Research into the history of klinefelters syndrome

Research into the history of klinefelters syndromeMany chromosomal ab familiarities occur early in develop workforcet and involve the end up chromosomes. Klinefelters Syndrome falls directly into this category. Klinefelters Syndrome is a hereditary condition affecting the male population. The following in strivingation observes who discovered Klinefelters Syndrome and when it was first diagnosed. The etiology or herit adapted and environmental factors of the condition ar discussed as good as perform description of the disability and the clear diagnostic criteria. The affects of Klinefelters Syndrome argon more(prenominal) recognized in adulthood, when it is typically diagnosed. Many Klinefelters patients live out their accurate lives without ever knowing they let the condition. Upon conclusion, there should be an adequate amount of information that impart give you, the reader, valuable knowledge into the diagnosis and treatment of Klinefelters Syndrome. news reportKlinefel ters Syndrome was first diagnosed in 1942 at the Massachusetts planetary Hospital in Boston Massachusetts (Schoenstadt, 2006). Dr. Harry Klinefelter was completing his fellowship at the Massachusetts General Hospital when he was assigned to work with Dr. Fuller Albright, in any case known as the father of endocrinology (Bock, 1993 Klinefelter Syndrome, 2006). Dr. Klinefelter came to examine nine adult men that had a harsh set of symptoms during the course of his fellowship (Klinefelter Syndrome, 2006). Dr. Klinefelter organized a case study that involved these nine men and their similarities and was encouraged by Dr.Albright to lead the study (Klinefelter Synrome, 2006). The daybook of Clinical Endocrinologywas published in November of 1942 with the completed case study of these nine mens similarqualities, which Dr. Klinefelter identified as Klinefelters Syndrome (Klinefelter Syndrome,2006). The report written by Dr. Klinefelter on these men described them as having testicular d ysgenesis, elevated urinary gonadotropins, eunuchoidism, azoo spermatozoonia, and gynecomastia, all of which concur an effect on the underdeveloped size of the testes, the lack of the amount of testoster one and except(a) produced by the testes, and sterility (Schoenstadt, 2006 Visootsak Graham, 2006). These adult males also exhibit enlarged breast and sparse facial hair (Schoenstadt, 2006). Two crowds gear up out fourteen historic period by and by Dr. Klinefelters veritable description of the syndrome, that the buccal mucosal cells contained an supererogatory chromatin mass or that the cells were chromatin positive (Klinefelter, 1966). Although the patients were described as having a positive egg-producing(prenominal) sex chromatin, Dr. Klinefelter states that the patients argon phe nonypic males and should never be considered otherwisewise (Klinefelter, 1996).Fourteen years after Dr. Klinefelter first diagnosed Klinefelters Syndrome, another case study was performed to further understand the characteristics that stipulate the condition (Klinefelter Syndrome, 2006). In 1956, Dr. Joe Hin Tjio and Dr. Albert Lavan took the research further to determine the factors that made those men with Klinefelters Syndrome dissimilar from universal adult males finished genetical research (Klinefelter Syndrome, 2006 Schoenstadt, 2006). With the advanced data-based methodology available, Dr. Joe Hin Tjio and Dr. Albert Lavan set that humans had 23 pairs of chromosomes, confirming 46chromosomes, which prior to this time there was thought to be 48 chromosomes (Bock, 1993Klinefelter Syndrome, 2006). This clarification by Dr. Tjio and Dr. Lavan is the basicfoundation for modern cytogenetics, the study of chromosomes and diseases originating fromnumerical or structural abnormalities in chromosomes (Klinefelter Syndrome, 2006). Dr. Tjio and Dr. Lavan discovered that men with symptoms of Klinefelters Syndrome had an unnecessary sex chromosome that created the chro mosomal ar dropment of XXY, which is distinct to the normal male chromosomal arrangement of XY (Klinefelter Syndrome, 2006 Schoenstadt, 2006,). Klinefelter Syndrome was still believed to be an endocrine disorder of unknown etiology at this time (Visootsak Graham, 2006).In 1959, just three years after Dr. Tjio and Dr. Lavan made their historical discoveries, an English police detective by the name of Dr. Patricia Jacobs and her associate Dr. J. A. Strong published a study supplementing earlier studies (Klinefelter Syndrome, 2006 Noble, 2003). Dr. Jacobs and Dr. Strong found the link between the endocrinal disease and the extra X sex chromosome (Noble, 2003). Dr. Jacobs linked forty-s until now chromosomes in Klinefelters Syndrome males and determined it to be the X chromosome, which she considered an aneuploidy defined as an unusual number of chromosomes and labeled 47, XXY (Bock, 1993 Klinefelter Syndrome, 2006 Schoenstadt, 2006).The 1970s brought forth a larger examination of mal es innate(p) with Klinefelters Syndrome (Bock, 1993). During this time doctors began screening newborn male babies for the extra chromosome (Bock, 1993 Visootsak Graham, 2006). The or so signifi seatt of the studies done at this time was sponsored by the National Institute of baby Health and Human Development(NICHD) whom examined over forty thousand infants for this extra chromosome (Bock, 1993Visootsak Graham, 2006). This study was important for the reason that well-nigh studies doneprior to the 1970s were biased and primarily done on adult males in mental institutions and thepunishable system (Visootsak Graham, 2006). At this time is when the prevalence of Klinefelters Syndrome was noticed as frequently as one in five hundred to one in one thousand male newborns (Bock, 1993 Visootsak Graham, 2006). Also observed in this study was the reduction in pitch and language abilities as well as diminishd drill and spelling achievement (Bock, 1993 Visootsak Graham, 2006). Along w ith these disabilities, Klinefelters patients are characterized by an increased tendency towards fertility, endocrinal, and psychiatric disorders (Noble, 2003). This study demonstrated that more or less but not all of these males born with the extra chromosome will have these characteristics, and many demonstrate varying degrees of the characteristics (Bock, 1993 Visootsak Graham, 2006). Based on this research it has been found that the extra X chromosome that causes Klinefelters Syndrome is very common, however, the symptoms and characteristics that are most recognizable are quit uncommon (Bock, 1993). Most males are not diagnosed as having Klinefelters Syndrome until they reach adulthood, and many that have the syndrome are never diagnosed as having this chromosomal defect at all (Bock, 1993). One pediatrician at the University of Colorado aesculapian School in Denver and the director of the National Institute of Child Health and Human Development (NICHD) during the major scree ning research referred to these newborn males as not having Klinefelters Syndrome because of the possibility that the characteristics may not develop into a syndrome (Bock, 1993 Visootsak Graham, 2006). aetiology and Genetic FactorsEvery normal human cell has 46 chromosomes that are made up of 23 pairs (Stewart, 2007). Of these 23 pairs, there are 22 that are exactly the same in both males and females calledautosomes (U.S. National Library of Medicine, 2010). The 23rd pair of sex chromosomes is what makes males and females antithetic in that the male will have only one X and Y chromosome whereas the female will have both copies of the X chromosome (Stewart, 2007 U.S. National Library of Medicine, 2010). During the formation of the egg and the sperm, or gametes, the chromosomes are halved through a process called meiosis (Stewart, 2007 The Dorsey, 2009). Cells that carry a single chromosome such as the X or Y chromosome are called haploid cells (The Dorsey, 2009). When the egg a nd sperm join carrying 23 chromosomes each they create the fertile egg, or zygote, which has 2 haploid sets of chromosomes (The Dorsey, 2009). therefore, the baby receives two copies of each chromosome, 46 total chromosomes, just kindred the parents (Stewart, 2007).The extra X in Klinefelter Syndrome is ca utilise from either nondisjunction or anaphase lag. Nondisjunction occurs when the chromosome pairs do not separate as they are intended in the meiosis I or meiosis II stage (Pineyard Zipf, 2003 Stewart, 2007). When this happens there may be a chromosome pair with 24 chromosomes instead of the 23 chromosomes (Stewart, 2007). If this chromosome pair of 24 joins with an egg or sperm with 23 chromosomes then it results in a karotype with 47 chromosomes (Stewart, 2007). In this case there will be three copies of chromosomes rather than the usual two copies of chromosomes (Stewart, 2007). The sperm or egg may donate the extra X chromosome at conception causing a chromosomal abnorma lity(Mayo Foundation for Medical Education and Research, 2008 Stewart, 2007). This forms the XXY chromosomal formation, which is diagnosed as Klinefelters Syndrome. At least half of 47, XXY conceptions are spontaneously aborted (Pineyard Zipf, 2003). The chromosomalabnormality is random and not known to be caused by any environmental factors (Genetic Science Learning Center, 2010 Mayo Foundation for Medical Education and Research, 2008 National Institute of Health, 2007).This anomaly happens entirely by chance and is orthogonal to family history prior to the male barbarians birth (Mayo Foundation for Medical Education and Research, 2008). This is to say that the male embryos likelihood of being born with Klinefelters Syndrome is not increased or decreased by what the parent does or does not do (Mayo Foundation for Medical Education and Research, 2008). Klinefelters Syndrome is not affected by race (Chen, 2010). This is a exclusively random occurrence of the sex chromosomes not s uccessfully separating during the formation of the egg or the sperm (Genetic Science Learning Center, 2010). Once this occurs the extra chromosome is then copied into every cell of the embryo (Genetics Science Learning Center, 2008).thither are extremely rare cases when there may be three or four extra X chromosomes in all copies of the cells known as 48,XXXY or 49, XXXXY (Stewart, 2007). The 49, XXXXY mosaic is also known as Fraccaros Syndrome and is the most rare form of Klinefelters Syndrome (Duenas et al., 2007). This rare chromosomal abnormality results in more exaggerated features of Klinefelters Syndrome (Stewart, 2007). There are instances where an extra X chromosome is found in only some of the cells (Stewart, 2007). This can be found as twodifferent chromosomal patterns (Stewart, 2007). One pattern occurs when