with similar patterns of medication filling during follow-up will be grouped together. The trajectory model was initially generated for the purpose of the assessment of medication adherence.32,33 In order to classify the trajectory groups for opioid use during the defined follow-up window, we first generate 6 dichotomous variables to indicate if a study participant fills a prescription of an opioid medication during each of 6 consecutive 30 day follow-up periods.11 we then model these 6 binary indicators of using opioids in each 30 day follow-up period as a longitudinal response in a logistic group-based trajectory.34,35 With a trajectory model, we will estimate the probability of membership of patients in each group, and the probability of the certain opioid exposure over time as a smooth function of time. We will fit the model using 2 to 4 opioid exposure groups with comparison of the Bayesian Information Criterion.36 The number of groups will be chosen based on the value of the Bayesian Information Criterion. In each group, a third-order polynomial (including linear, squared, and cubic terms) of time will be used to model the probability of being exposed to opioids. Patien ts will be assigned to different trajectory groups, which are generated from these models and have highest probability of the membership. Based on the model results, the group of patients with the highest probability of filling opioids over time will be defined as the chronic use. Other trajectory groups were classified as nonchronic users. The trajectory models provide new advanced approaches to utilize the observed data to determine distinct filling patterns of opioids in our study population during the year after hysterectomy surgery. It classifies patients into groups with similar opioid exposure patterns without relying on a priori and subjective cutoff line for the definition of chronic opioid use. The trajectory models will be conducted using SAS Proc Traj (SAS, version 9.4, SAS Institute Inc., Cary, NC, USA). Patterns of Chronic Opioid Use After chronic opioid use is defined using trajectory models, we will compare the frequency of the incidence of chronic opioid use over time from 2010 to 2013. The secular trend will be analyzed using Joinpoint regression program (National Cancer Institute, Calverton, MD) to identify the joint points and slopes. The rates of chronic opioid use in women post hysterectomy will also be compared with varied age, comorbidities, co-medications, as well as characteristics of initial opioids exposure, including opioid types and doses. The geographic variation of chronic opioid use will be mapped and analyzed using ArcGIS 10.5 geographic information systems software (ESRI, Redlands, CA). The opioid prescription policies and socioeconomic status in different states will be compared with the geographic variation of chronic opioid use. Predictors of Chronic Opioid Use We will identify the predictors of chronic opioid use at baseline or the time of the initial opioid prescription. A previous study demonstrated that hysterectomy, older age, and higher levels of pain-related dysfunction were associated with opioid prescription.15 Potential predictors in this study would include age, year of surgery, smoking, illicit substance abuse, alcohol abuse, hysterectomy type, psychotropic medication use, pre-operative depression, pre-operative pain condition, primary indication for hysterectomy, co-medications, and characteristics of the initial opioid exposure. Although the benefits of minimally invasive surgical procedures have been documented,37 hysterectomies performed for benign indications in 2010 in the US still consisted of 40.1% total or subtotal abdominal hysterectomies, 30.5% laparoscopic hysterectomy, 19.9% vaginal hysterectomy, and 9.5% robotic-assisted hysterectomy.21,25 Hysterectomy type has been related to the initial opioid prescription,15 how ever, the results from randomized clinical trials showed that abdominal hysterectomies didnt increase postoperative chronic pain.38,39 The primary indication for hysterectomy is defined based on the following algorithm: (i) precancerous conditions will be assigned the primary indication if endometrial cystic hyperplasia or carcinoma in situ of female genitourinary system is listed as an indication associated with hysterectomy surgery; (ii) whichever is listed first of endometriosis, uterine prolapse, or uterine leiomyoma will be assigned the primary diagnosis associated with hysterectomy if cancer or a precancerous condition is not listed; (iii) endometrial cystic hyperplasia is combined with in situ under precancerous and that pain and bleeding were included as reported reasons for hysterectomy, and (iv) other was assigned the leading for the remaining diagnoses.19 Over 60% of patients have reported pain as pre-operative symptoms for hysterectomy.39 After hysterectomy, the