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1012 — Stepped-Wedge Randomized Controlled Trial to Improve Remote Monitoring Adherence for Veterans with Pacemakers/Implantable Cardioverter-Defibrillators
Lead/Presenter: Sanket Dhruva, San Francisco VA
All Authors: Dhruva SS (San Francisco VA Health Care System), McLaughlin MM (San Francisco VA Health Care System), Tarasovsky G (San Francisco VA Health Care System), Raitt MH (Portland VA Health Care System), Whooley MA (San Francisco VA Health Care System).
Remote monitoring of pacemakers and implantable cardioverter-defibrillators (ICDs) is a Class 1 (Level of Evidence A) recommendation that is the standard-of-care because it reduces hospitalizations and mortality. However, adherence to remote monitoring is suboptimal (60% in 2020). We sought to determine whether (a) an educational postcard could improve remote monitoring adherence, and (b) the effect of an educational postcard on adherence differed by messaging.
We conducted a stepped-wedge randomized controlled trial (RCT) of Veterans with pacemakers/ICDs who had missed the most recently scheduled remote transmission by at least 10 days. In the first wedge, patients were randomized to be mailed a postcard (with protect/warn or encourage/reward messaging) versus no postcard (control). The protect/warn postcard described risks of non-adherence to remote monitoring, and the encourage/reward postcard framed the same content with a positive/beneficial message. Both postcards contained instructions about how to send remote transmissions. In the second wedge, all patients received either a protect/warn or encourage/reward postcard. In both waves, patients who did not send a remote transmission within 28 days were mailed a second, identical postcard. The primary outcome was receipt of a remote transmission within 70 days.
There were 6331 Veteran patients with pacemakers/ICDs randomized (3166 protect/warn messages and 3165 encourage/reward messages); 2400 of these Veterans served as controls in the first wedge. Mean age was 73 years, 76% were white, and 17% were Black. Five percent of postcards were returned as undeliverable. Overall, 2974 patients (49.5%) who received a postcard sent a remote transmission within 70 days, compared to 565 patients (23.5%) who did not receive a postcard (absolute difference 26.0%, p < 0.001). Twenty-six percent of patients who sent a remote transmission did so only after the second postcard. Remote transmission rates were similar between patients randomized to protect/warn versus encourage/reward messaging (49.9% vs 49.1%, p = 0.51).
Informational postcards to Veterans with pacemakers/ICDs who were non-adherent to remote monitoring more than doubled adherence. There was no difference between a protect/warn or encourage/reward strategy.
Because this intervention improved adherence to remote monitoring and, therefore, access to virtual care, for Veterans with pacemakers/ICDs, it has now become a routine part of VANCDSP operations.


