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

Examine the roles of the witches in ‘Macbeth’ Essay

In the Elizabethan times, the people believed in witches and witchcraft. They were described as ugly and evil. Nowadays the people would not believe in them. The people in the Elizabethan times would be very scared of witches. This was equivalent to the people of nowadays being frightened about terrorists. The people thought that they were powerful beings. They thought that they would cast spells on them; they thought that the witches were the ones that influenced the weather and also someone’s personality. They were most likely to be old women with moles on their body. If the people wanted to find out if someone was a witch or not, they would tie the woman onto a ducking stool and then place them under the water for along time. If the people saw that the woman was dead they would definitely be relieved, as the woman would not be a witch. If the woman survived for a long time in the water then the people would take the woman out and then burn them or they would hang them. For people to be terrified by witches was very common. This was very good for William Shakespeare because then he could make the play much more frightening. This would be equivalent to a horror film nowadays. There are three or four scenes in the book, which include the witches. In the beginning the witches are just making plans about where to meet again. They say that they are going to meet Macbeth on top of the Heath. This scene is important because this is where the witches are telling the audience about where they are going to make the predictions. Another scene that involves the witches is when they are explaining the predictions to Macbeth and Banquo. The three predictions are: Macbeth will be Thane of Cawdor: â€Å"All hail Macbeth, hail to thee Thane of Cawdor† He will be king: â€Å"All hail Macbeth, that shalt be king here after† Banquo’s children will be king after: (to Banquo) â€Å"Thou shalt get kings, though thou be none† Macbeth is very surprised at this point because he says to himself, â€Å"The Thane of Cawdor lives† These predictions are very important because they set the scene for the rest of the play. Further into the book, Macbeth kills King Duncan and Banquo. This happens because the predictions that witches made are coming true. Macbeth wants to know more information about the predictions, † Stay you imperfect speakers, tell me more† The witches are very important and play a very vital role in the story. They are the ones that made the predictions and they are also the ones that Macbeth needs guidance from. The witches would not be very realistic for a modern audience because the people nowadays don’t believe in witches. In the Elizabethan times the scenes with the witches would be very terrifying and horrific for the audience because the people of that time would believe in witches and thought that they were evil and possessed special powers. Nowadays, the audience because of good acting would appreciate the people who would act as witches, and they would also think that the story was well written. The audience would be as horrified with the apparitions as they would be with the scenes with the witches. A modern audience will find the scene very interesting. The two characters that meet the witches are Macbeth and Banquo. When they met the witches, both of them had different views about them. When Macbeth sees the witches he says, â€Å"Speak if you can: what are you?† Macbeth believed in the predictions that the witches made and he took it very seriously. On the other hand Banquo takes it more lightly as it would not affect him, it would affect his children. The audience in the Elizabethan times would favour Macbeth more than Banquo as Macbeth takes the witches much more seriously. Nowadays, not many people would believe in witches and witchcraft and so would not believe in the spells and predictions. The people nowadays would favour Banquo. Banquo and the people of nowadays would agree that the predictions are not true. He has a dream and he starts to believe in the witches, â€Å"To you they have show’d some truth† This shows that Banquo’s views seem to change. Macbeth starts to take the witches much more seriously when he finds out that their predictions are coming true. There is a lot of dramatic impact in the play. The drama includes the battles in the beginning when the Norwegians try to take over Scotland; the murders of king Duncan and Banquo; the hallucination that Macbeth sees with the dagger, which is full of blood and it, is taking him towards killing king Duncan; and the witches with their spells and the predictions. The witches are some of the most important characters in the play because they are the ones who cast the spells and also make the important predictions. The witches would make a dramatic impact on the stage. When the witches cast the spells then the audience would react in a terrified manner. They would believe in what they see because they believed that it was possible that witches existed and it reflected reality. During the Elizabethan times there would have been a lot of limitations. For the battles they were missing sound effects and also the music had to played live instead of a recording; the costumes were not very good; when the witches needed to vanish there was no smoke effect which would make it much more realistic, but they did have a trap door; the problem that there was while performing the part of the witches was that females were not allowed to play, so they had to be played by men; the scenery was unsatisfactory; and they did not have lights which meant that they had to perform during the day. An Elizabethan director would portray the witches as being ugly and terrifying. The witches would probably wear masks that would have a mole on the face. They would try to make them look like old women because these are the kinds of people that the public thought were witches. The director would try to make it realistic just to add dramatic impact. An Elizabethan audience would react in a different way compared to a modern audience. An Elizabethan audience would be terrified as this would be equivalent to a horror film nowadays. They would have thought of the witches as being symbols of evil. A modern director would have a bigger advantage when setting up the play. There would be a lot of facilities that the director could use. He could use the sound effects for the battles; thunder and lightening for when witches were casting a spell; projection; women would allowed to play which would make it much more realistic; there would be better scenery; they could use curtains at the end of the scene just to explain to the audience that the scene was over; and also a modern director could use recorded music instead of having a live band. A modern director might portray the witches the same way that the directors in the Elizabethan times would have except that the part of the witches would be played by real characters. They might use special effects to show witches disappear. A modern audience would react differently after watching the play. They would not believe in witches because they know that it has been proven that witches don’t exist. A modern audience would not react to the play as if it was a horror film but they would think of the play as being very good and interesting. They would watch it for entertainment and the special effects would have dramatic impact on the audience. The impact on the audience would change over the years. The people would not believe in it because they will know that it is proven that witches don’t exist which is why the reaction of the audience would change over time. There were a lot of differences between Elizabethan and modern interpretations of the witches. The director in the Elizabethan times would make the witches wear costumes, and they would try to make them scary for the audience. The audience in the Elizabethan time would be scared as they thought witches were real, whereas a modern audience would not think of it as a horror film but as an interesting story.