some cells have 46 chromosomes and some have 47 chromosomes (Stewart, 2007). The other pattern is called the mosaic XXY syndrome, or chromosomal mosaicism, and affe cts approximately six percent ofthese cases, with the most rare cases being the 48, XXXY or the 49, XXXXY, or other arrangements of X chromosomes (Stewart, 2007).The mosaic XXY syndrome occurs only after conception from a mistake in cell division (Stewart, 2007). Anaphase lag is a result of a gamete lacking a sex chromosome (Klinefelter, 1966). When this chromosome lags it is not merged into the new cell during the mitosis stage (Kinefelter, 1996). Anaphase lag is thought to be a reason for the mosaic variations of Klinefelters Syndrome (Klinefelter, 1966).Although the chromosomal abnormality of 49, XXXXY is considered to be a variant form of Klinefelters Syndrome, it appears to have a very independent, distinct phenotype (Duenas et al., 2007). Males that show the 49, XXXXY chromosomal structure have much more severe clinical features than that of a Klinefelters Syndrome male (Duenas et al., 2007). This is the most rare of the Klinefelters Syndrome variants and has been inform in over one hundred cases with the frequency being approximately 1 in 85,000 newborn males (Duenas et al., 2007).There have been reports of an blush more extreme variant of Klinefelters Syndrome mosaic in newborn males (Duenas et al., 2007). This variant is a 47, XXY/48, XXXY/49, XXXXY mosaicism and has only been inform in three cases according to a researcher in Mexico (Duenas et al., 2007). This means that the male newborn would have the whole spectrum of XY variations.Another variant that affects only males is the 46, XX chromosomal variation (Bock, 1993). This condition occurs when individuals have two X chromosomes in each cell, but are male in appearance. These individuals have male external geniltalia. These individuals also havesmall, undescended testes possibly on with an urethra opening on the underside of the penis. A small amount of 46, XX Males have external geniltalia that dont clearly resemble either male or female genitalia. These individuals are typically raised mal e. Phenotypically, there are three groups of these sex-reversed individuals. The first group includes phenotypically normal XX Males, the second group includes the males with genital ambiguities, and the third group is the true hermaphrodites (Bock, 1993).Description of Characteristics or TraitsKlinefelters Syndrome has only one constant physical description and that is the small testicular size (Visootsak Graham, 2003). Boys with Klinefelters Syndrome have variablephenotypic characteristics with no obvious facial dysmorphology (Visootsak Graham, 2003). The presence of gynconemastia, or enlarged breast, and other findings of eunuchoid body habits and sparse body hair vary (Visootsak Graham, 2003). Eunuchoid or eunuchoidism is defined as an abnormal condition in males, characterized by underdeveloped reproductive organs with some female characteristics, such as a higher voice or the lack of facial and body hair that results in the lack of male sex hormones (Eunuchoidism, n.d.). Go nadotropins are produced by glands, such as the pituitary, and can result in sparse body hair when not produced adequately (Gonadotropin, 2010). The medical dictionary states that eunuchoidism is marked by a deficiency of sexual development with the diligence of prepubertal characteristics, and oftenhas the presence of characteristics that are typical of the opposite sex (Eunuchoidism, n.d.). Another likely characteristic is azoospermia (Schoenstadt, 2006 Visootsak Graham, 2006). Azoospermia is defined as having little or no sperm count (Azoospermia, 2010). Testiculardysgenesis, or gonadal dysgenesis, is another characteristic of Klinefelters Syndrome (Schoenstadt, 2006 Visootsak Graham, 2006). Testicular dysgenesis is considered a reproductive system developmental disorder that causes a continuous tense loss of primordial germ cells, or cells that create gametes, in the developing gonads of an embryo (Gonadal dysgenesis, 2010). This gonadal dysgenesis can lead to the extremely hypoplastic, or underdeveloped, and disfunctioning gonads mainly dispassionate of fibrous tissues (Gonadal dysgenesis, 2010).Most infants and children with the 47, XXXY chromosomal abnormalities go through normal growth stages. It is not until puberty that the Klinefelters Syndrome characteristics or traits become more prevalent and noticeable (Visootsak Graham, 2003). There is a significant increase in height between the ages of five and eight (Visootsak Graham, 2003). Another characteristic of Klinefelters Syndrome is the elongated length of arms and legs (Klinefelter, 1966). There is a decrease in androgen production that causes the secondary sexual characteristics to not fully develop (Visootsak Graham, 2003). An androgen is any substance such as androsterone or testosterone that supports male characteristics (Androgen, n.d.). Typically Klinefelters males are infertile (Visootsak Graham, 2003). However, there have been cases of impregnation without the financial aid of med ical technology (Visootsak Graham, 2003).Autoimmune diseases such as juvenile arthritis can also be present in Klinefelters adolescents. Whereas boys with Klinefelters Syndrome are generally tall with long limbs andremain thin until puberty, they tend to suffer from obesity latter in life. Neurocognitive do of Klinefelters Syndrome may be more subtle than that of the physical stigmata. Klinefeltersmales have been found to have relative deficits on vocal IQ subtests and have verbal IQ scores around 20 points lower than those of unaffected siblings. There are also deficits in articulation, word finding, phonemic processing, verbal computer storage, language comprehension, spontaneous expression problems, as well as linguistic processing speed. It seems that the speech/language problems and some motor deficits are most common in Klinefelters males that have an extra X chromosome. Ninety-two percent of individuals with Klinefelters Syndrome confirm difficulty learning to read. Seve nty percent had reading achievement discrepancies or absolute reading deficits on standardized testing. A group of boys with mental backwardness and suspicion of fragile X were subject to a genetic screening and the results showed that eight of these boys had Klinefelters Syndrome. Most of the more extreme verbal, visuospatial, and motor skills, such as found in mental retardation and fragile X syndrome are typically spared. However, some boys with Klinefelters Syndrome suffer from silly manual dexterity and are commonly found to be clumsy and below average in sports (Wodrich Tarbox, 2008).There are many different factors that may underlie linguistic and reading problems. One possibility is a dysfunction of the left hemisphere that may be related to diminished gray affaire or a lack of hemispheric asymmetry, or both. It is also possible that executive and head-on deficits may be a cause (Wodrich Tarbox). There is secern that language is a fundamental issue for Klinefelters ch ildren and this can result in further scholastic issues. This problem seems to manifest as dyslexia as defined by poor reading in the setting of normal learning.Klinefelters males have also been observed to have difficulties with arithmetical functions. The deficits in auditory processing and verbal memory are the two key cognitive processes thatunderlie these difficulties. These deficits are also true for normal chromosomal children with dyslexia. The findings are supportive of the concept that defects in frontal systems seem to be caused by a language-based, left frontal-systems problem (Geschwind Dykens, 2004). self-aggrandizing Klinefelters males have reported to have difficulties with mental flexibility (Wodrich Dykens, 2004). Even with these studies, it should be storied that not all adults that have Klinefelters Syndrome show these guileless patterns of verbal deficits that are observed in children (Geschwind Dykens, 2004). However, these findings are not appropriate f or all Klinefelters males, many of which complete high school and move on to post-secondary knowledge successfully (Wodrich Tarbox, 2008).Two characteristics that has been falsely associated with Klinefelters males in the past, is sociopathy and criminal behavior. There is, contrary to this belief, fewer psychiatric problems reported among these individuals. However, there are commonly traits of introversion, unassertiveness, and a paucity or lack of ambition. There are also possible traits of impulsivity and social inappropriateness (Wodrich Tarbox, 2008). A Reiss profile of Fundamental Goals measurement was used to assess the degrees of which Klinefelters males were move in 15 domains (Geschwind Dykens, 2004). The Reiss Profile generates a profile that is based on the motivational sensitivities across the domains of aversive sensations, citizenship, family,curiosity, honor, independence, food, order, physical exercise, rejection, power, sex, socialcontact, vengeance, and soc ial prestige. The Reiss Profile is a well-established psychometricmeasure that is being used more and more to assess people with and without mental retardation(Geschwind Dykes, 2004). The results suggested that the Klinefelters male group was notparticularly motivated by the need for social prestige, independence, or the desire to seek vengeance. This group was also not motivated to avoid physical pain. The general motivator for all the Klinefelters males in this group was curiosity. There were no age effects to this study (Geschwind Dykes, 2004).Characteristics in AdulthoodThere is a persistent deficiency of androgen in adulthood that can result in the loss of libido, decreased muscle bulk and tone, decreased debone density, a propensity for thromboembolism (an obstruction in a vein or artery from a blood c diffuse), and an increased risk of mortality from cardiovascular and diabetic complications. A common characteristic for Klinefelters adults is gynecomastia (Wattendorf Muen ke, 2005). Gynecomastia involves the risk of developing breast carcinoma. There is 200 times more of a risk for Klinefelters males to develop breast carcinoma than other karyotypically normal individuals. This may be a result of the estradiol (the prominant sex hormone in females) to testosterone ratio being so much higher that karyotypically normal men. Another possibility is that it is caused by the increase of peripheral conversion of testosterone to estradiol (Visootsak Graham, 2006).There are different views as to whether Klinefelters adult males are more obstreperous or have a greater chance of psychological issues depending on the resource. One study describes the differences as relative