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Posted on 12 June 2020 11 June 2020 by Pastor Steve
"Wilting in the Face of Worldly Power"
Matthew 14 teaches us several things about John's character. Mark makes the point that John was a righteous man, explaining that "Herodias nursed a grudge against John and wanted to kill him. But she was not able to, because Herod feared John and protected him, knowing him to be a righteous and holy man." Although Herod was far from righteous himself, he recognized righteousness in John and tried to protect him. Matthew tells us that Herod imagined that God had vindicated the character of His prophet by raising John.
It is one thing to be righteous; it is another thing to be outspoken about it, especially when standing before the great and powerful of this world. John was both.
Charles Colson tells what he witnessed when he would bring visitors to meet Richard Nixon when Nixon was president of the United States and Colson was special legal counsel to the president. Colson would gather the guests in a room outside the Oval Office, where they would talk to each other about what they were going to tell the president when they were face to face. "It was always the same," Colson wrote. "In the reception room they would rehearse their angry lines and reassure one another. 'I'll tell him what's going on. He's got to do something.'
"When the aide came to escort us in, they'd set their jaws and march toward the door. But once it swung open, the aide announcing, 'The president will see you,' it was as if they had suddenly sniffed some intoxicating fragrance. Most became almost self-conscious about even stepping on the plush blue carpet on which was sculpted the Great Seal of the United States. And Mr. Nixon's voice and presence—like any president's—filled the room.
"Invariably, the lions of the waiting room became the lambs of the Oval Office," said Colson.
It is sad to say that none were more meek than the religious leaders. Of all people, they should have been the most outspoken. But they too wilted in the face of worldly power. Such is the awe of majesty that high office evokes. But John the Baptist did not cower before worldly power. He spoke out boldly and continued to do so, repeatedly saying to Herod, "It is not lawful for you to have her."
John was also courageous, for he could not have failed to know the danger he was placing himself in by continuing to denounce Herod for his marriage. Kings do not like to be confronted. Even more dangerous was the hatred of Herodias. John knew people well enough to know what was happening, but he continued to speak out and eventually died for his convictions.
John's fate reminds us of the kind of world in which we live. It is a world that has rejected Jesus and will reject His best disciples too. The world does not want to be told that it is sinful, that it has broken the holy law of God, that it needs a Savior, who is Jesus. But those who walk in the footsteps of John and the other saints who have preceded us will be as bold as these men were. How are any to be saved if we do not speak the truth about sin and preach the Gospel boldly?
The story does not tell us only about John, however. It also tells us about Herod, and what it reveals is that he was the exact opposite of John at every point. John was righteous, but Herod was an evil man, even though he was not a particularly bad king as kings go. Herod had seduced his brother Philip's wife, had wrongly imprisoned John, and now in a weak and drunken moment consented to John's murder without any kind of a trial. The execution was an outrage by Roman as well as by Jewish law. Moreover, it was Herod's knowledge of this wrong that caused him to suspect John had somehow come back to life after his unmerited execution. Herod was a Sadducee; Sadducees did not believe in the resurrection. But Herod's guilty conscience reduced his skeptical creed to dust, and he trembled at the thought of God's final judgment of him for this and for what had certainly been other evil actions.
John was outspoken, but Herod was crafty, shrewd, sly, deceptive, hypocritical, and devious, wanting to kill John but afraid to do it for fear of the people. Matthew says that Herod actually wanted to kill John and would have done it earlier except that he was afraid of the people who considered John a prophet.
John was courageous, but Herod was feeble and weak, as many are who are more concerned for their reputations than for what is just or right. Herod knew that John was a righteous man. He knew that ordering his execution was an evil act. He knew that he had blundered in promising Salome anything she wanted because he had been infatuated with her dancing. But he was too weak to admit his mistake and too frightened of his wife's tantrums to uphold the moral law, which was his duty as the tetrarch. Herod could take a firm stand on wrong things, but he was weak on right things. Even his stand for the wrong betrayed his weakness.
Many people who reject God's truth but nevertheless have an awareness of right and wrong become superstitious when they do wrong, because they sense that this is a moral universe and things cannot possibly go well for evildoers. Many follow horoscopes and believe almost any bizarre "spiritual" idea that comes their way. This is sad, but it always happens when people reject God and His written revelation in the Bible. When people stop believing in God, they do not believe in nothing. They believe anything.
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Below is a list of frequently asked questions. If you cannot find the answer to a question you have please call us at 302-856-3636 so we can help you.
How many students are enrolled in Sussex Academy?
When the school opened in the fall of 2000, there were 225 students enrolled. Our charter now allows us to enroll up to 770 students once we have expanded to include grades 6 through 12.
How many openings are there each school year?
Generally, the school has 100-110 spaces open for sixth graders and 40 to 50 for the high school grades. Students who do not get in are placed on a waiting list.
Who runs the school?
The day to day responsibility of running the school is left to the Executive Directors and the teachers and support personnel. A Founding Board planned and developed the academy for approximately three years until the school opened in September of 2000. In the Fall of 2000, the newly organized Executive Board of Directors was formed. The board includes community members, parents, and a teacher representative. Parents are expected to take an active part in the school's activities.
What is the support system for the staff?
The teachers receive training and ongoing technical assistance consistent with the practices of Expeditionary Learning (EL) and the International Baccalaureate program. Additional teacher inservice training takes place throughout the year.
How many teachers does the school have?
Sussex Academy has full-time teachers for the core subject areas of reading, writing, math, science, and social studies that allows approximately 1:20 teacher to student ratio. In addition, there are part-time teachers for the exploratory subjects of coding, STEM, physical education, art and music.
How is the school funded?
Funding for the school comes from 2 major areas. Operating expenses are paid for by the state and the local districts in which students reside. Since neither of these sources provides funding for our physical plant, the Sussex Academy Foundation actively raises funds to expand and enhance our facility.
What does the state allow for our budget?
Based on the number of students, the state provides money for the operating expenses including teacher salaries, equipment/technology, utilities, and transportation.
If my child has special education needs, how will you serve him/her?
Students with special needs will receive all of the services they are entitled to as written in the IEP (Individualized Education Program). Our faculty includes highly qualified staff with special education training.
Are charter schools held to the same standards as other public schools?
Sussex Academy of Arts and Sciences has high expectations for academic performance and student decorum. At a minimum, charter schools are held to the same standards as other public schools. Students are to meet all of the state testing standards related to promotion guidelines and regulations as they apply to discipline, attendance, and health requirements.
Are Sussex Academy's students required to participate in the end-of-year state testing?
Yes. Passing these state tests is one component required for passing to the next grade.
Will there be multi-age classrooms?
Not at the middle school level. However, our practice has been to loop students in grades 6 and 7. Therefore, a student stays with the same team of five teachers throughout the sixth and seventh grades. One of the ways students will track their academic progress is by maintaining a portfolio of their work throughout these two years. Toward the end of seventh grade, each student will present his or her portfolio of work for parental review.
Does my child have to be immunized to attend your school?
Yes. The Sussex Academy is a public school and, as such, must abide by the state regulations regarding immunizations and health records.
Do students have to wear uniforms?
The Sussex Academy has established high academic and personal standards for the students who will be attending the school. School uniforms project an image that is consistent with the high standards of the Academy and also reflect an appropriate academically oriented school climate.
Students at the school are required to wear school uniforms selected from and supplied by Flynn & O'Hara, 800.441.4122, F: 215.637.6392. www.flynnohara.com.
Other rules of neat, clean, appropriate dress apply also. Students are not to wear clothing that is too tight or revealing and are not to "shag" (wear their pants on their hips). They are not to wear uniforms adorned with other logos, most particularly those implying drug, alcohol, or tobacco use, or having any vulgar language. Hair color must be a natural color.
They are to wear outerwear (e.g. gloves, headgear, coats, etc.) only outdoors and store these articles during their stay in the building. The students are to wear appropriate shoes, (e.g. athletic shoes, oxfords, etc.) not open-toed footwear such as sandals or "flip-flops."
The Executive Director has the authority to determine what is or is not acceptable dress and appearance.
How is lunch provided?
The school has a warming kitchen but does not prepare food. Instead, Sussex Academy has contracted with Preferred Meals to provide lunch daily. Orders are placed online and paid for in advance. Students may pack their lunch. Meals are eaten in the cafetorium.
What busing system is used for students?
As a public school, the academy receives state funding for transportation. Our bus routes operate on a hub system with no door-to-door busing.
What is the discipline policy?
See the Student Code of Conduct in the Student Handbook for a general overview. Our students are held to a high standard of conduct.
Do you use a traditional grading system?
Yes. A traditional grading system of letter grades from A to F is used with an A being equal to a numerical grade from 93 to 100, B from 92 to 85, C from 84 to 75, D from 74 to 70, and F from 69 to 0.
How many computers are available for the students to use?
The school has a computer classroom with computers available for individual use or large group instruction. Students can use computers for electronic research and access to the Internet. Each grade level also has a mobile, wireless laptop lab. In addition, all high school students are issued an iPad tablet upon enrolling in the school for use during their 4 years at the school.
Can my child attend Academic Challenge?
Yes. Students who are eligible to attend for Academic Challenge Program are provided with transportation to and from the program.
What kind of sports activities are offered?
Sussex Academy runs an after-school interscholastic sports program during the fall, winter and spring. We are currently offering boys' and girls' soccer, girl's and boys' basketball, field hockey, softball, baseball, swimming, volleyball, cross country, golf, and lacrosse.
What other activities are available to students?
Students can participate in Chorus and Band. Also, students participate in clubs of their choosing such as literary magazine, science, chess, and scrapbooking. In addition, teachers and parents sponsor academic activities such as Math League, Science Olympiad, Technology Student Association, and Odyssey of the Mind. The high school also has a Student Government Association, National Honor Society, and Leo Club. Additional clubs and activities are being added to address the interests of the students.
The success of the school depends on the participation of the parents. In addition to having parents serve on the Board of Directors, volunteers are needed in numerous areas. Some of those areas include:
• Serving on the student Portfolio Review Committees.
• Volunteering in the classroom or on field trips.
• Sponsoring after school activities or clubs.
• Participating in PTO.
• Participating in Sports Boosters.


Authors, one of the most important things you owe your readers is to be unimpeachable. That's shorthand for know what you're talking about. If you make a mistake, you'll lose the reader's trust. If you lose their trust, you may find your book skittering against the walls, removing the paint.
And really, there's just no excuse. You have the time to research everything that goes between the pages. Why take shortcuts?
Sure, it's a small thing to you, but it's tantamount to admitting you're bantha fodder to a reader with a knowledge of guns. Don't be bantha fodder. Or a nerd herder, for that matter.
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One Response to If You're Gonna Write It, Know It!
Yes and No on this one. While 'magazine' is technically correct, 'clip' has been used, however improperly, in its place for decades and by many who know guns well and use them often. Even checking my 7th edition Merriam-Webster (1970 pub. date) reveals a definition for 'clip' that begins 'a magazine for….' Thus, if one is creating a fictional character, the author might want to question which word would be the better fit. I wonder if 'clip' came into use, not because of a confusion with an actual ammunition clip, but because the magazine soundly 'clips' into the weapon upon insertion.