Human Performance Technology

Human Performance Technology (HPT) uses a wide range of interventions that are drawn from many other disciplines including, behavioral psychology, instructional systems design, organizational development, and human resources management. It stresses a rigorous analysis of present and desired levels of performance, identifies the causes for the performance gap, offers a wide range of interventions with which to improve performance, guides the change management process, and evaluates the results. Human Performance Technology Process The human performance technology process begins with a comparison of the present and the desired levels of individual and organizational performance to identify the performance gap. A cause analysis is then done to determine what impact the work environment (information, resources, and incentives) and the people (motives, individual capacity, and skills) are having on performance. Solution to performance problems can fail when they are selected to treat only visible symptoms rather than underlying causes. When the root causes of a problem are uncovered and eliminated, however, the likelihood of significantly reducing or eliminating problems is greatly enhanced. Once the performance gap and the causes have been determined, the appropriate interventions are designed and developed. These may include measurement and feedback systems, new tools and equipment, compensation and reward systems, selection and placement of employees, and training and development. The interventions are then implemented and the change process managed. Evaluation is done after each phase of the process. Initially, formative evaluation assesses the performance analysis, cause analysis, intervention selection and design, and intervention and change phases. Then evaluation focuses on the immediate response of employees and their ability and willingness to do the desired behaviors. The final evaluations are centered on improvement of business outcomes (such as quality, productivity, sales, and customer retention, profitability, and market share) as well as determining return on investment for the intervention. Components of the Human Performance Technology One of the most powerful steps a company can take is to establish measurable, observable criteria whereby a competent individual can determine if a specific, critical task has been done correctly and completely. If individuals have no formal, structured means to evaluate their own performance, supervisors will have no structured, formal means to evaluate an individual performance and provide useful feedback. Training can only address skill deficiencies, that is, the â€Å"can't do† versus â€Å"won't do† behaviors. Nonetheless, training can have a dramatic impact by increasing productivity, decreasing unplanned downtime, reducing the learning curve, and reducing trial-and-error learning. A deficiency that companies must often overcome is the lack of standard operating procedures (SOPs), job aids, and other visual tools that can be used to minimize or mitigate process variations introduced by people. The processes, systems, or methods whereby information is conveyed to job incumbents individually and as a group are integral to the total technology plan. Give the workforce early and frequent information. Give all ranks of employees plenty of advance information regarding the impending technological changes. Help them to understand – in clear and simple terms- project objectives. Educate them as to why these technological upgrades are necessary and how they present opportunities for changes in the way things are done. Let workers know that concurrent with your commitment to technology upgrades is an equal commitment to employee development. Assure them that you will provide them with adequate and timely training support. Finally, set up a structure to harvest process improvement ideas during the debugging and trial run stages. A human performance technologist, high levels of human performance is usually accomplished through instructional technology and performance technology. Instructional technology attempts to improve organizational performance through improving the ability of individual to perform. While performance technology attempts to improve organizational performance through improving the work environment and the work practices of the organization. In today's educational environment, educators use computer applications to perform many rudimentary tasks, such as preparing instructional materials, reporting student progress, and delivering instruction. The objective of most performance technology into a work environment should be to assist the teacher in completing the tasks. So, human performance technology applied to the design of teacher tools, which is an electronic performance support tool for teachers that will help them in their work environment and task performance by recording the occurrences of tasks, such as grading, lesson planning and reporting and the amount of time performing the tasks. But most of the teachers are not proficient in using the latest technology so they revert back to the manual way of doing their tasks. They need enough time to use the new technology because current work responsibilities demanded a great amount of time. However, the perception of more time needed to use the technology can be elimina ted when teachers realize that the technology is an easier method of performing some of their current work tasks. Many students have limited access to technology because some educational institution cannot afford to adapt to the latest technology because of limited resources. In some instances technology is provided but students have not yet develop the necessary skills to learn it (e.g. the client are kindergartens.