to individual testosterone levels and the age at which they legitimate the diagnosis (Morris, Jackson, Hancock, 2009). Equally, there is an impact from the way the diagnosis is reacted to by the Klinefelters male, the family, and friends or peers. The seven major themes that emerged from this study were the diagnosis, the testosterone treatments, healthcare problems, appearance, self-identity, relationships, and school and education. Of the Klinefelters adults studied, 60 % reported clinical levels of anxiety and 34% had clinical levels of depression. The results of this study show that a prolonged lack of testosterone can have far reaching negative effects on the Klinefelters adult (Morris, Jackson, Hancock, 2009). The historical studies show a disturbingly increased risk for psychiatric disturbance, criminality, and mental retardation. However, these results are outdated and extremely questionable effrontery the initial examinations were given to institutionalized populations (Chen, 2010).Differential DiagnosisClassic Klinefelters Syndrome, 47, XXY, cases make up approximately 80-90% of all Klinefelters diagnosis. There are approximately 6-10% of these cases that are mosaics, which are the cells with 46, XY/47, XXY 46, XY/48, XXXY and 47, XXXY/48, XXXY (Chen, 20 10 Visootsak Graham, 2003 Visootsak Graham, 2006). In 5% of the cases there are two X chromosomes without a Y chromosome or 46, XX (Visootsak Graham, 2006). The other cases were karyotypes 48, XXXY, 48, XXYY, 49, XXXXY, and 49, XXXYY (Visootsak Graham, 2003). Approximately 1% of these cases are ascribable to a structurally abnormal X with a normal X and Y chromosome described as kayotypes 47, X,i(Xq)Y and 47, X,del(X)Y (Chen, 2010). Klinefelters Syndrome variants occur much less frequently than the classic 47, XXY chromosomal abnormality (Bock, 1993 Visootsak Graham, 2006).Klinefelter variant 48, XXXY is characterized by being average or tall stature with visual hyperterlorism, which are widely spaced or belatedly set eyes flat nasal bridge curving of the fifth finger, or clinodactyly. Other characteristics are small penis and testicles with hypergonadotropichypogonadism, which is the absence or decrease in function of the male testes. Theses individuals intelligence quotien ts range from 40-60. Variant 48, XXYY is characterized by having a tall stature, an eunuchoid habitus with long legs, sparse body hair, small testicles and penis, hypergonadotropic hypogonadism and gynecomastia. These individuals intelligence quotients range from 60-80.Males with variant 49, XXXXY are severely affected. They have smaller than averagehead circumference also known as microcephaly, short stature with ocular hypertelorism, flat nasal bridge, and upslanting palpebral fissures. Cleft palates are present along with small geniltalia and a heart defect known as patent ductus arteriosus. These individuals intelligence quotients range from 20-60. (Visootsak and Graham, 2003).Klinefelters Syndrome 47, XXY, has no major physical signs, which explains why it may go undiagnosed or misdiagnosed throughout an individuals life. Also with no physical signs, it is truly only diagnosed when genetic testing occurs for a variety of unrelated reasons. Klinefelters Syndrome may be diagnosed prenatally or during early childhood, as an adolescent during puberty, or as an adult when there are recognized fertility problems (Bock, 1993). Klinefelters Syndrome can be diagnosed prenatally through amniocentesis or chorionic villus sampling (Bock, 1993). These tests are normally done if the pregnant woman is elder than 35, if there is a family history of genetic defects, or when other medical indications exist (Bock, 1993). A pediatrician may suspect a male child as having Klinefelters Syndrome if there are delays in learning to talk or difficulties in reading and writing as well as physical abnormalities during adolescence (Bock, 1993).Treatments and Interventions each(prenominal) hope is not lost when it comes to the treatment and interventions of the undesirable traits and characteristics that males diagnosed with Klinefelters Syndrome may display or develop. It is recommended that Klinefelters males have a comprehensive neurodevelopmentalevaluation as soon as they have be en diagnosed. A multidisciplinary developmental evaluation can determine the appropriate treatments during infancy and early childhood. These treatments may include physical therapy, infant simulation programs, and speech therapy (Wattendorf, 2005). If the language difficulties are detected in childhood, then there is more of a possibility for intervention.The language barriers that Klinefelters males may have to cope with can not only affect their academics, it can obstruct their building of social relationships and learning social skills necessary for these relationships. Here is where the Klinefelters child could benefit from a social skills formulation program. In a social skills training program, the Klinefelters child will be able to practice talking and listening, observing childrens making friends processes, sharing of information, attitudes, and beliefs. This will also assist them in proper classroom behavior and playground behavior. Language disabilities and barriers can prevent Klinefelters males from fitting in socially, so this kind of intervention and assistance can benefit the child greatly. Hearing can be an issue if frequent ear infections occur. Hearing test and screens should be done to ensure that a hearing impairment is not a part of the language difficulties. If the Klinefelters child is not communicating effectively with single words by the ages of 18 to 24 months, then consultation with a speech and language pathologist will be very beneficial (KlinefelterSyndrome Information, 2002).Teachers should be informed of the difficulties that a Klinefelters child may be dealingwith in the classroom. A teacher may consider the Klinefelters child to be lazy and daydreaming and a teacher may even forget the child is even in the room. This can result in the Klinefelterschild falling behind and eventually being held back a grade. down the stairs the Public Law 94-142, theIndividuals with Disabilities Education Act, adopted by Congress in 1975, all children withdisabilities have a right to a free, and appropriate public education (Klinefelter SyndromeInformation, 2002).Once the Klinefelters male reaches puberty there is usually an inability to produce a normal amount of testosterone. This along with hypogonadism can result in impaired bone mineral density and skeletal muscle development. Also associated with testosterone deficiency is a decrease in libido and energy (Wattendorf Muenke, 2005). Androgen therapy or Testosterone Treatment should begin by time the Klinefelters male reaches middle school, approximately 12 to 14 years of age, based on the level of pubertal development (Klinefelter Syndrome Information, 2002 Wattendorf Muenke, 2005). Testosterone Treatment will ultimately increase the muscle size and strength, as well as, promoting the growth of body and facial hair. It must be noted that Testosterone Treatments can also beget on psychological changes. It is important to adequately inform the parent(s) and the c hild of these changes so that they can make the most informed decision (Klinefelter Syndrome Information, 2002). There are different ways to receive Testosterone Treatment and that is through injections, transdermal (patches, gels, or creams), spontaneously, or implantation. The kind of testosterone injection will dependmainly on the dosage used and the country in which you receive the injections. Some injectable testosterone esters are Testosterone enanthate, Testosterone cypionate, Sustanon, Testosterone propionate, Testosterone phenylpropionate, Omnadren, and Aqueous testosterone suspension.Types of transdermal patches are Androderm and Testosterone TTS. Two different kinds oftestosterone gels and creams are Androgel, and Testim. A few oral supplements includeMethyltestosterone and Testosterone undecanoate. The last form of Testosterone Treatment is the Subcutaneous testosterone pellet, which is delivered by implanting a pellet of pure, crystalline testosterone under the skin of the buttocks or abdomen (Testosterone Types and Delivery, n.d.).Adult males with Klinefelters Syndrome usually develop gynecomastia which predisposes men to breast pubic louse. Therefore, it is important that Klinefelters males do monthly breast examinations. If gynecomastia causes psychological or physical problems, then possible treatment would be cosmetic surgery to remove the breast tissue (Wattendorf Muenke, 2005). Swerdlow et. al (2005) stated that men with Klinefelter Syndrome have elevated risks of several cancers. Prostate cancer, along with breast cancer was more prevalent. Men with Klinefelter Syndrome are also at a substantially higher risk for non-Hodgkin lymphoma, and possibly lung cancer. Breast cancer risk is higher in 47, XXY mosaics. Adult males may face possible infertility issues due to the lack of testosterone production, but if diagnosed early on, this can be minimized and they will be able to reproduce without outside assistance.SummaryKlinefelter Syndrome is one of the more recently discovered medical syndromes. Klinefelter Syndrome is not one that causes major dysfunctions and is usually only discovered during genetic testing for infertility or during prenatal testing due to maternal age or prior genetic issues within the family. Because Klinefelter Syndrome has not had a lot of research until the last few years, there is no federal funding set aside for this syndrome. Families with sons that are found to be affected by it have no real support system that is knowledgeable of this syndrome and have to research on their own and create resources to fit their situation as none are available in most areas.

Patient Healthcare Using SMS Technology Application