For more Kaley Cuoco pictures and videos, please visit our friends at Celebarazzi!
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Liv Boeree on Multipolar Traps
techstepgenr8tion
Joined: 6 Feb 2005
Location: The 27th Path of Peh.
17 Sep 2022, 12:56 pm
It's Liv on Lex Fridman and they hit more topics but I really love how much she's raising 'Moloch' awareness.
For anyone not familiar with Liv - famous Australian poker player, got out of poker and got a degree in astrophysics and has gotten really interested/active in the complexity, x-risk, etc. communities as well as some of the rationalism groups like Less Wrong. What I'm really glad of is she's now adding something of a celebrity face to GameB and complexity ideas that have needed to get out but didn't have any great channels (closest proximate perhaps being Tristan Harris and his Center for Humane Technology).
In the second hour (a little before 1:15:00) they touch on Slate Star Codex's 'Meditations on Moloch' and get into the question of what multipolar traps are and how they're as much of an x-risk as claimed. I like the way Liv phrased it in a different interview, that multipolar traps are sort of the 'final boss' in terms of being the generator of negative and zero-sum games. She mentioned in that interview as well that there were people who claimed that it all came down to entropy but disagreed, as I would, that there are many different ways that you could deal with entropy. Multipolar traps, OTOH, really are a Darwinian thing and they feed on Darwinian self-interest in ways that feed wars for gene supremacy which, if every actor is self-interested, no one will voluntarily lose a game even if they objectively had bad genes thus letting that maximize is a recipe for the perfection of Machiavellianism and psychopathy.
Where I think some optimism can be had is that there's a good chance that a world where people were commonly self-aware about these things is a world where people would have instincts carving in a different direction because they'd see red flags and rather than reacting in the immediate moment they'd be more likely to tell friends and family about a problem and the result would, ideally, be to do things that diffuse rather than escalate it.
Anyway that was for the 'TL:DW: lets talk about it' crowd.
"Love takes off the masks that we fear we cannot live without and know we cannot live within. I use the word "love" here not merely in the personal sense but as a state of being, or a state of grace - not in the infantile American sense of being made happy but in the tough and universal sense of quest and daring and growth." - James Baldwin
shlaifu
She's totally right, but I couldn't hear much of a solution apart from 'make people pay for twitter to change twitter's incentive'.
Basically what jaron lanier has been preaching for years.
I can read facial expressions. I did the test.
If this is as long-range, network related, and persistent a problem as to be something like the foundational human problem and part of its definition is you can't solve it by direct action from within a given system because any law or rule set can be gamed if that's the intent, it's a much more abstract war - ie. to solve the intent in far more of the populace, and I'd add - actually empower that part of the populace as well in a way that they don't pay for their virtue by falling to the bottom by not giving cut-throat hierarchy climbing their every ounce.
Well.duh. But apart from basically removing abstract monetary gains from the entire system and relying on something like social recognition as reward for behaviour - which worked in small groups but there's a reason it hasn't scaled - I'm unsure what to do.
There's an approach by some German or Austrian guy that goes by 'social wealth economy', in which taxation is dependent on social aspects of how the enterprise is run. Some ideas are: a capitalist will have zero taxation on his profits, if his enterprise fulfills certain environmental and social standards. - everyone gets paid properly and the company doesn't do any damage - that's going to decrease profits, but then, there's no reason to tax the company because there's no damage to fix.
....it at least sounded like something worth thinking about in more detail
There's that or the radical opposite approach, via block chain, where you're logging every little noteworthy thing you do to various block chains for $$ - whether it's getting your steps in on Sweatcoin, or getting your stay-at-home-mom credit through some future MomCoin, or tracking your spiritual or philosophic development through JesusCoin, MasonCoin/EasternStarCoin, SocratesCoin, KierkegaardCoin, or your artwork gets minted as an NFT and bought for an immediate small sum but gets larger rewards on resale, that at least monetizes all kinds of things that weren't well monetized before - OTOH its closer to sticking a probe in every orifice for data collection and runs into the dystopic scenario Mary Harrington and Paul Kingsnorth were talking about a while back - where it's nakedly obvious that we're as much standing reserve as the trees in the woods behind us or the iron ore and coal veins in a local mountain. The other problem - if we'll try to hack/game any system we'll find ways to even make that more dystopic because, if we're here to shred each other over genes, it's what we do.
techstepgenr8tion wrote:
And jesuscoin would be something people trade? What would stay-at-home-mom-coin derive its value from? With NFTs and cryptocurrency SO FAR it's clear that it derives its value from people buying it for dollars and euros and ruble.
You think I should convert to christianity? Jesus-coin is trading higher than atomist-coin right now ....
shlaifu wrote:
And jesuscoin would be something people trade?
Yeah, that's my Catholic upbringing coming forward. Guilty as charged.
What would stay-at-home-mom-coin derive its value from?
Pawtocol looks like it would be a good example of that. It's ticker is UPI, ie. Universal Pet Income.
The pet generates a certain amount of UPI, the owner buying certain brands of product from the pet store yields UPI, or you can use UPI to buy certain things at the pet store.
I do walk a couple miles each evening and I do use sweatcoin which is worth probably $.05 but you get a sweat coin for every mile you walk with an available 2x 20 minute bonus (if you know you'll be walking for 20 min or longer) and three advertisements you can watch per day to score additional sweat coin.
My guess is a stay-at-home-mom-coin would be like that, ie. clocking certain activities, being paid directly in a coin to watch advertisements, bonuses for buying certain products, etc.
If they did that 'right' however they'd find some way to make it a larger store of value that would treat each holder's coins like shares and they'd be getting dividends on shares.
The thing I'd worry about though is that this would be like a passable living if someone is juggling activities with nine or ten coins, and yeah - volatility would make that important as well. That and yeah, we all become traders and words like 'long', 'short', 'margin', and 'margin call' become household terminology (so still a lot like gig economy, just without anyone dangling you by a string and holding a knife to it based on performance).
With NFTs and cryptocurrency SO FAR it's clear that it derives its value from people buying it for dollars and euros and ruble.
There's something going around right now with buying fractional shares in artwork (though I'm always disappointed when they're mentioning Banksy, I don't understand some people's tastes). The idea is that this is part of how the rich store value, that its higher yielding than stocks or real estate, and at the same time what is most art of the collecting variety other than canvas NFT's? Maybe the one thing canvas has is that someone could be painting the Adriatic from Italy and put some sea water in the paint for extra 'place' saturation but aside from a slight fishy-briny smell that's about all the difference you get.
So the big question is whether there will ever be a 'Mona Lisa' NFT.
That's a good question. I'm guessing no, you might trade jesus-coin but I'm guessing you'd have to be Christian in order to stake / yield farm it.


Find a Camping trip that explores South Africa. There are 6 tours to choose from, that range in length from 7 days up to 10 days. The most popular month for these tours is September, which has the most tour departures.
"G was an amazing guide. We are going to do another tour with even more friends because..."
"We had a great trip, a lot of fun and our guides had a lot of knowledge about Africa."