CAPM and the use of it Essay Example | Topics and Well Written Essays - 1500 words

CAPM and the use of it - Essay Example Capital asset pricing model delivers a very simple and easy theory. It offers an utilizable measure to calculate risk that facilitate financier to find out that how much return they are going to get for putting their funds at risk. This model mainly targets the risk averse investors. Capital asset pricing model is the widely used and mainly preferable model for risk and return used in finance. CAPM specifies the association between the risk and expected return that an investor gets on asset. This model is basically used to determine the expected required rate of return on assets and to determine the price of risky securities in the portfolio. This is the model in which securities are priced in such a manner that investors get compensation for the risk involved in the security by offering them return. Systematic risk is the market risk and the one that cannot be diversified easily or that can totally out of range to diversify away. It includes wars, an unpredictable variation in interest rates and many other macro economic factors. Unsystematic risk on the other hand involves those which can be sort out easily because this type of risk is related by means of the individual or stock an investor has in his portfolio. This is also identified as specific risk. This risk is not exposed to in general as a whole. An investor can diversify away unsystematic risk by raising the figure of stocks in his portfolio. So in technical words it can be stated that unsystematic risk does not move with the market as a whole. According to Modern Portfolio theory, it is concluded that unsystematic risk can be diversified but systematic risk still one of the troubles for the investors which cannot be ignored. So here the capital assets pricing model fully fitted and solve the problem because it is applicable for both type of risk either systematic or specific by diversifying it. CAPM itself exposed to some factors that are prevailing within capital

Source evaluation Essay Example | Topics and Well Written Essays - 750 words - 1

Source evaluation - Essay Example As seen in this crowdsourcing article, collaboration and online organisation is the main objective of this project. Over and above, the theme of internet collaboration and organisation is vivid in all the chapters in the book. This book source is therefore, reliable and useful to students and researchers (Pallof, & Pratt 43). This is because it highlights the basis of learning community via the internet, innovativeness and critical thinking skills it fosters to the internet users. â€Å"The online environment can be a lonely place. Students and faculty alike report feelings of isolation when working online. The benefits of taking or teaching an online class - being able to connect any time and any place, from one’s bedroom in pajamas and bunny slippers or from a library or computer lab – also can be a detriment of sorts given that, for the most part, the people with whom one is interacting are represented by worlds on a screen.† (Pallof, & Pratt, 32) This is an easy to read book where the author, Pallof, & Pratt have taken their ample time to showcase their vivid thoughts and reflection towards online collaboration. They clearly indicate that collaboration and internet organization is the backbone of the media in the present day. The fact that the book highlights the process of media embracing the digital technology in a means to spread out their audiences is a clear sign of contemporary/modern networking and collaborative development. In reference to Pallof, & Pratt (2005), focus is put on using technical and internet related channels to bring people together for their own success. As seen in the book, the authors Pallof, & Pratt (2005), have managed to fill the gap in the internet world by spreading out to digital channels of communication that targets the old internet users and further brings about new internet users for collaborative purpose: The ways in which