persevering wellness c atomic number 18 exploitation SMS Technology natural coveringChapter 1 Introduction to forbearing grapple development SMS Application perseverings travel considerableer distances for the opinion of advisor which is non affirmable either overdue to patient situation or due to distances. enhancement of health c atomic number 18 in assorted locations and separate remote argonas erect be turn overd apply peregrine phone industrys 1.1.1 Problem Statement schooling of wandering communication meshs playing an all grave(predicate) part in the enhancement of a vigorous medicine. long-suffering perplexity Using SMS Application re lays a vicapable root of patient c be much(prenominal) as text messaging and booking accommodations use mobile phones, which be best aspects of mobile medicine. The main appraisal is correct patient b opposite to healthc atomic number 18 encouraging patients to riding habit mobile health finish and stick u ping people with long term conditions 5.1.2 ObjectivesIncredible step-up of mobile communication and recognition of crude generation Wireless protocols has initiated the advance SMS ground health check checkup applications. Following that facts Patient cargon using SMS based application for mobile application for patient is good solution 5 6.* To design and develop a WAP enabled wireless applications that leave enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis--vis Exchange Server etc* Main aim of this application is to achieve great quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patients c ar 5 6.1.3 ScopeThe goal of Patient business organisation Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between cosmopolitan practicians an d consultants c be pay off to be provided. The heartbeat is sufficient exchange of patients development convey to be provided.Addition aloney, privacy of communication and stored culture has to be guaranteed. Both ethical and good aspects are as important 7.1.4 Existing ashessThe existing agreement of treatment consists of two unalike transcriptions. They are as retraces* handed-down or manual organization* Online application1.4.1 Traditional or Manual strategyThe present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that arcminute of time, waiting to get register themselves and whence consulting the doctor which is a time consuming work out.1.4.1.1 Drawbacks* Time consuming* Patient expect to stand in long queues to make appointments* Patients not make up prescription medicine directions once they set forth the surgery or hospital. Research has showed that more than 50 percent of patients not f ollow the focussing advised by their doctors may be due to lack of time and interest.1.4.2 Online system of rulesOnline application is withal lendable where the delectationr is provided a login and word through and through which he tummy entrance the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be at that place and we cannot get alerts 4, 5. The online systems are discussed at a lower place are* EMIS* VISION brass1.4.2.1 EMIS SystemEMIS stands for Egton medical Information Systems Limited. EMIS provides a service that enables you access to your health consider online 9. posthumousr on registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their put on and update personal study if manage has set up these features online 10. This example has b een rationalizeed in detailed in chapter 2.1.5.2 Example 2 becharm SystemVision 14 is the most famous system in intake UK, at bottom the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP coifs which are using Vision system across the UK each day.Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, prove and reliable. The strong product-base has allowed other features such as advanced-scanning, PDAs support and corporate voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third fellowship systems 14. In this project we are more concentrating on EMIS rather than Vision system. cardinal FeaturesMessaging Incorporated outside system Appointments reference work coach-and-four Problem Orientated V iews Community Caseload Search and Reporting7. Clinical Audit Vision and the National Applications 14Few of the above features are explicate below 141. MessagingThis system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patients education from number of a elan sources including the NHS anchor or local CPRs to be good accessed and used indoors Vision, sustenance the requirements of the NHS IT-strategy.Vision also manages a range of clinical messages from third party systems to support the patient compassionate as follows* Choose and Book Referrals (electronic booking)* E- Discharge Summaries* Radiology surveys and Encrypted pathology reports* OOH SummariesWith a powerful XML event and messaging engine, Vision is designed to tick the carrying into action of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message casef uls are managed.2. Incorporated External SystemIn the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be unseamedly from the Vision desktop.The patient is automatically recognised in the target system, when the infallible info is passed to the third-party application. For integration into the patient account book when required, important info may also be write back to Vision3. Patients AppointmentsThis Vision system allows user full access to the appointment screen. Using session ushers real by the send the appointment books are defined in advance.The view of appointment book can be defined by user all significant doctors and other healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctors room or leave the surgery, their status is recorded.Our evaluations are based on EMIS system, its features and limitation which confirm been explicateed in ulterior chapters.1.5 Thesis OrganisationIn chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are instructly explained in this chapter along with it features and disadvantages.The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, electronic Patient records and determine codes are explained.In the chapter 4 we have focussed on Patient show ups and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of electronic patient records with s and examples are discussed in this chapter.The chapter 5 focuses on Read codes and its organises. In this chapter 3 versions of read codes are explain with examples. caution of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions.The chapter 6 is about EMIS informationbase, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. bulletproof Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare professional person access patient records has been explained.Advance system and its features are discu ssed in this chapter 7. Waterfall Models activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations.The chapter 8 explains the SMS system requirements such as condition requirements, practicable requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol computer architecture and WAP boniface are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter.Chapter 2 Egton Medical Information SystemsEMIS and EMIS intellectual technology are art names of Egton Medical Information Systems Limited. EMIS had begun 18 years ago in a rural area dispensing practice in Egton coterminous Whitby in North Yorkshire 11.EMIS head-offices are based in Leeds, including Development and Support departments. Training for public practices is localised and headed by Provincial Operations Directors 11.2.1 Practice Care System EnterpriseDue to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMISs Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at umteen levels and ease safe access 24/7 by the wider health care-community 11.PCS Enterprise for PCTs has been designed with capability of rising technological and keeping development in mind, such as manduction data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 recitation 3 the patient data is transferred between utilise health care systems directly 11.2.2 An ov erview of PCS EnterpriseThis edition has been designed to develop EMIS provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with overlap EPRs and seamless data exchange. This system is based on three-tier architecture, part utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to outmatch to thousands of instant(prenominal) user connections 11.EMIS Primary Care System Enterprise edition is designed to meet GP bespeaks as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system2.3 EMIS Primary Care System Practice editionHealth information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has b een designed to meet GP needs, combining functionality with simplicity of use 11.Key features of EMIS PCS* plump patient record management* Quick and good prescribing* Formulary managements* Incorporated consultation mode* Incorporated appointments* Mentor Library* Integrated with MS joint support* User defined templates* Drug Explorer2.4 EMIS LV Version 5.2In the PCS market, EMIS Live Version 11 is the main text based medical system. nigh 5000 GPs currently using EMIS LV system (which is shown below) in the UK. The system offers GPs consultation mode option, medical record, search and reports option, prescription and booking appointments.2.5 Population ManagerThis system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager 11 has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy a nd standardised information entry. Population managing director is an incorporated part of EMIS LV system.2.6 Version 5.2 featuresThis is the most recent release of EMIS LV. This LV offers users the following key features 112.6.1 MS cry incorporationPatient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to bring about patient related garners in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS.2.6.2 Referral template for Cancer patientsIf cancer is suspected GPs requires produce and facsimile or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks hence these referrals are named as two week rule referrals. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2.2.6.3 Electronic Insurance reportsOne of the most common and time taking medical information requests for GPs is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system.2.6.4 Scanning and attachmentsThis module enables to scan corresponding or images and attaches them directly to a patients record in consultation mode. These documents are instantaneously available during consultation.2.7 EMIS Clinical Communication ModulesThe following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care 11.1 Online Referrals with Booked Admissions2 Electronic Referrals3 launching Reports including Electronic Discharges4 Online Results OrderingWith an approved listing of suppliers this Clinical Communication Modules work. Us ing the common set of messaging standards currently creation developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the yet rilling of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below 112.7.1 Online Referrals and booked admissionsTraditionally referring patients from doctors at command practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and passing(a) exhalation. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment.Requirements Each EMIS practice moldinessiness have* EMIS LV 5.2* NHS Net connectivit y* Router access for EMIS* Version 2 clinical terms (5 byte Read Codes)The Secondary Care Provider will need* An EMIS approved website2.7.2 Electronic ReferralsThis module enables us to create a referral letter within EMIS LV and transmit it electronically to a subsidiary care consultant 11.The way electronic referrals workYou can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission coiffe Yes and the referral letter is rigid in the communication theory outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter at a time or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen.RequirementsEach EMIS practice m ust have* EMIS LV 5.2* NHSnet connectivity* Router access for EMIS Support* SMTP or DTS mailbox* MS-Word IntegrationThe secondary care provider will need* SMTP or DTS mailbox* Suitable software capable of sending and receiving XML messages and acknowledgements* SMTP/DTS and EDI code addresses of the practices knobbed the trust should obtain these from the health spot or national tracking database2.7.3 Incoming Reports including electronic dischargesUse this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hours services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider 11.How does the Incoming Reports module work?Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the next report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider.When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for screening, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode.RequirementsTo use Incoming Reports, an EMIS practice must have* EMIS LV 5.2* NHSnet connectivity* Router access for EMIS* A DTS addressTo use Incoming Reports, a secondary care provider must have* A DTS address.* The DTS addresses and EDI codes for all required practices this information is available from the health effectiveness or from the national tracking database.* Software to create and send XML messages and receive acknowledgements2.7.4 Online Test OrderingRequesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service.The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a batten down NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results 11.Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current pati ents demographic and GP details are transferred to the laboratory system when you request the required tests.After you have tenacious the tests, the test information is transferred to your EMIS system and filed in the patients record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can bell ringer a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as curtly as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before 11.RequirementsEach EMIS practice must have* EMIS LV 5.2 or EMIS PCS* NHSnet connectivity* Router access for EMIS* Version 2 clinical terms (5-byte Read codes)Support issuesThe overall Online Test Ordering process relies on different services and software all working in conjunction with each other the EMIS software, the laborat ory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to purport issues with the two areas therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities.2.8 Storage area network (SAN)Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run 11, on which EMIS stores data Detail explanation in later chapter.Chapter compendiumThe chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.Chapter 3 Drawbacks of Online systemsAlthough online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example.3.1 Patient Record Time required to put all relevant information onto system Possible security issues Doctor can focus too more than on patient informati on onscreen which could intimidate the patient Scanning and entry of data is more time consuming. Important information lost can when autocratic the record. Medical record print-outs are often of poor quality and operose to understand necessary information In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable. Often using computer and paper records together will make patient data nerve very difficult. Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data163.2 Appointments Patients have to be checked into appointment system by receptionist Problematic if patients cant read, or unable to view sign (e.g. blind people)3.3 Prescriptions Relies on dose information being up to date Aptitude of doctor in using computer effectively Some times doctors issue hand written prescription they may not be available on computer. The acute and repeat prescribing registers can make it mor e confused. Printouts of Pharmacy still required 16.3.4 e-mail Relies on doctor checking their mail daily Troublesome patients abusing the system Hospital letters not emailed (would be preferred)3.5 Security issues Doctors have to go to bother of sign on and off EMIS Forgetting passwords Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be utterly in-operable sledding computer on Locum doctors Experts are need to show computer frauds and misuse 163.6 Internet connection Continuous internet connection required The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts 4, 5.3.7 Backup System backed up any darkness onto tape Two copies- Fireproof safe Remote location3.8 Read codesMaintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the article of faith because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility 17.The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems get from different uses and from the different views of Healthcare professional. 17.Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its preconception prick closely mirrors ICD9, even though this doesnt always reflect a clinicians view, and correct hierarchy placement of a concept according to ICD9 rules may attend false to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map right on to ICD9 17.Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated 17.Read/SNOMED CodesRead/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. Unlike the monger of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical natural process to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners 24.Read codes has been explai ned more clearly in chapter 4.3.9 GP2GP Record transferThe experience of the GP2GP record transfer and the clinical involvement are explained this section.3.9.1 The vestigial principle for electronic GP-GP record transferThe vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable residual of these practices use their computer systems for recording patient record information in whole or in part 33.This results from a variety of causes whose main headings are* Patient records that are an unpredictable mix between paper and electronic.* The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant ( exactly un-quantified) mental imagery implications for practices. There is also widespread anecdotal evidence of resulting ominous make on patient care. The rationale for the elect ronic transfer of records is therefore* As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities.* To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus turn out resource implications* To reduce the risks to patients arising from the transfer of confusing records.3.9.2 The nature of electronic GP-GP record transferElectronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of 33* Record encounters what constitutes a single transaction with the record like a doctors consultation, a letter received from hospital or outside, an examination result etc* Names for these encounters e.g. hom e visit,* Headings within these encounters* Complex clinical constructs* Read code mappings such medical specialty codes sets* Codes and associated text* Major modifiers of clinical meaning3.9.3 The Problems of electronic GP-GP record transferThere are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below 33.Medication informationThere are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are* The multiple coding schemes used and* Failure of previous code mapping exercises (see chapter 5 on data transfer).3.10 The Problem Oriented Medical Record (PMOR)Electronic health records (EHR) are more used in UK General Practice despite inveterate improbability about its legal ity and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple incidental list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) 31.3.10.1 Limitations of the PO Medical RecordThe limitations of POMR are explain below 31* It is very easy to pick up but very difficult to maintain.* In the strict way of the word not all headings are problems. For example, the heading of Immunisation is used usually to indicate where all the entries related to a immunization history may be found.* Many different problems may be discussed within a single consultation* To check scanned documents is very difficult especially when patient record is too big* Problems are frequently linked in a fundamental way.* The PO Medical Record moreover gives a basic measure of the state of a problem.* polar clinicians, view the clinical r ecord, required different information from the medical record as well as with different views.* Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again.Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress 31.3.11 Other Disadvantages* Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms.* Many screen need to be changes to find results and mouse activity* Information can be hidden as only the informatiPatient Healthcare Using SMS Technology ApplicationPatient Healthcare Using SMS Technology ApplicationChapter 1 Introduction to Patient Care Using SMS ApplicationPatients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health ca re in different locations and other remote areas can be achieved using mobile phone applications 1.1.1 Problem StatementDevelopment of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare encouraging patients to use mobile health application and supporting people with long term conditions 5.1.2 ObjectivesIncredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution 5 6.* To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis--vis Exchange Server etc* Main aim of this application is to achieve greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patients care 5 6.1.3 ScopeThe goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants care have to be provided. The second is sufficient exchange of patients information have to be provided.Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important 7.1.4 Existing SystemsThe existing system of treatment consists of two different systems. They are as follows* Traditional or manual system* Online application1.4.1 Traditional or Manual systemThe present system of treatment consists of manu ally consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process.1.4.1.1 Drawbacks* Time consuming* Patient need to stand in long queues to make appointments* Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest.1.4.2 Online SystemOnline application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts 4, 5. The online systems are discussed below are* EMIS* VISION System1.4.2.1 EMIS SystemEMIS stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online 9.After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information if practice has set up these features online 10. This example has been explained in detailed in chapter 2.1.5.2 Example 2 Vision SystemVision 14 is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day.Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDAs support and incorp orated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems 14. In this project we are more concentrating on EMIS rather than Vision system.Key FeaturesMessaging Incorporated External system Appointments Consultation Manager Problem Orientated Views Community Caseload Search and Reporting7. Clinical Audit Vision and the National Applications 14Few of the above features are explain below 141. MessagingThis system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patients data from number of external sources including the NHS Spine or local CPRs to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy.Vision also manages a range of clinical messages from third party systems to support the patient care as follows* Choose and Book Referrals (electronic booking)* E- Discharge Summaries* Radiology reports and Encrypted pathology reports* OOH SummariesWith a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed.2. Incorporated External SystemIn the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop.The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision3. Patients AppointmentsThis Vision system allows user full access to the appointment screen. Using session templates developed by the practice the appointment books are defined in advance.The view of appointment book can be defined by user all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctors room or leave the surgery, their status is recorded.Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters.1.5 Thesis OrganisationIn chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages.The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Pa tient records and read codes are explained.In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter.The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions.The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained.Advance system and its features are discussed in this chapter 7. Waterfall Models activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations.The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter.Chapter 2 Egton Medical Information SystemsEMIS and EMIS intellectual technology are trading names of Egton Medical Information Systems Limited. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire 11.EMIS head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors 11.2.1 Practice Care System EnterpriseDue to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMISs Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community 11.PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly 11.2.2 An overview of PCS EnterpriseThis edition has been designed to develop EMIS provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections 11.EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system2.3 EMIS Primary Care System Practice editionHealth information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use 11.Key features of EMIS PCS* Complete patient record management* Quick and good prescribing* Formulary managements* Incorporated consultation mode* Incorporated appointments* Mentor Library* Integrated with MS Word support* User defined templates* Drug Explorer2.4 EMIS LV Version 5.2In the PCS market, EMIS Live Version 11 is the main text based medical system. Approximately 5000 GPs currently using EMIS LV system (which is shown below) in the UK. The system offers GPs consultation mode option, medical record, search and reports option, prescription and booking appointments.2.5 Population ManagerThis system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Popula tion Manager 11 has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system.2.6 Version 5.2 featuresThis is the most recent release of EMIS LV. This LV offers users the following key features 112.6.1 MS Word incorporationPatient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS.2.6.2 Referral template for Cancer patientsIf cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks hence these referrals are named as two week rule referrals. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2.2.6.3 Electronic Insurance reportsOne of the most common and time taking medical information requests for GPs is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system.2.6.4 Scanning and attachmentsThis module enables to scan corresponding or images and attaches them directly to a patients record in consultation mode. These documents are instantly available during consultation.2.7 EMIS Clinical Communication ModulesThe following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care 11.1 Online Referrals with Booked Admiss ions2 Electronic Referrals3 Incoming Reports including Electronic Discharges4 Online Results OrderingWith an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below 112.7.1 Online Referrals and booked admissionsTraditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding pati ent demographics and clinical information and in some cases booking an appointment.Requirements Each EMIS practice must have* EMIS LV 5.2* NHS Net connectivity* Router access for EMIS* Version 2 clinical terms (5 byte Read Codes)The Secondary Care Provider will need* An EMIS approved website2.7.2 Electronic ReferralsThis module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant 11.The way electronic referrals workYou can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission answer Yes and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the seco ndary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen.RequirementsEach EMIS practice must have* EMIS LV 5.2* NHSnet connectivity* Router access for EMIS Support* SMTP or DTS mailbox* MS-Word IntegrationThe secondary care provider will need* SMTP or DTS mailbox* Suitable software capable of sending and receiving XML messages and acknowledgements* SMTP/DTS and EDI code addresses of the practices involved the trust should obtain these from the health authority or national tracking database2.7.3 Incoming Reports including electronic dischargesUse this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hours services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider 11.How does the Incoming Reports module work?Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider.When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL f unction in Consultation Mode.RequirementsTo use Incoming Reports, an EMIS practice must have* EMIS LV 5.2* NHSnet connectivity* Router access for EMIS* A DTS addressTo use Incoming Reports, a secondary care provider must have* A DTS address.* The DTS addresses and EDI codes for all required practices this information is available from the health authority or from the national tracking database.* Software to create and send XML messages and receive acknowledgements2.7.4 Online Test OrderingRequesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service.The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results 11.Online T est Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patients demographic and GP details are transferred to the laboratory system when you request the required tests.After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patients record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before 11.RequirementsEach EMIS practice must have* EMIS LV 5.2 or EMIS PCS* NHSnet connectivity* Router access for EMIS* Version 2 clinical terms (5-byte Read codes)Support issuesThe overall Online Test Orde ring process relies on different services and software all working in conjunction with each other the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities.2.8 Storage area network (SAN)Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run 11, on which EMIS stores data Detail explanation in later chapter.Chapter SummaryThe chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.Chapter 3 Drawbacks of Online systemsAlthough online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example.3.1 Patient Record Time require d to put all relevant information onto system Possible security issues Doctor can focus too much on patient information onscreen which could intimidate the patient Scanning and entry of data is more time consuming. Important information lost can when overlooking the record. Medical record print-outs are frequently of poor quality and difficult to understand necessary information In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable. Often using computer and paper records together will make patient data look very difficult. Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data163.2 Appointments Patients have to be checked into appointment system by receptionist Problematic if patients cant read, or unable to view sign (e.g. blind people)3.3 Prescriptions Relies on drug information being up to date Aptitude of doctor in using computer effectively Some times doctors issue hand written prescription they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required 16.3.4 Email Relies on doctor checking their mail daily Troublesome patients abusing the system Hospital letters not emailed (would be preferred)3.5 Security issues Doctors have to go to bother of signing on and off EMIS Forgetting passwords Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable Leaving computer on Locum doctors Experts are need to show computer frauds and misuse 163.6 Internet connection Continuous internet connection required The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts 4, 5.3.7 Backup System backed up every night onto tape Two copies- Fireproof safe Remote location3.8 Read codesMaintenance of enormous clinical expressions or code s is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility 17.The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. 17.Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesnt always reflect a clinicians view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 17.Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated 17.Read/SNOMED CodesRead/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners 24.Read codes has been explained more clearly in chapter 4.3.9 GP2GP Record transferThe experience of the GP2GP record transfer and the clinical involvement are explained this section.3.9.1 The underlying principle for electronic GP-GP record transferThe vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part 33.This results from a variety of causes whose main headings are* Patient records that are an unpredictable mix between paper and electronic.