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Predicting what will happen between Beal and the Wizards
Bradley Beal and the Washington Wizards did not agree on an extension before yesterday's deadline passed. This wasn't a shocking development, but it still, technically, leaves Beal's future up in the air.
What will happen over the next eight months to influence next summer's resolution? Here's a prediction from Bleacher Report:
Beal has been a scoring monster, averaging 25.3 points on 46.6 percent shooting from the floor. Through three games he's nailed half his three-point attempts, and he's already jacked up 20.
There's no doubt Beal gets a max offer, be it from Washington or another team. He's so good.
Beal is growing as an all-around player, and as a scorer. That's to be expected, given his youth and the fact that he's finally fully healthy for the first time in quite a long while. Along those same lines, it's not a lack of production or expected stagnation that prevented him and Washington from coming to terms on an extension. Come this time next year, Beal will be signing for max money. That much is just about guaranteed, regardless of whether he's working alongside Kevin Durant or Otto Porter Jr. at the 3.
Kyrie Irving to miss Nets' game, day after trade request
NBA Roundtable: Which teams must make a trade deadline move?
NBA Front Office Confidential: Uncertainty defines upcoming trade deadline


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Lisa, I really value you and the wisdom you have shared with me over the years. During the year I have often thought about the things that you said and the clarity and strength that you have. You have no idea how much of an inspirational and empowering role model you are for me. I'm very grateful for you in my life. I really look up to you and am inspired by your strong sense of self as a woman. It gives me a lot of encouragement that I can do it (in my own way) too. Thank you, Lisa. You inspire me and give me permission to be me in far more ways than you will ever know.
Thank you for the invaluable information and guidance you provided us in our consultation. By drawing on your experience and expertise as well as taking time to complete the questionnaire, we were able to clearly define our financial goals and what we want for our family's future. The questionnaire especially helped us to identify areas that needed some work such as our insurances and estate planning and the good and not so good financial habits we have. At first it seemed a daunting task to complete but was well worth the effort. We came away from our meeting with perspective that helped us to make financial decisions we had put in the too hard basket. We are now focused and confident with what needs to be done to achieve what we want thanks to you.
The greatest thing about my meeting with Lisa Dudson was, because she listened, prompted and made me feel so comfortable about 'talking money,' I actually enjoyed myself!
This is a huge admission from a woman who had always 'buried her head in the sand' with regard to her finances. The thought of 'facing the dollars' had always been such a scary prospect.
If you can relate to my fears I thoroughly recommend you give Lisa a call right now!
Lisa has the ability to instil the self-confidence required in order to make changes you know you must make. She also provides recommended steps to achieve those changes.
Now – several years later, I thank Lisa from the bottom of my heart. I sometimes find it amazing I'm now living in my beautiful freehold home and actually enjoying keeping track of my accounts!
I first met Lisa 3 years ago as a financial planner. I have seen how she has lived these Money Management principals and applied them to her own life very successfully and effectively: I would totally recommend her work and services without reserve.
We were fortunate enough to have Lisa speak at our Conference this year. She was fantastic and by far one of the most popular speakers of the day. She encouraged the women who attended her sessions to be responsible for their own financial situation and to not just be passengers in life, but to be financially aware. Her sessions were packed out and you could tell how much value she adds by how many women were taking notes. We would love to have her come back again next year.
Lisa has presented at several 1 day seminars I have run. The feedback from all the attendees has been excellent. She delivers the information in an easy to understand way leaving behind tools and strategies to make improvements. She uses so many real examples and case studies so people can really relate to the information.
Financial speakers can be very dry. Lisa, however, is easy going and down to earth, has a great sense of humour and encourages interaction and questions.
I just wanted to drop you a line to thank you for the seminar you ran for our Property Investors May meeting. It was a record turnout which was a great relief to us as this was the first time we had booked such a large venue . We are still getting comments from those who attended (many of which are sponsors) who were really impressed with not only the turnout but the content you covered. The whole evening raised not only the profile of the NZPIF but also our local businesses and sponsors. We already have several sponsors coming back to us saying that they would be happy to sponsor similar evenings.
I loved that you gave good common sense practical advice. It meant that everyone there could relate and as such everyone got something out of it. Obviously there were more technical and complex issues touched on but it was great how you allowed the evenings proceedings to govern where you put your focus on. When there was an interest generated on a particular area, you spent more time on that. The Wealth profiles were definitely the most popular and caused the most comment.
I think the follow up that you offered was of huge value and we are still getting enquiries as to when you will be coming back. We ourselves have made the commitment to host a "Women in Business" all day seminar later in the year and would welcome the opportunity for you to come back and run this. Having such a high profile speaker such as yourself will obviously be of huge benefit to those attending (Plus it makes it easier to secure Sponsors). We look forward to sharing more initiatives in the near future.
Lisa was one of the wellbeing speakers in 08. She spoke on "Tips to Stretch the Dollar". Lisa is an excellent presenter – the following comments are a sample of what our employees said about Lisa's talk.
Very good informative presentation that we can all take things from.
Lisa Dudson was an inspiring speaker at one of our Waikato Property Investor meetings. Speaking to a packed audience of about 300 members, she provided meaty, informative concepts for managing one's finances and growing wealth overall. We encouraged our members to bring their children and were pleased to see them patiently absorbing Lisa's nuggets of information for almost two hours! An impressive feat in itself! An accomplished businesswoman with an easy listening style and obvious enthusiasm for sharing her financial knowledge, Lisa made this one of our most memorable and talked about meetings. We will be more than happy to invite her back to speak again.
I would like to highly recommended Lisa Dudson as a speaker to any property or financial groups. She spoke to the Rotorua PIA recently and we got fantastic feedback from our members. Lisa's presentation was original, relevant and delivered with energy and humour. She provided information that was immediately applicable. We will definitely be inviting Lisa back to speak to our association and can recommend her to yours.
As a professional Business Speaker, I was very impressed with Lisa's ability to take the important but often seemingly unexciting fundamental concepts of 'wealth creation' and turn them into interesting and exciting, easy to grasp wealth creation strategies that leaves you little doubt as to Lisa's ability to execute only the best strategies for her clients. She is one of the few true wealth creation professionals.
"The best seminar we have ever attended" commented by customers who have attended a significant amount of residential, property and financial seminars in NZ.
"Far outclassed Westpac's Residential Seminars they use to provide" commented by ex employees of Westpac.
"Shame Lisa Dudson wasn't my high school girlfriend, I would have been a millionaire by now" provided by a baby boomer.
"Very professional, and informative seminar, we got an incredible amount of information" provided by new customers to Residential Investment and a customer who owned 4 properties!
Lisa Dudson was the speaker at Tauranga Property Investor Association's monthly meeting, attracting a good turnout of members. Her talk on financial success was applicable to people at all levels of knowledge, from those thinking about starting investing through to those who are very established, and the topics were presented in a clear, easy to understand way that made logical sense. This was supported by a visual presentation.
Examples given from personal experience underlined the messages she was passing on, which were about building a stable base, having a clear direction, and how to find that direction, while making it fit with your lifestyle and values. Lisa also encouraged people to question their advisors, know their worth at any given time, and to keep on track for the future.
The talk was inspiring and thought provoking. I am sure many members went home to look up moneyblog and enroll in the free online moneyclub course.
In August 2009 Lisa addressed our Hawkes Bay Property Investors Assn. on Financial Planning. This address attracted one of our largest audiences and was by general acclaim an excellent address. In fact one of the best addresses we have had. Lisa is a financial planner who can see the big picture and focuses on the client, rather than recommending a fixed suite of investments that are easy to sell. I can strongly recommend her as an entertaining thought provoking speaker who is a leader in her field.
Graham Duff, Vice President, Hawkes Bay Property Investors Assn.
Lisa spoke at the Manawatu Property Investors Association at the end of 2009. We had a great turnout, sold all her books and people found the advice very informative. There were lots of facts and wonderful explanations on investment options and guidance on how they fit into your life planning. I highly recommend Lisa as a speaker and I have used her guidance personally for many years.
Hearing Lisa speak at the Property Expo the other week, I really enjoyed her clearly presented ideas on money management. Her confident presentation and anecdotes were a thought provoking wake up call around an often avoided topic.
Delivery of money management information does not need to be serious or boring – not any longer anyway thanks to Lisa Dudson. Personally, I was pleasantly informed, inspired and motivated to take action after listening to Lisa's 'successful money management' presentation.
In 30 minutes Lisa delivered the cold hard facts on our rising personal debt, reliable knowledge on what our rising debt will mean later on when we retire and helpful tips on how to get our personal finance under control now so we can have the lifestyle we desire sooner than we think. And you'd think this stuff would be boring to listen to – well think again, Lisa has the knack of making it all seem quite fun and we like doing fun things don't we?