The Themes and Purposes of Art Essay Example | Topics and Well Written Essays - 500 words

The Themes and Purposes of Art - Essay Example However, as to the purpose of a work of art, I have often been confused whether art is for art’s sake or art is for man’s sake. Now, the online visit to the National Gallery of Art (NGA) helped me a lot to resolve much of the conundrum of the purpose of art. I found that whereas Benton’s visionary appeals value a human being’s sake or art’s aesthetic purpose, its static dynamism is for art’s sake, which is for eyes that are more skilled. After reviewing Thomas Hart Benton’s Trail Riders, I realized that his iconography is too simple that its naturalistic majesty can be exaggerated in no way. Amid the three-dimensional landscape of heartland America, the iconographic presence of the horse riders who are seen from a remote panorama conveys the static dynamism of his theme. The vantage point of the artist is such that it turns the remote objects and horse-riders almost into abstraction with the use of contours in implied lines. Though the use of light and shadow clearly contributes to the realism of Benton’s work, the glow of the light surpasses the reality of its atmosphere and adds to its surrealism to a great extent. It is the surrealism that evokes motion of spirit in the minds of the viewers. Remoteness is also a prevailing theme and perspective of this piece of Benton’s artwork. It has thoroughly been maintained through the manipulation of shapes of the contents within the works. Even the nea rest objects such as the flowers, the bush, and the stones do not have the individual clarity. Remoteness as well as the zenith of the mountain contributes to the silence of the artwork in which the motion of the riders refers to the fourth dimension, Time. Also Benton’s work can be interpreted from atmospheric perspective. From this perspective, human being’s kinetic smallness has been contrasted with the vastness of the universe. Though the overlapping of the

Applying Philosophy to Life Assignment Example | Topics and Well Written Essays - 1000 words

Applying Philosophy to Life - Assignment Example these setups are extremely vulnerable due to their illness and if the services of hospitals are not under ethical controls, the visitors can possibly get affected by the behavior of hospital staff. Another reason that makes ethical oversight necessary is the sensitive nature of information about patients that is accessible by the hospital staff. The availability of information in digital format renders the hospital patients more vulnerable to misuse of information. This misuse can have far reaching detrimental consequences for the patients and it is therefore necessary to associate this access to information with certain ethical principles to ensure patients are not harmed in any way (Stahl et al, 2013). In the view of Immanuel, moral requirements are interlinked to rationality standards; an immoral behavior is therefore irrational by nature. It therefore follows that for any action to be morally acceptable, it has to be rational; Immanuel has referred to this rationality standard as ‘Categorical Imperative’. Other proponents of this philosophy include Hobbes and Locke. An extension of this notion is the idea of good will which clearly associates the nobility of any action to the principle that governs that action. If this underlying principle follows a moral law, the action regardless of its outcomes should be considered as being moral. As far as the application of principles of this philosophy is concerned, there is a need to apply a high degree of rationality in decisions that are being made. The responses of interviewees need to be judged on rational basis and irrational responses should be regarded as indicators of unethical behavior. Secondly, since morality is re lated to the underlying principles upon which actions are based; the questions asked during interview should attempt to get an insight into the basic principles upon which interviewees base their decisions. This will enable the interviewer to understand the capability of interviewees to work

Aspects of Love in Love Songs Essay Example | Topics and Well Written Essays - 1000 words

Aspects of Love in Love Songs - Essay Example The song has many intriguing special moments in terms of perfect interchange of tempo crescendo and focuses in a way that creates harmony and musicality that makes the song all the more unique and rich in most aspects. The song employs very limited accompaniments and they are each uses rather sparingly appropriately to give the song a clear and prà ©cised feel. The beats, for instance, are specifically light and well-timed with the lyrics to embolden a tender sensation associated with love and romance.The song has a relatively slow romantic rhythm which gives it the completeness and allure associated with love and romance. The slow rhythm is also complementary to the lyrics as it ensures full clarity and heavy articulation that creates the theme of love in a more pronounced and precise way. Not only does it also allow the other accompaniments, especially the violin and acoustic guitar the full incorporation to result in an extremely rich and lulling effect associated with love but a lso ensures sensational and sharp blend that fully maps the lyrics and gives the song a theme so distinct, unique but obviously romantic. The song has a wonderful melody that captures the theme and rhythm in a way the lyrics are easily infused to fully enrich the song. The melody makes the song a little simple so as to easily bring the audience into the participation as it is performed. The accompaniments are a complete harmony with the rich acoustic tune of the guitar setting the stage for a soothing thatching hum of the violin.