* The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore* As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities.* To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications* To reduce the risks to patients arising from the transfer of confusing records.3.9.2 The nature of electronic GP-GP record transferElectronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of 33* Record encounters what constitutes a single transaction with the record like a doctors consultation, a letter received from hospital or outside, an examination result etc* Names for these encounters e.g. home visit,* Headings within these encounters* Complex clinical constructs* Read code mappings such medication codes sets* Codes and associated text* Major modifiers of clinical meaning3.9.3 The Problems of electronic GP-GP record transferThere are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below 33.Medication informationThere are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are* The multiple coding schemes used and* Failure of previous code mapping exercises (see chapter 5 on data transfer).3.10 The Problem Oriented Medical Record (PMOR)Electronic health records (EHR) are mo re used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) 31.3.10.1 Limitations of the PO Medical RecordThe limitations of POMR are explain below 31* It is very easy to pick up but very difficult to maintain.* In the strict way of the word not all headings are problems. For example, the heading of Immunisation is used usually to indicate where all the entries related to a immunization history may be found.* Many different problems may be discussed within a single consultation* To check scanned documents is very difficult especially when patient record is too big* Problems are frequently linked in a fundamental way.* The PO Medical Record only gives a basic measure of the state of a problem.* Different clinicians, view the clinical record, required different information from the medical record as well as with different views.* Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again.Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress 31.3.11 Other Disadvantages* Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms.* Many screen need to be changes to find results and mouse activity* Information can be hidden as only the informati

Social Policy Development In Education

Social Policy Development In EducationIntroductionThis essay discusses influences of kindly constitution development in education over the last 30 years. It also discusses the impact of these policies in relation to social exclusion, unlikeness and poverty.Throughout the post-war period, there have been many interrogationines to reform the UK education system, much with an explicit intention to raise standards and make it more productive. Notable reforms have included a nation al whizzy prescribed curriculum, vigorous attempts to raise participation in post-compulsory school daying and the introduction of tuition fees for full(prenominal)er education. In addition to concerns about widening access and educational inequality, in the 1980s there emerged widespread fears about brusk and falling standards in UK education system (Machin and Vignoles, 2006). Specifically, there were concerns that too many individuals were leaving school too early and with little in the way of ba sic skills. Examination underachievement had also been recognised by education form _or_ system of government-makers as a particular conundrum (ibid).In the light of these concerns, successive Conservative governments in the 1980s and 1990s summationd the pace of reform and introduced so called market mechanisms into the UK education system, in an attempt to force schools to raise standards. The move towards a quasi-market in education, was kick started by a significant piece of legislation the 1988 Education Reform Act which non only introduced the market reforms discussed here, but also the National Curriculum.At the last election, Labour swept to power on the catchphrase education, education, education however, check to (Wood, Jaffrey Troman in Fielding, 2001) there has been widespread disappointment in New Labours education policies, which on the whole have not steered too far wide of those put in place by Margaret Thatcher. David (2003) also agrees with this notion but argues that New Labour continues to develop educational policies on excellence, introducing notions of social exclusion and inclusion and identifying policies specifically to accept issues of poverty through education. It may therefore be argued that raising education standards for all is important not only to the success of a modern economic system but also to the creation of a socially just society.Since the 1990s, New Labours political values have shared many neo-liberalism characteristics especially in pitiful what has been called a post-welfare society. In implementing many of their education policies, they have continued with an emphasis on moral values, individuality and personal responsibility (Jones, 1996, pp.17-18). However, David (2003, p.356) argues that New Labour redefines much(prenominal) notions on an individual basis rather than on the basis of social groups, such as social class or those economically disadvantaged on the basis of family circumstances. This rais es a question about fairness of opportunity in education for some social groups, for example Black and Minority Ethnic (BME) groups nerve additional barriers to inclusion relating to their ethnicity and are disproportionately likely to perform poorly and suffer exclusion, including employment, educational out comes, truancy and school exclusions (SEU, 2004).It may be argued that a few(prenominal) of the policy developments in education have had issues of equality of opportunity uppermost or explicitly on the agenda. The driving force behind policy qualification may therefore have been more to do with value for money and quality assurance but largely out-of-pocket to political influence. In addition, the frequent sector is more exposed to political direction and scrutiny than the private sector public policies in education stipulate the conditions under which schools must operate. However, according to Kemmis (1990) many of the changes in educational policies over the past thirt y years or so, have been due to the political work of organised social movements exerting immense pressure for change, with calls for action on poverty, women inequalities, minorities and people with disabilities leading the government to formulate policies and programmes in education which sought to provide equality of educational opportunity. He unless notes that these movements were dissatisfied with the role that education plays in the maintenance of the existing social order. Showing that, people are no longer prepared to leave policy making to politicians and bureaucrats. They wish to be involved in the steering of policy processes. For example the feminist movement will not permit issues of gender inequality in education to drop off the policy agenda. Similarly, BME groups want a direct say in the policy making process. Thus the language of educational policy, according to Kemmis (1990), is linked to political compromises in the midst of competing but unequal interests.Sec ondly, Changes in social attitudes towards authority, particularly among immature people, have also created new pressures for education. As (Willis 1990 cited in Taylor, Fazal and Rizvi, 1997. P.4) has argued, students brought up on the cultural values of the globalised mass media are unlikely to be comfortable with the requirements of bureaucratically defined regimes of discipline. Such cultural and attitudinal changes have demanded policy shifts in education.Alcock (2008, p.198) states that social policy development is also closely dependent upon the economic structure of the society and upon the economic growth within it. While, Blakemore and Griggs (2007, p.147) state that due to economic pressures, the government abolished free tuition and instead passed the Teaching and Higher Education Act that requires students to pay tuition fees. As a consequence, there has been an increase in the number of English students choosing to attend Scottish and Welsh universities to avoid tuiti on fees. On the other hand, the youth labour market has led to calls for educational policies designed to ensure greater retention in senior secondary schools and curricula that are more vocationally responsive leading to the Education Maintenance Allowances (EMA) subvention for 16 to 19 year olds. Evaluation of EMA suggests substantial impact from the subsidy that overall, educational participation post 16 was 4.5 percentage points higher than before (Dearden et al., 2005).Political, economic and social influences have not however been the only factors responsible for changing policy in education. Technological changes may also have demanded revision to educational policy, and in particular to curriculum priorities and teaching styles. With ever emerging new technologies changing partners of e genuinely(prenominal)day life, then education cannot remain oblivious to these changes. Governments have been readily to invest large amounts of money in the teaching of Information Commu nication Technology (ICT) in schools and lifelong learning programmes.The introduction of new educational policies should to begin with be to address personal and academic development and ultimately provide a more equitable education system for all. However, the Department for Education and Skills (DfES) (2006) stated that the impact of educational services not always able to meet individual needs has over the years disproportionately affected particularly groups of BME one-year-old people, which is recognised in the Every Child Matters (ECM) consultation paper, as it asserts that teenagers from some BME groups face greater challenges than others in growing up (Youth Matters Green Paper. 