Excellent. Practical, real, and provides the tools and encouragement to take the steps we need to achieve our own financial well being. You find out or are reminded of what to do to support the financial wellbeing of yourself and or family. Take action and the returns will be phenomenal in the longer term, as well as in your sense of empowerment as you take charge of your daily financial life. Thoroughly recommended. Thank you.
I have found the services and advice provided by Lisa Dudson as both a personal financial advisor as well as a Business Coach invaluable in helping me achieve my personal and business goals. Lisa's many years of business, financial and property success means she walks the talk and has the experience and credibility.
In a market crowded with wannabe coaches and consultants who often are little more than failed commission sales people, Lisa is the real deal. Lisa also has the skill to combine strategic thinking with practical what to do advice.
When you work with Lisa not only are you accessing her many years of experience but also her extensive network of professionals. Lisa operates with the highest level of integrity and I have no hesitation recommending her.
Since starting with Lisa I've doubled my income while having more freedom and working less. By helping me clarify my goals, manage my cashflow and focus on what was truly important to my business I've seen amazing results. And now I count on Lisa's guidance as I take my business development to the next level again.
There are lots of business and financial advisors out there to choose from. The problem is they're just that… advisors. Most of them have never built and sold a successful business or made a decent income from investments.
Lisa is different because she can speak from experience. She's been there and can guide you from personal experience. She also knows the personal journey that we must go on if we want to be successful business owners.
This is why I value Lisa's opinion so highly and turn to her for business advice on a regular basis. Not only does she answer all my questions but presents new angles that I'd never even considered. This is the value in having someone who has walked the path successfully before you.
If you're a business owner I recommend you book at least one session with Lisa right now. Because it's only in that session where you will understand her true value. But I feel if you're willing to take the first step then at the end of your time together you'll be wishing you'd done it much sooner.
We have been working with Lisa Dudson for approximately ten years for both personal and business advice. It was imperative we work with an advisor that has 'walked the walk'. Lisa's credentials speak for themselves, so impressive, she has been pivotal to the success of our personal and business goals and aspirations.
We are a husband and wife team which had been challenging at times. Lisa helped us identify our differences through a profile program and it was a turning point in our working relationship, it was huge!!! We learnt to work with our strengths and weaknesses and not sweat the small stuff. Our goals and desires were regularly assessed and re-directed relative to our stage in life.
Lisa's style is pragmatic which is essential, but at the same time Lisa made sure we realized that if mind, body and soul are not in sync, then it can all be in vain. It was 'bigger picture' visualization, not just about financial achievements, and making sure we stayed true to our values.
Thank goodness for this approach as we did have a health challenge thrown at us along the way and huge adjustments were made by us with Lisa's empathy and consultation. At the risk of repetition, Lisa has been without a doubt, paramount to our success and she is an inspiration.
Thanks for helping us get so much more clarity on what our property investment strategy should be. We have attended a number of courses and read lots of book but we have struggled to put it all into action. I guess we were overwhelmed by the amount of information and were so focused on getting it right that we couldn't get started. You helped us understand what was relevant to our individual circumstances so we now feel comfortable moving forward.
I've been thinking about writing to you for a while. My partner and I had heard you speak a number of times and finally got around to coming to see you. I'm so glad we did as we have made so much progress since we saw you. We now have a number of rental properties and are now well on our way to achieving our financial goals.
Our only regret is that we didn't do it sooner as I'm sure we would have been so much further ahead by now. We tell all our friends about you and we hope they have the foresight to come and see you. Thanks so much for your practical and sound advice.
I would like to say a big thank you for your presentation I attended before xmas on "Feeling the pinch at Xmas time". Im glad I took time out of my busy work day to attend!!
The information you provided gave me some real insights as to what my husband and I have been so wrong about all those years.. I had some key moments where I was thinking throughout your presentation "oh REALLY.. is it that simple!!" Even though we could not do much at Xmas financially, you empowered me to take control of our financial situation.
I then registered for your "7 Week Financially Free Course" shortly after. Both my husband and I sat down every week to review each segment over the 7 weeks and went through the course. I must say it took us strength to review and analyse every single bank transaction over the month of November, but this was such a blessing in disguise… the amount of discrepancies on the tiniest of items when we added it up on some items literally had us gob smacked! We had to look at it again and again and went no…YES… OMG that is not how much we spend on blah blah blah each month!! It was a big wake up call.
We set up our goals on what we want to achieve and worked on our own little "Lake Money System" even my son who is 11 years old we educated him on how it worked and he now calls it his "sanity pocket money" and shares this to friends and family, too cute.
We are not frugal with our spending any longer and taking out our sanity money every fortnight, was easy once you get in the habit of it. We have set up various saving accounts to our needs and our real test is to review how we are tracking at the end of February as our budget is now in full swing! We looked at other avenues on how we could make money and have a Korean student stay with us for 6 weeks who not only is the same age as our son so he has a new friend but it is also helping us pay off our debts faster.
Again, thank you for all your help for empowering us.. and will be excited to watch our net worth grow over this year.
The course was real, structured and valuable. Lisa provides the tools and the expertise to do what we need to do to take responsibility for our financial wellbeing, and to begin building the life of our dreams. These tools and insights are applicable to most people; whether you are new to the world of managing your personal finance or are refreshing yourself on the fundamentals that need to underpin a sustainable long term wealth generation strategy. This seminar will give you the encouragement and reminder of what you can do to make your life a financial success. Thanks for a great course.
Hi Lisa, I recently read your book 'get your head out of the sand' and am delighted at the inspirational, straight-forward way you have dealt with financial issues, I usually get 2-3 books out from the library each month to keep me focused on my financial goals. Sometimes I do not relate to them easily, perhaps the topic might be beyond my current goals, or just the way the book is written, so it was great to read and re-read your book and recommend it to other women. Your step by step tasks and constant inspiration made it for me. Write More!
I have no investments, no savings, -at present, but I will have -and that is my success. I am 50, parenting alone my 2 children aged 11 and 8. I work fulltime and am finishing a post-graduate diploma in health sciences. Five years ago I discovered my husband had re-mortgaged the family home to finance his gambling. I was devastated. I separated, got back together and eventually separated for good 2 years ago. When first separated I had a credit card and over 18 months booked up $2062 just buying groceries when I ran short. I became appalled by this and when I received a tax refund for $2064.64 I decided!!! I paid off the card, gave it to a friend for emergencies only and vowed to live within my means no matter what. 18 months later I told my friend to chop up my card and I cancelled the account.
I have found it hard, especially, last year 2005 when I suddenly had to find $100 a week for after-school care, but I did it. Food is always the flexible option and often I would have $120 to spend on it a fortnight, I shop only fortnightly, apart from fruit/veges. I shopped at Savemart for clothes, and made coffee out a special treat. At the beginning of 2005 my children, a friend and I decided we would go to Auckland in Jan 2006 -see the Lionman, and all the Auckland kiddie things. As hard as it got during the year I stuck to my saving plan $75 a fortnight and reached my goal of $1400 for the trip. We had a great time and no debt, and no Xmas debt, so now as I enter 2006 I feel free- no back bills !!!
I've knocked $30,000 off the mortgage in the last 5 years AND replaced the roof and painted the house. ($14,000) I have an old house and do a lot of other repairs myself. I aim to be mortgage-free in September 2009. Then those mortgage payments I will use for retirement savings- I have no ideas about how to do this, so will need to learn. I am considering doing a Masters in health sciences but there is little career structure which would repay my time and increase my income, so I am wondering if I need to put that 20 hours a week I would study into developing another income source-what, I have no idea and, obviously now, no resources, but am willing to explore this.
My kids have done it hard not having the latest gadgets as their friends but are learning the value of money. This year I have decided to involve them in the fortnightly finance planning/decision-making. I set up education funds for them 5 years ago, not much, and will increase this as I can. I feel in control of my finances. In the middle of the night I do wake worrying I've left it too late to save much for retirement and really have to 'pull my head in' as I am determined to do as much as I can and be as wise as possible. I have copied your goal-setting and completed the exercises in your book AND in the middle of the night re-read these.
Thank you so much for your inspiration. I look forward to your next book.
I am writing to thank you for coming to speak at the Waikato Property Investors Association last month. I had so many comments from members but the best one was from a parent who said her 10 year old child went home and slapped a piece of paper on the table and said she was going to buy a farm when she left school, so she needed to do a plan for savings. How awesome is that? Thanks very much Lisa. It was very much appreciated.