Modern medicine vs herbal medicine Research Paper

Modern medicine vs herbal medicine - Research Paper Example The reason for modern medicines to take place in the lives of current world is the non availability of medicinal plants and the difficulty in production. Usually, herbal medicines required much effort from the physicians as well as patients and many a times can involve allergic effects to the patients. Plants have been used for medicinal purpose since civilization has known to exist. Ancient Indian and Chinese people have studied and used herbal plants in a scientific manner to bestow health and wellbeing to people for long time. However, as time passed, their importance and value started declining due to scientifically advancement of human generation. With advancement, physicians started inventing modern technique and methods to impart health to people in a sophisticated manner. In his journal (Wise,1994,pg.46-49) has written that â€Å"It is generally accepted that modern medical science came about in 1876 when Louis Pasteur and Robert Koch demonstrated (almost simultaneously and unknown to each other) the idea that contagion passes from one individual to another†. Normally speaking, we can observe that herbal medicines are in every way better than modern medicines as nature is the best curer by all means. The use of herbs for physical and mental ailments has been practiced since ever by civilizations all over the globe. There were all types of herbal medicines available for any kind of illness in ancient times. All indigenous groups used extensively herbal medicines for all diseases, and procured long life and health from it. However, as natural resources started getting scarce and with population increase, the use of herbs and medicines became lesser and unpopular. Research has revealed that people in different regions of world used same plants for same health problems. The highlight of herbal medicines is that, it gave relief to patients on a long-term basis and impacted less negatively on their health. These herbal medicines are natural form of tre atment and are a gift from nature and require proper guidance from physicians to give full benefit to patients. The herbal medicines were very prominent until the scientist and physicians started discovering new medicines of chemical origin, which gave instant and prolonged benefit to people with health problems. The modern medicines have been ardently proven to be effective in treating diseases and illness of fatal nature .Without modern medicines many diseases would have been difficult to resist before a century or so. It can be definitely stated here that, human life span would have been cut short half if modern medicine would have been absent from our daily life. In the website (Alternative Medicine,2011)it is stated that ,â€Å"Conventional medicine is comprised of drugs that suppress the body's natural immune responses†. It is the world of the American Medical Association (AMA) which is aligned with the multibillion dollar pharmaceutical industry. There is no better med icine when it comes to surgery, emergency and trauma† The modern medicine has many benefits as it has allowed people to live healthily life with more comfort. As per (Singh,2010,pg.17-29)â€Å"Modern medicine has done much in the fields of infectious diseases and emergencies to aid cure†. However, when one focus on the side effects of modern medicines, all its value dooms in to dark. The modern medicines also being very costly, is many a times unaffordable for normal people .Another prominent dark side of modern