prevalent pain was reduced to 4.7% to 31.9% during 1-2 years after surgery, while new onset pain at follow-up was reported in 1-14.9% patients and increased pain was in 2.9-5% of patients with pre-operative pelvic pain.39 Therefore, in our study, we plan to assess pre- and post-operative pain, as well as the pain conditions, including pelvic pain, back pain, fibromyalgia, and migraine or other headache syndromes using ICD-9-CM codes. Patients with pharmacy claims for opioids or diagnoses for opioid abuse (ICD-9-CM: 304.xx) during the 6-month baseline period will be identified as opioid users prior to hysterectomy. Preoperative depression that has been found significantly associated with postoperative chronic pain,40 will be identified using diagnoses, as well as medication use at baseline. Antipsychotropic medication use will be obtained using prescription information. The psychiatric comorbidity, will be assessed using prescription information instead of ICD-9-CM codes for greater specificity.11 Co-medications refer to the use of other medications on postoperative pain management. The postoperative use of Nonsteroidal anti-inflammatory drugs (NSAIDs) or Acetaminophen with opioids has been found safe and effective on pain relieve with reduced opioid dose.41 All potential predictors, including characteristics of initial opioid use, will be adjusted in multivariate analyses to identify the significant predictors for chronic use of opioids in patients post hysterectomy. Statistical Analysis Statistical tests and modeling will be conducted to identify potential significant risk factors for chronic use of prescribed opioids in women post-hysterectomy. Categorical variables will be examined and compared using Chi square or the Fisher exact test. Continuous variables will be compared using the student t test. The covariates will be selected from all demographic and clinical variables using statistical modeling. A univariate analysis will be performed with the initial opioid exposure variable and then with each covariate added one at a time to monitor the change of the estimate of the major exposure variable. The covariates that modify the estimate of opioid exposure (variable >5%) or significantly predict the chronic use of opioids will be selected for further multivariate analysis. To account for many confounding factors, we will also utilize propensity score matching method to combine all confounding factors into a propensity score. The patients with initial opioid exposu re will be 1:5 matched with the patients without initial opioid exposure using the propensity score with a caliper of 0.01. A multivariate conditional logistic regression model will be utilized to measure the adjusted odds ratio of initial opioid exposure on chronic opioid use in two matched groups. A probability of type 1 error (alpha) = 0.05 will be considered to be the threshold of statistical significance. Tukey-Kramer method will be applied to correct the inflated p value due to multiple comparisons. Statistical analysis will be performed using SAS software (version 9.4, Cary, NC). Sensitivity Studies In order to address unmeasured confounding factors, sensitivity analyses will be conducted in two sections: subgroup analyses and instrumental variables. Subgroup analysis In order to investigate the effects of initial opioid exposure in women post hysterectomy, multivariate analysis will be conducted in the following subgroups: women with postoperative chronic pain, women without postoperative chronic pain, women with postoperative NSAIDs use, women without postoperative NSAIDs use, women with postoperative Acetaminophen use, and women without postoperative Acetaminophen use. Interactions between the drug exposure and the important factors will be examined in the multivariate analyses. Subgroup analyses will likewise be conducted if the interaction is statistically significant. Instrumental Variable We plan to use propensity score matching to address all measurable confounding factors and generate two balanced comparison groups. However, the unmeasurable confounding factors, like confounding by indication, may still impact the study validity. Instrumental variable is an advanced methodology that has been utilized in pharmocoepidemiological studies to control for the unmeasurable confounding factors, such as confounding by indication. In the sensitivity study, we will use the physicians preference as an instrumental variable and reexamine the initial opioid exposure on chronic use of opioids post hysterectomy. D. Timeline Table. Study Timeline of the Study. Time Period Study Progress Before 07/01/2017 Obtain IRB approval and Optum data use permission 07/01/2017 08/01/2017 Complete data cleaning, manipulating, and variable editing. 08/01/2017 10/01/2017 Complete analyses for demographic and clinical characteristics 10/01/2017 01/31/2018 Complete trajectory modeling to determine chronic opioid use. Analyze the time and geographic trends. 02/01/2018 02/28/2018 Submit an abstract to the annual meeting of International Society of Pharmacoepidemiology (ISPE) 03/01/2018 06/30/2018 Complete analyses for specific aim 1 07/01/2018 01/31/2019 Complete predictive modeling as described in specific aim 2 02/01/2019 02/28/2019 Submit an R21 to NIH, and an abstract to the annual meeting of ISPE 03/01/2019 06/30/2019 Compete analyses for specific aim 2, including all sensitivity studies. Submit a final paper to a high impact journal 09/01/2017 12/15/2017 Complete course PHP 2090 01/01/2018 05/15/2018 Complete course PHP 2470