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After a decade or so, the light of peace, shimmered first initiated again in 1963, then in 1972 and again in 1980 respectively, was enlightened again in October 18, 1990 at Pangsai, a sleepy border town of Sino – Myanmar, Northern Shan state. The peace – talk between KIO and NWT was able to be initiated on the peace – bridge being connected by peace mediators: former Israel Ambassador Duwa Hpauyam La Wawm, Rev. Lahtaw Saboi Jum and Mr. Lahtaw Hkun Myat.
The KIO team members were Lt. Col Banma Zau Hpang, Mr. Lama Gumhpan, Maj. Manam Tu Ja and Lt. Hpunggan Hkun Nawng. In the NWT team, lead by Col. Tin Win, were Lt. Col. Kyaw thein, Maj. Than Aye and Capt. Myint Swe. In order to materialize the peace process again, the Kachin peace mediators first tried to consult KIO chairman Mr. Maran Brang Seng.
Maj. Tin Maung Win (No. 9 Int. Unit Commander).
The meetings were held on 6th March, and then continuously 18th – 23rd of March, 1993 in Myitkyina for further more negotiations with SLORC. The KIO had a number of urgent issues needed to be discussed and to be decided upon among themselves. Before going further from their present position, KIO Vice – Chairman Malizup Zau Mai called for an emergency meeting of KIO Central Committee at his residential office on 31st March 1993.
On 6th – 7th of April, 1993 the meetings were held by both delegates at Malihka Yiktha in which Maj. Gen. Aye Kyaw gave a short opening speech and then, Brig. Lamung Tu jai and Mr. Lanyaw Zawng Hra both from KIO, gave speeches respectively. Then, both sides mainly discussed about the relocation of armed forces. After that, without consuming much time, the peace talks were again on the table at Malihka Yiktha on 26th – 27th May 1993. On 1st – 6th of July, 1993 both delegates negotiated to reach an agreement about the ceasefire between KIA and Tatmadaw in the Kachin State and the northern Shan state areas known as Kachin Sub – state in former times. With the intention of making a ceasefire agreement and peace talks, KIO Chairman Mr. Maran Brang Seng and General Secretary Mr. Lanyaw Zawng Hra, both prepared to come down to Myitkyina. Meanwhile, they dispatched a delegation led by Brig. Lamung Tu Jai to Myikyina as a point – team. In spite of the fact that the due date was October 27th, on which date KIO Chairman and General Secretary would be arriving at Myitkyina, they could not reach there because of the KIO Chairman's failure health. However, Brig. Lamung Tu Jai who had already arrived at Myitkyina held a meeting with Northern Div. commander Maj. Gen. Saw Lwin on 01st January 1994.
During this meeting, Brig. Lamung Tu Jai informed to Maj. Gen. Saw Lwin that although the ceasefire agreement had not yet been signed due to its state of unreadiness the KIO wanted to begin the "Regional Development" in their own areas. Therefore, at 08:00 AM on 12nd January 1994, the Regional Development Programme was discussed in detail at the meeting held at PWT conference room in which KIO, NWT and PWT delegates concerned were attending. There were over 50 participants, including 11 KIO delegates.
The meeting held from 18th to 24th of February 1994, were more significant than usual. The SLORC government, however, was perfer to negotiate about the immediate issues such as cessation of hostilities, regional development and some other regulations rather than main political issues that causes the armed conflicts at this moment. Overtly, SLORC leaders expressed that the political issues can be sought and negotiated not with the current military government, but to the next coming civil government.
Maj. Gen. Aye Kyaw and Maj. Gen Malizup Zau Mai, both gave speeches at the meetings. After several lengthy negotiations, including about ceasefire, they decided to form a drafting committee for a ceasefire agreement. Finally, they approved the cease fire agreement. On 23rd February 1994 at 15:00 PM, SLORC General Secretary1 Lt. Gen. Khin Nyunt emphatically addressed about the ceasefire agreement between KIO and SLORC in some detail and gave instructions to all in the meeting room of the Northern Division Command. The KIO delegates – head Maj. Gen. Malizup Zau Mai also expressed the necessities to be negotiated and submitted them to the higher authority of SLORC. On the evening of that day, to mark the historic milestone of ceasefire agreement in Kachin history, the traditional "Peace Manau" ceremony was happily celebrated by all the stakeholders such as SLORC delegates, the KIO representative, the Kachin peace mediators and the local elders, scholars and well – wishers of the Kachin State at the ground of MPKh.
After dancing the "Peace Manau", all the persons concerned were offered the Kachin traditional "Magun Shat Lit" of honor and all the participants shared it as the opening mark of momentous chapter of peaceful coexistence. On the next day at 02:10 PM (24th February 1994) for the sake of people's peace, SLORC and KIO signed the ceasefire agreement officially at the meeting room MPKh (Northern Div. Command). Those who signed were as follows.


text:
\section{Introduction}

\IEEEPARstart{T}{here} are various traditional approaches for retrieving structured information from clinical free text, which are generally based on term importance metrics from text corpora and are not very efficient in determining the similarity between relevant formats and encountered texts, even if there are small variations between the sequences to be matched. These methods suffer from several other issues, such as data sparseness, high dimensionality, out of vocabulary (OOV) words, ambiguous words in the corpus. Other hardware limitations are also encountered in processing the data, such as memory usage and time complexity.

Q-Map tries to circumvent these issues while retaining a robust retrieval mechanism for efficient discovery and annotation of medical concepts from the clinical free text. We try to solve issues of concept aggregation that are irregular in Unified Medical Language System (UMLS) \cite{bodenreider} Knowledge Sources \cite{lindberg} using data-driven approaches. We also introduce a rule-based phrase sense detection algorithm for marking the negated concepts in a text.