Teaching and Culture Essay Example for Free

Teaching and Culture Essay Cumulative cultural texts give a foreground and a context into what to expect for that particular culture. In fact there is a criteria in which any text may be classed as this. Intergenerational, Intertextual, Multidimensional. In short these words mean that the texts within this accumulation relate to each other, they refer to each other within themselves or insinuate links or they apply to the masses and are regarded of any particular text type. In this essay I will be exploring different Cumulative texts within the boundaries of Teaching. By first examining the key arguments of Mitchell and Weber (1999)’s prescribed article and what their views are in which these texts can change teacher Identities. Furthermore comparing and contrasting their study with Dead Poets society (1989) and how typical texts can be linked and provide support for identity within the classroom for both teachers and students. Part A Mitchell and Weber (1999) discuss the importance of the role of cumulative cultural texts in the portrayal of â€Å"The teacher† in society and explore this impact it can have on self-evaluation and analysis of pedagogies of the â€Å"real classroom†. This is done by focusing on a lead text in Dangerous Minds but complimented through comparing and contrasting to intertextual links within the Teaching movie genre. From this examination we can come to the conclusion that from looking at past texts teachers can have some form of model either a how to or a how not on the kind of pedagogies they will engage with and their sense of self as teachers in the classroom. Looking at Dangerous Minds, Good Morning Miss Dove, and To Sir with Love, Mitchell and Weber note the ‘popular texts wouldn’t be popular unless they managed to tap into particular desires of many readers [viewers]’ (Mitchell and Weber, (1999), pp. 167). Texts such as these are a window into the profession of teaching and give society a distorted knowledge on what it is to be a teacher. The dramatization of these texts gives a false sense of expertise to the common man/woman. It leads to an impression that Joe Blow can come up and tell you what it is to be a teacher and how you should go about your classroom. When in fact they are getting a completely skewed view into what the real classroom looks like thus popular culture in the form of the â€Å"hero teacher† having a negative effect on the profession. This leads to the ‘unrealistic and potentially harmful expectations by encouraging teacher fantasy at the expense of reality’ (Mitchell and Weber, (1999), pp. 181). It’s these expectations formed from the cumulative cultural texts which lead to disappointment for both students and teachers. Although these â€Å"hero teachers† stem from real people on the film reel their characters are over romanticised leaving new teachers at a turmoil between the pulling of the popular hero vs. the curriculum. The recurring theme and what can be argued as a centre focus of Mitchell and Webers exploration of the cumulative culture texts of teaching, is that they provide an opportunity for professional development through critical reflection and evaluation. An area in which we can link the contrasting nature between teaching pedagogies in popular culture for uses or reflection and evaluation, is the excerpt where Weber looks at To Sir with love and Dangerous minds. Both of these teachers have been portrayed as â€Å"Hero Teachers† and both have a similar style of racially diverse and disadvantaged rebellious class. As goes with the hero teacher story both teachers break through the barriers faced by these particular children. Who have been recognised as the outcasts of classroom which have been â€Å"turned around† by these teachers Miss Johnson and Sir. But with Webers close analysis between the two we can pick out distinct differences between teaching styles and can be used for some self-evaluation of how to compare your own teaching methods. For example Sir attempts to raise the students intellect through leading by example, guidance to high culture and teaching them self-control, respect and toughness of the mind (Mitchell and Weber, (1999), pp. 178 where as Miss Johnson is ready to step into their shoes on every level including language, dress and position to illustrate to the students that there will be challenges and obstacles in which they have to make their own decisions about. This style lead her to let her arm them with words and ideas in order to make them tougher (Mitchell and Weber, (1999), pp. 178). This little contrast illustrates show teachers can have the same goals and ambitions for their pupils but varying pedagogies will be best suited to you as the teacher and your students. Once this comfort has been achieved there is no wrong or right way to use the classroom. In short Mitchell and Weber argue that teachers should be using popular cultures view on teachers to apply this to their own self-evaluation and self-criticisms of themselves. As this can help us to re-invent and rejuvenate ones role and ones ambitions for what teaching is and how they want to go about teaching their classes on the daily basis. Part B Dead poet’s