200513). The impact of poor service delivery to BME young people is compounded by the fact that minority ethnic population is over represented in almost all measures of social exclusion (ODPM, 2003) and their poor socio-economic position is closely associated with low educational attainment. This in turn impacts on their prospects to gain employment which in turn often results in being drawn into a life of crime. African Caribbean young men in particular are over represented at every stage of the criminal justice system (Graham in Sallah and Howson, 2007, p 176). One could argue that in fact the education system has systematically ensured that Black young people do not succeed (Richardson, 2006). This is not surprising as it has also been acknowledged that the British education system has also failed or let down the aspirations of the poor and or White working class people (Se swell, 1997). This is particularly important in that, poor achievers are most obvious amongst the poor and disadvantaged. For example, high socio-economic groups appear to have better information on, and understanding of school performance, via league tables (West and Pennell, 1999). Whether parents act on this information, choosing for their children to attend the best schools, then there is a exte nd tension between strategies to raise standards and policies to reduce inequality. Socio-economic background also relates to school quality and pupil performance via peer groups. For example, attending a school with very few children from lower socio-economic groups is highly beneficial academically speaking (Feinstein, 2003). If parental choice leads to greater socio-economic segregation across schools, such peer group effects may further reinforce social exclusion.The motivation behind the introduction of the market reforms was to raise standards and achievement, rather than issues related to inequality. The evidence on the impact of these reforms on childrens achievement is minimal, however, empirical evidence from the USA (Chubb and Moe, 1990) is supportive of the view that decentralised schooling systems can produce better results, measured in terms of educational outcomes (Hoxby, 2000). Evidence for the UK by Bradley et al (2001) found that schools with the best examination performance grew most quickly and that, increased competition between schools led to improved exam performance. Gibbons, Machin and Silva (2005) report little evidence of a link between choice and achievement, but find a small positive association between competition and school performance. However, they attribute this to school location or pupil sorting.Evaluating the impact of nationally introduced education policies and the impact of continual vocational systems is not patrician according to Machin and Vignoles (2006). Perhaps the best way to evaluate new qualifications is to consider their labour market value, since this reflects the demand by employers for this type of qualification and the skills embodied in it. The evidence is that NVQs and indeed GNVQs, have minimal economic value in the labour market (Dearden et al., 2002). In particular, NVQ2 qualifications may actually have a detrimental impact on individuals wages, in many sectors of work.Higher Education (HE) in the U K is viewed as a success story, with continually rising participation in HE since the late 1960s. However, there have been concerns about who is accessing HE. Evidence by Machin and Vignoles (2006) showed that during the last fifteen years, participation in HE had largely been the preserve of the higher socio-economic groups in the UK. Furthermore, there is evidence that the gap in HE participation between richer and poorer students actually widened, at least in the mid and late 1990s (Blanden and Machin, 2004). obstinate to what many believed before the expansion of higher education, the expansion appears to have actually acted to increase educational inequalities, so that a greater share of HE participants is from well off backgrounds (ibid). It may be argued that although poorer students are more likely to go on to higher education than they were in the past, the likelihood of them doing so relative to their richer peers is actually lower than was the case in earlier decades. Fu rthermore, tuition fees introduced by labour in 1999 leave poorer students with huge debts to pay on graduation.ConclusionThis essay concludes that, educational policies do not emerge in a vacuum but reflect compromises between competing interests expressed by the dominant interests of capitalism in the one hand, and the oppositional interests of various social movements on the other. While it is true that some policies are responses to particular social changes, it is also the case that these changes may themselves be represented in a variety of different ways and accorded contrasting significance. Educational policy initiatives may thus be viewed as responses to the struggle over particular constructions of social political, economic and cultural changes. However, the evidence of positive impact of the reforms on the poor, minorities and the socially excluded is minimal. In this way, it can be concluded that the state is not neutral and politically driven with respect to the chang es occurring in education, as its own interest in sponsoring some changes and preventing others is reflected in policy development.

The Life and Literary Works of Shirley Jackson Essay -- Essays Papers

Shirley capital of loseissippi was born on December 14, 1919 to Leslie and Geraldine Jackson. Her surroundings were palmy and friendly. Two years after Shirley was born, her family with her newborn brother moved from San Francisco to Burlingame, California, about thirty miles away. According to her mother, Shirley began to compose verse almost as soon as she could write it (Friedman, 18). As a child, Shirley was interested in sports and literature. In 1930, a year before she attended Burlingame High School, Shirley began writing poetry and short stories. Jackson enrolled in the liberal arts program at the University of Rochester in 1934. But after periods of unhappiness and questioning the loyalty of her friends, she withdrew from the university. For the succeeding(prenominal) year Shirley worked night and daylight on her writing. In doing so she established work habits, which she maintained for the rest of her life. After a year of becoming conscientious and disciplined writer, Jackson judgment she better return to college for more schooling. In 1937, she entered Syracuse University. At first she was in the School of Journalism, but then she decided to transfer to the incline department. For the next two years, while at Syracuse, Shirley published, fifteen pieces in campus magazines and became fiction editor of The Syracusan, a campus humor magazine. When her position as fiction editor was eliminated, she and fellow schoolmate Stanley Edgar Hyman began to plan a magazine of literary quality, one that the English Club finally agreed to sponsor. (Friedman, 21) In 1939, the first edition of The spook was published. Although the magazine became popular, the English department didnt like the biting editorials and critical essays. But inspite of the departments constant watch over the magazine, Leonard Brown, a modern literature teacher, backed the students and the publication. Later, Jackson was always to touch on to Brown as her mentor and in 1959 she dedi cated her novel The Haunting of Hill House to him.(Oppenheimer, 45) But in the summer of 1940, since Jackson and Hyman were graduating, it was announced the The Spectre had been discontinued. Apparently hard feelings on the part of school authorities lasted for quite some time and may have been one of the reasons why neither Miss Jackson, even after becoming a successful author, nor Mr. Hyman, a known critic, was named as a recipi... ... Yorker. 28 June 1948. p. 292. Janeway, Elizabeth. The Grotesque Around Us, The rising York Times restrain Review. 9 October 1966. p. 58. Kittredge, Mary. The Other Side of Magic A Few Remarks About Shirley Jackson. Discovering Modern evil Fiction. Starmont House, New York, 1985. p. 4, 12, 14, 15. Kosenko, Peter. A Marxist/Feminist Reading of Shirley Jacksons The Lottery . The New Orleans Review. Spring 1985. p. 225. Nebeker, Helen. The Lottery Symbolic Tour de France, American Literature Duke University, North Carolina, 1974. p. 107. Oehlshlaeg er, Fritz. The Stoning of Mistress Hutchinson Meaning of Context in The Lottery. Essays in Literature. No. 2, Fall, 1988. p. 259, 261. Oppenheimer, Judy. hole-and-corner(a) Demons The Life of Shirley Jackson. G.P. Putnams Sons New York, 1988. p. 45, 60. Park, John G. Waiting for the End Shirley jacksons The Sundial. Critique Studies in Modern Fiction, No. 3., 1978. p. 21, 22. Wolff, Geoffrey. Shirley Jacksons Magic Style. The New Leader. No. 17. 9 September 1968. p. 18. Woodruff, Stuart. The Real Horror Elsewhere Shirley Jacksons Last Novel. Southwest Review. Spring, 1967. p. 155.

Importance of the Forest in The Scarlet Letter :: Scarlet Letter essays

Importance of the Forest in The Scarlet Letter             The travel guidebook strangled onward into the mystery of the primeval forest(179).  This sentence displays just one of the multiple personalities that the forest symbolizes in The Scarlet Letter written by Nathaniel Hawthorn.  In the Scarlet Letter the forest symbolizes much more than one might imagine.  Each character brings out a opposite side of the forest, provided the forest also brings out a different side in each character.  For some the forest may be a place of coloured thoughts and wrong doing, but for others it is a place of happiness and granting immunity.             The first encounter with the forest we have symbolizes just some of the evil that lingers within the darkness of the forest.  As Hester and Pearl are leaving governor Bellinghams estate they are confronted by mistress Hibbins who explains that the witches are meeting in the forest, and she then invites Hester to become more late involved with her evil ways.  Wilt thou go with us tonight(113) asked mistress Hibbins, yet Hester refused to sign her name in the black mans book on that night.  She explains that the only reason she does not sign is because Pearl is still in her life.  At this time the forest itself is a open door to another world, a wicked world that would take her away from her present situation, but that is not the only door that the forest holds.             The forest is an open door to love and freedom for both Hester and Dimmesdale.  It is a place where the letter on their bodies can no longer have an effect on them if they choose.  A world ruled by nature and governed by natural law as opposed to the artificial strict community with its man made puritan laws.  Its as if the forest represents a key to the shackles the Hester and Dimmesdale have been forced to wear, all that they have to do is unlock it.  Although if they choose not to unlock them, they begin to dwell on the things that they have make to deserve the shackles. In this the forest represents a thing of truth, weather it be good or bad.             In pearls eyes the forest has a totally different concept.