Military Commander & the Law Essay

Both in the civilian and the military population, the issue of legal drinking age has been a contentious issue. The proposal to lower the minimum drinking age among members of the military in different states has attracted a lot of debate all over the United States. The basic argument has been individuals who are able to defend the country and participate in combat missions in Afghanistan and Iraq among other areas are responsible enough to be allowed to legally buy and consume alcoholic drinks irrespective of the age. However, any debate that deals with changes in the law is always a controversial issue. There are a large number of people in support of the lowering of the drinking age in the military to 18 years irrespective of the laws in the state in which the military base is located. On the other hand, it has been opposed by a large number of individuals and groups (Bray & Hourani, 2007). However, it is important to note that if an individual is mature enough to take part in military duties, he is mature enough to drinking and therefore the drinking age in the military should be lowered to 18 years. Surveys carried out in the United States have always indicated that majority of Americans support the abolishment of legal drinking age limits in the military. The Americans are generally for the argument that all individuals in active duties in the armed forces should not be limited by the law to consume beer. Being a democratic country, the policy makers have no option but act according to the will of the majority. In the past, all military officials in active duty were allowed to consume alcohol in their military bases irrespective of the laws limiting the drinking age in the state. This changed in the 1980s when the congress enacted laws that required the states and federal laws on legal drinking age be enforced in the military bases (Powers, 2009). Since then, there have been suggestions to abolish this law in different states. The basic argument has always been if the individual is man enough to be in a battlefield, he should be able to handle beer responsibly. Common sense indicates that an individual is recruited and allowed to work in the military because they are adults and therefore should not be limited by the law (Hoellwarth, 2007). An 18 years individual in the United States has attained the majority age and is considered to have the ability to make informed decisions such as participating in general elections. The person can also take a weapon to defend his country. Does it make sense really for such a person to be denied the right to consume alcohol? I don’t think so. The common believe that tolerance to alcohol increases with age is not necessarily true. There are cases where younger people have been found to be more tolerant. Moreover, tolerance to alcohol is an issue of responsibility and discipline rather than age. Many young people serving in the US military are more responsible that some senior members of the society (Jacobson, et al, 2008). In conclusion, it does not make sense the limit the military personnel from consuming alcohol based on their age. The fact that they are mature enough to take part in combat missions and defend their country suggests that they are mature enough to control their drinking. Moreover, majority of the Americans are in support of abolishing legal drinking age in the military. Reference Bray R. M & Hourani L. L. (2007). â€Å"Substance use trends among active duty military personnel: findings from the United States Department of Defense Health Related Behavior Surveys,† 1980-2005. Addiction; 102(7):1092-101 Gittins, R. A. (1996). The Military Commander & the Law, ISBN 0788172603, DIANE Publishing Hoellwarth, J. (2007). Corps lowers drinking age to 18 in some cases, Retrieved on July 22, 2010 from: http://www. marinecorpstimes. com/news/2007/05/marine_alcohol_070511/ Jacobson I. G, Ryan MAK, Hooper TI, Smith TC, et al. (2008). â€Å"Alcohol use and alcohol-related problems before and after military combat deployment. † JAMA; 300:663–675. Powers, R. (2009). U. S. Military: Military Drinking Age. Retrieved on July 22, 2010 from: http://usmilitary. about. com/library/polls/blmildrinkingage. htm