society (1989) gently slips into sub categorical role of the Hero Teacher in the cumulative cultural texts of teaching. It centres on the teacher John Keating (Robin Williams) taking the creative art of poetry and literature to the highest level of priority within his class room. While simultaneously throwing curriculum and structure out the window. Keating encourages students to go outside the box of Welton colleges standards and become free thinkers. Being a former student of Welton Keating encourages the boys to re-unite an old â€Å"dead poets society† in which the boys would come together and discuss the works of other free thinkers and fight back against the strict views of Welton and their families’ expectations. There are many different forms for representations of teachers within ‘Reels† but the most common and uplifting story which is what seels the movie seats and tickets are the stories of hero teachers. The story of Keating and his throw the curriculum out the window is not dissimilar to the texts in which discovered by Mitchell and Weber in the reading. As discussed before Keating only ads a further end to the spectrum of teaching styles covered in modern day representations of teacher life. The only big issue to be considered when looking back up on theses texts for the purpose of professional development is that they aren’t realistic for the common classroom. Movies always have the perfect conditions or it’s a stable environment designed to the specifications of whatever the director so chooses. Classrooms do not work this way there are many variables and this expectation of the hero teacher can smash the hopes and dreams of many graduate teachers in their pursuit for popularity. Thus we can see the turmoil the teachers in these movies are all perfect souls and do not have underlying ambitions behind becoming popular to students, some people may have hidden motives in which actual learning is set behind of become a hero teacher and getting the status level that people like Keating, Sir and Miss Johnson could achieve. Each in their own way. On deeper analysis of Dead Poets Society (1989) it can be used as a model of what not to do as a teacher. Such as the situation arising between the ambitions of student Niel to follow acting and the performing arts. But this is against the wishes of his parents and he secretly engages with dramatically activities at the encouragement of Keating. As a result the parents find out and a rift is set between Neil and his parents which leads to his death as he commits suicide from the pressure. Evidently this is a reminder of the importance to note the impact and jurisdiction of parents. As teachers we should not intervene in student lives beyond what is necessary, as seen in the movie this encouragement to break the boundaries think outside the box can go too far. Part 3 Essentially I consider that the representations can quite possibly have a positive effect which was well noted by Mitchell and Webber (1999) but can just as much negatively affect a pre-service teachers understanding of what it is for the teacher to do in the classroom. As discussed in part one by comparing to texts of similar contexts which apply to the three criteria of being a cumulative cultural text. These can be used as a mock model in which we can evaluate to ourselves what it means for us to be teachers. But furthermore it can give us insight into the many different ways of teaching. Such as the wildly differing spectrum offered through texts I have looked at. For example the Control styled approach of Sir (Mitchell and Webber, (1999)) and the more involved hold up the mirror lead style by Miss Johnson encouraging students to spread forth and realise their true potentials. Compared to that of Keating in Dead Poets Society who just through curriculum out the window and went for a creative independence lead teaching style. Thus leading to my next point that although there are positives to these texts there are equal negatives that can bring down the teaching profession or set unreasonable expectations on those wishing to pursue the career and become and educator. As mentioned in part 1 ‘popular texts wouldn’t be popular unless they managed to tap into particular desires of many readers [viewers]’ (Mitchell and Weber, (1999), pp. 167). , This highlights the fact that overall these films are not real classrooms and give society and pre-service teachers either a false satisfaction or a welcoming surprise to be introduced into the world of educators. In conclusion I would have to say that the positive far outweighs the negative associated with the cumulative cultural type literature. Therefore texts uch as these can be classed as useful as well as providing a way for teachers to design themselves or re-evaluate their own teaching. It sets a positive eye for the community around teachers and promotes the profession showcasing stories in which teachers are truly making a difference to the lives or their students. These high amount of publication and popularity increases popularity of teachers and the profession in general. These benefits associated with the knowing you can use these texts to model yourself makes them useful.