The algorithm aims to find the phrases which are medically relevant in a single step parse. The next stage then eliminates the phrases that seem to be negated in the context. For example, if the text contains \qq{Patient does not have diabetes}, then the term \qq{diabetes} should not be detected positive even though it has a medical association. Together with spell correction, negation detection and phrase detection using the UMLS Metathesaurus \cite{schuyler}, the algorithm provides a very fast way of parsing large text dumps.

The rest of the paper is structured as follows. Section II describes the background related to the work. Section III briefly explains related works in the field. In section IV, we dive into the data, methodology, algorithms, and architecture of the system. Section V presents results of comparison between Q-Map and MetaMap \cite{aronson} with examples. Conclusions are summarized in section VI. Finally, we end with acknowledgement and references.

\section{Background}

\subsection{Clinical Documents}

Clinical Documents are the end result of the clinical documentation, which can be defined as the generation of digital or analog medical record detailing the course of treatment, clinical trial or tests undergone by an out-patient or an in-patient. There are different types of clinical documents namely, discharge summary, progress notes (summarises the diagnostic findings and patient status on a daily basis), surgical reports (surgical procedures are noted as a written operative report), radiology reports etc. Most of these clinical documents are in free text format where the detailed reports are narratives by physicians, care-providers, or specialists. These clinical documents serve as input to the Q-Map system after it is trained to extract systematic data from them.

\subsection{UMLS Metathesaurus}

The main requirement for building an Information Retrieval (IR) system is to have an exhaustive knowledge source. The UMLS is a collection of concise but detailed medical concepts from many controlled vocabularies in biomedical sciences. UMLS Metathesaurus is the base knowledge source of UMLS which is a database consisting of over 1 million biomedical concepts and 5 million concept names, which are collected and periodically updated from over 100 different controlled vocabularies like, ICD-10 \cite{icd}, MeSH \cite{lipscomb}, SNOMED CT \cite{donnelly}, LOINC \cite{mcdonald}, PubMed \cite{pubmed}, PMC \cite{pmc}, RxNorm \cite{liu} etc. UMLS Metathesaurus organises all these data from different sources under different Concept Unique Identifiers (CUI), which effectively helps in organising synonymous terms. UMLS also creates another hierarchy by grouping similar CUIs under semantic types. Semantic types are identifiers denoting the class of concept strings. UMLS has 133 different semantic types, such as finding, disease and syndrome, injury or poisoning etc. UMLS Metathesaurus configured using options, such as CUI clustering (explained in IV-A) and semantic type filtering (explained in IV-D), forms the knowledge base of the system we developed in this work.

\section{Related Work}

Many different systems have been developed in the past for the purpose of text mining. Few of such systems are Metaphrase \cite{tuttle}, CLARIT \cite{evans}, MetaMap, cTAKES \cite{savova}. These systems have been employed in various different applications and have had a varying degree of success based on how well the data is structured.  One of the most reputed tool for medical text mining currently is MetaMap.  MetaMap builds on top of UMLS Metathesaurus and SPECIALIST lexicon \cite{browne}, but suffers from the issue of massive complexity, and hence debugging and additions to the system is a challenging task.

Q-Map tries to achieve the same objective with a much simpler approach with better flexibility in the system while producing a comparable performance with added benefits of speed and handling huge amounts of datasets. We present the Q-Map architecture and its future scope and present a comparative study with MetaMap. Our original contribution includes the design and architecture of the system and the ensemble of algorithms used with various modifications explained in the following sections, that help put together a stack efficient in clinical concept retrieval. We also try to remove the discrepancies in UMLS knowledge sources using data driven approaches explained in next section.

\section{Procedure and Architecture}

\subsection{CUI Clustering/Bagging}

Although the UMLS Metathesaurus is a comprehensive collection of medical concepts, it has some flaws in data organization. Concepts which have the same meaning but comprise of different root words are often bagged under different CUIs. We try to remove such discrepancies by clubbing all the similar terms under unique identifiers using natural language processing (NLP) techniques.

This bagging algorithm can be configured to define how aggressively the concepts need to be clustered. It is based on thresholds of concept mapping metrics which is based on edit distance. For example, bagging can be performed with stemming of concept terms which would be more aggressive in mapping the terms, or it can be performed without stemming. Similarly, there are options to remove stopwords and consider the word order. After this process, a masking table is produced which maps the old CUIs to the new ones. For example, \qq{diabetes} occurs under the following CUIs - C0011847, C0011849, C0011860 in Metathesaurus, but after the bagging process, all the terms under the 3 CUIs will be clustered together under one CUI. Our algorithm also takes care of transitive nature of concept matching during this clustering process. For example, \qq{diabetes} occurs under CUIs - C0011847, C0011849 and \qq{DM} (Diabetes Mellitus) occurs under CUIs - C0011849, C3250443, so effectively all the terms under these CUIs are grouped together under a single CUI.

This masking process gives promising results in the subsequent classification tasks fed with features retrieved from Q-Map.

\subsection{Aho-Corasick Algorithm}

Aho-Corasick algorithm \cite{aho} is a string search algorithm similar to the implementation of a trie but is optimized by maintaining failure states in case of an unsuccessful character match. It is a finite state machine (FSM) with characters as its transition states and failure loops as its fall-back states. This dictionary matching algorithm locates the elements of a finite set of strings in the dictionary within a text document. The complexity of the search is linearly proportional to the length of the string from which the medical concepts are being mined. The failure states help in fast transition between states whenever a character mismatch is encountered. This efficient failure transition prevents the algorithm from backtracking to the root to restart the matching process.

  \begin{figure*}[thpb]
      \centering
      \framebox{\includegraphics[scale=0.35]{flowchart.jpeg}}
      \caption{Q-Map Architecture Flowchart}
      \label{figurelabel}
   \end{figure*}

\subsection{Spell Correction}

Edit distance is one of the most popular ways of determining string similarity. An edit in the edit distance can be one of the following operations: deletion (removal of a character from the string), addition (add a new character to the string), substitution (replace a character with another in the string) and transposition (swap two characters in the string). The correction of a spelling error is based on probability theory where the most likely spell correction for a misspelt word is chosen based on the above-defined edit distance metrics.

So, we try to find a correction c, among all the possible candidate corrections to maximize the probability of c being the intended candidate, given the word w. Mathematically, it can be written as follows,

\begin{equation}
argmax_{c \in candidate} P(c|w)
\end{equation}

\subsection{Q-Map Algorithm and Architecture}

Q-Map is built as a very flexible system with various configurable options (All the examples presented here use UMLS Knowledge Source 2017AA). Each of these configurations are explained in detail later. These options help in defining how the system should parse the data for retrieving information. The Q-Map system can be broken down into three phases, namely, preprocessing, indexing, search.

The speed of the system in search process can be attributed to the first stage, the preprocessing. All the overhead for maintaining minimal representation for achieving maximum overlap during search phase is dealt with in this step. The configuration setup during this step defines how aggressively the system annotates medical concepts in a clinical free text. Various configuration options available during this step include CUI clustering, stemming or lemmatization etc. The configuration options are explained below and the setup of the entire system is summarized briefly in Fig 1.