The 4 Gospels and their Themes

The 4 Gospels and their Themes The authors of the four gospels in the Bible had a specific group of people they wrote to and in this assignment I am going to look at those specific people and what the authors said about the life and work of Jesus. I am going to also going to look at the main themes of these four gospels, beginning from Matthew to John. The author of the book of Matthew is the Apostle Matthew who was one of Jesus` disciples. The gospel of Matthew was written in Greek. The author wrote to a particular group of people mainly Greek speaking Jews, even though the author wrote to certain group of people the writing does have a worldwide outlook. Matthew concentrated more on the fulfilment of the Old Testament than the writers of the other gospels. In Matthew Jesus teaching pointed to the blessings of the kingdom being extended to gentiles. MATTHEWS MAIN THEMES The main purpose of Matthew is to prove that Jesus Christ is the Messiah which means the anointed one. Jesus can also be interpreted as Joshua in Greek which means the Lord saves. Matthewss goal was to convince his readers that the King of kings has come, with this in mind he uses words and names that the Jews are familiar with. Also unique to Matthew is the expression, that it might be fulfilled which is spoken by various prophets.  [1]   THE MAIN PURPOSE AND FOCUS OF MARK The gospel of Mark was written by John Mark. Mark was a close associate of peter, it was from Peter that he received the tradition of things done and said by the Lord Jesus Christ. Mark has more of the preaching of Peter, put together by John Mark. According to early church tradition Mark was written in the region of Italy more specifically in Rome. In book of Mark John Mark explains Jewish customs and interprets Aramaic words John Mark seemed to have an interest in persecution and martyrdom. John Mark wrote that the suffering Jesus was also the Son of God, the Son of Man, the Christ and the Lord. MARK`MAIN THEMES Marks gospel is simple and holds an important account of the ministry of Jesus Christ, with an emphasis on more of what Jesus did than what he said. Mark moves quickly from one scene in Jesus` ministry to another. Even though Mark bases his emphasis on the humanity he does not neglect the deity of Christ. Mark wrote to strengthen and guide the Roman believers who were being persecuted by Nero. After the death of Peter and eyewitnesses to Jesus` life, this gospel message needed to be written down.  [2]   THE MAIN PURPOSE AND FOCUS IN LUKE The writers name is not mentioned but evidence points to Luke. The gospel of Luke was written to Theophilus and the message in this gospel was meant for his own instruction and also for those among whom the book would be distributed. Luke was probably written around A.D. 59-63. The book of Luke would have likely been written in Rome. Luke had an outstanding command of the Greek language. Lukes words in general seem to reveal geographical and cultural sensitivity. Lukes gospel centers on Gods plan to provide salvation to the world. LUKE`MAIN THEMES Luke was written to strengthen the faith of all believers and to give an answer to the unbelievers. It was written to displace and unveil the false reports about Jesus. This third gospel presents the works and teachings of Jesus that are especially vital for understanding the way of salvation. The first two chapters of Luke emphasize the Old Testament and its promises of a Messiah while the third and part of the fourth chapters show clearly that Jesus is the Messiah, who can fight against the evil one, Luke continues in the rest of the chapters to write about the life and works of Jesus and everything that had been revealed by the law, the prophets and the Psalms about Jesus had been fulfilled.  [3]   Luke often stressed the humanity and compassion of Jesus. Lukes favourite expression is the Son of Man. The disciples were witnesses of to this fact and their mission was to share this Good News with all nations. THE MAIN PURPOSE AND FOCUS IN JOHN Some translators have felt that Johns aim was to present a forth from a different view point the Christian message that would appeal to Greek thinkers. John would have been thinking of the Greek readers some of whom were being influenced by heresy. John` main purpose was evangelistic, to build up believers as well as to win new converts. John also focuses on Jesus` claim that He was God by including Christs seven I am statements. John records certain occasions when Jesus equals Himself with the Old Testament I AM. John 8:58 Most assuredly, I say to you, before Abraham was, I AM. JOHN` MAIN THEMES The writer of John also said that These are written that you may believe that Jesus Christ the Son of God and that believing you may have life in His name John 20:31. John also speaks of Jesus as the pre-existent divine Word who became a human being so as to speak the words of God, reveal the glory of Gods grace and truth, to put a bridge between the children of light and the children of darkness, to bring judgment on the unbelieving world and to give eternal life through the gift of the Holy Spirit to all believe and abide in Jesus. John wrote that Jesus was and is the saviour of the world.  [4]   John reveals the Bibles most important message, believe and follow Jesus, because He is the way to eternal life. John speaks of Jesus as the light of the world and the bread of life, the way, the life and the good shepherd. CONCLUSION The four canonical gospels are very detailed and factual about the life and work of Christ. Matthew writing to prove to the Jews that Jesus is their Messiah, while Mark stressed the humanity of Jesus but he does not neglect His deity. Luke wanted to show that the place of the gentile Christian in Gods kingdom is based on the teachings of Jesus. Luke` main theme is the nature of Jesus Christ` messiah ship and mission. The gospel of Luke presents Jesus in ways that would appeal to an audience of high minded gentiles. The gospel of John is presented firstly with a prologue or introduction. John speaks of Jesus as one sent from God to reveal His love and grace to man. All the four gospels have unique story on the life and ministry of Jesus Christ and they all speak of one person only Jesus who is the saviour of the Jews and the saviour of the world. All the resources I used are very helpful for doing a research like this one and I would recommend any theological student to use these book s when doing their essays or research work.  [5]