Limiting the number of semantic types can help in indexing only the relevant data depending on application requirement. For example, one can index data from only LOINC, RxNorm etc. if the retrieval aims at fetching drug information from the corpus. Also, many of the semantic types often have a lot of noise in terms of concepts present in them which might not be relevant to all types of applications. For example, the semantic type \qq{finding} has concepts named, \qq{disease}, \qq{syndrome} etc. which might be totally irrelevant when the application is medicine based because these concepts, even though have a medical association do not carry any importance in terms of information contained. Hence, depending on the use case, one can limit the number of semantic types used for indexing.

Removal of stop words while indexing is an option that can be toggled as per requirement. If the stopwords are removed, it can help in a successful match even when the inflection of terms in a document are different. For example, \qq{tumour of brain} and \qq{tumour in the brain} would match successfully if the stopwords are filtered. Similarly, other forms of the phrase, such as \qq{brain tumour} would also match successfully. This robustness can be attributed to the comprehensive collection of concepts in the Metathesaurus. It gives very promising results and does not require any additional effort to produce more forms of a given phrase.

Similarly, stemming is another option of preprocessing which helps in achieving uniformity when the terms are derivative of same root term. For example, \qq{diabetes} and \qq{diabetic} would both stem to \qq{diabet}. Even though the final word does not have a meaningful spelling sometimes, empirically the added benefits of uniformity far outweigh any drawbacks of lack in meaning due to spell errors. Alternatively, one can use lemmatization which is basically a dictionary lookup to get the accurate root word and would keep the spelling correct and meaning intact at the cost of increased processing time.

The preprocessing step standardizes the data in appropriate form for the second step, which is indexing to generate the FSM. Indexing consists of two steps in itself. The first step is the building of the trie where each node is a character. The step two is the main compute intensive step, where in for each node its failure state transition is determined that searches for other branches that have the longest prefix which is also the suffix of the failed branch. Also, the payload stored with each concept name in the index of FSM can be easily modified to store additional data which should be returned upon match of terms.

The speed of the algorithm can be attributed to this search automaton which reduces the time complexity of concept retrieval, which is proportional to the length of the document on which the algorithm is operating for mining the clinical concepts.

The third step of the Q-Map system is search, where same preprocessing configuration as used during the first step is applied on the corpus that is undergoing the annotation task in order to maintain the uniformity of analysis.

The additional option of spell correction, introduced in section IV-C, is available for preprocessing the text before search phase.

There is a configurable option for the output generation from the search process. One can define whether the response should return all the concepts or the superset concepts only. By superset, we mean the string in the concepts mined that are not a substring of another string being returned. For example, if we search on a document containing \qq{Patient is diagnosed with type 2 diabetes mellitus and hypertension}, then the output of search on this document would return \qq{diabetes}, \qq{diabetes mellitus}, \qq{type 2 diabetes mellitus} and \qq{hypertension}. Here, \qq{diabetes} and \qq{diabetes mellitus} are the substrings of \qq{type 2 diabetes mellitus}. So, if the search is configured to return supersets only, then returned concepts would be only \qq{type 2 diabetes mellitus} and \qq{hypertension}. This option has various benefits when one wishes to keep the most informative terms only and not all the variations.

\begin{table*}
\label{table_example}
\caption{Comparison of Q-Map and MetaMap Outputs}
\begin{center}
\begin{tabular}{C{8cm}C{3cm}C{3cm}}
\hline \hline
Document & MetaMap Output & Q-Map Output \\
\hline
Ligament tear observed in Radiograph. Patient is a 53 year old female and has been recommended for unilateral Total Knee Replacement. Patient was given Heparin as a prophylactic treatment to prevent DVT. & \textbf{Diagnosis:} \newline
Ligament Tear \newline
\textbf{Procedures:} \newline
Total Knee Replacement \newline
Radiography \newline
Prophylactic Treatment \newline
\textbf{Medicines:} \newline
Heparin
 & \textbf{Diagnosis:} \newline
Ligament Tear \newline
\textbf{Procedures:} \newline
Total Knee Replacement \newline
Radiography \newline
Prophylactic Treatment \newline
\textbf{Medicines:} \newline
Heparin\\

\hline
Patient, F / u / c / o seizure disorder on CBZ, now admitted with nausea, vomiting and generalised  tiredness. EEG was normal. Dose of Tegretol was reduced. For throat discomfort and vomiting, ENT consultation and laryngoscopy was done and said to be normal.
&
\textbf{Diagnosis:} \newline
Seizure Disorder \newline
Vomiting \newline
Throat Discomfort \newline
\textbf{Procedures:} \newline
EEG \newline
Laryngoscopy \newline
\textbf{Medicines:} \newline
Tegretol
&
\textbf{Diagnosis:} \newline
Seizure Disorder \newline
Vomiting \newline
Throat Discomfort \newline
\textbf{Procedures:} \newline
EEG \newline
Laryngoscopy \newline
\textbf{Medicines:} \newline
Tegretol
\\

\hline
Patient is a 48 year old male and presented himself in the Emergency Department with chest pain. AFib and massive cardiac arrest was observed. ECG, Echocardiogram and Chest CT was ordered along with Troponin test, HBA1C test and Serum creatinine test. Patient was given Warfarin on a tapering down dosage starting with 3mg. Patient needs to undergo CABG.
&
\textbf{Diagnosis:} \newline
Chest Pain \newline
Cardiac Arrest \newline
\textbf{Procedures:} \newline
Chest CT \newline
ECG \newline
Serum Creatinine Test \newline
Echocardiogram \newline
\textbf{Medicines:} \newline
Warfarin
&
\textbf{Diagnosis:} \newline
AFib \newline
Cardiac Arrest \newline
Chest Pain \newline
\textbf{Procedures:} \newline
HBA1C Test \newline
Chest CT \newline
Troponin \newline
Echocardiogram \newline
Serum Creatinine Test \newline
CABG \newline
\textbf{Medicines:} \newline
Creatinine
\\
\hline \hline
\end{tabular}
\end{center}
\end{table*}

\subsection{Negation Detection}

The system implements negation detection based on the algorithm proposed in NegEx \cite{negex}. NegEx is a simple syntactic algorithm for identifying negations given the phrases to be tested for negations and the sentences they occur in. Based on the regular expression, the algorithm is capable of detecting different classes of negations, namely pseudo-negations and positive negations. Pseudo-negations consists of cases such as double negatives (e.g. not ruled out), modified meaning (e.g. gram-negative), or ambiguous phrasing (e.g. partial presence of symptoms).

With the help of NegEx, the system is capable of differentiating among positive and negative cases which is in-turn helpful in fixing false positives that would be detected otherwise.

\section {Results}

Both Q-Map and MetaMap are tools to retrieve medical concepts from free text datasets, but vary in their approaches and algorithms. MetaMap is based on prolog engine and has a few extra features like those of minimum phrase parsing of a sentence, word sense disambiguation (WSD). But we noticed that we did not require minimum phrase parser with our approach in Q-Map. This is mainly because of the rich data available in Metathesaurus which is used of the indexing and creating the Q-Map FSM.

Also, the performance of minimum phrase parser and WSD depends largely on how well the input text is structured. If the input is grammatically sound and follows the rules of sentence formation, then performance is appreciable. But it is observed that in many cases the sentence formation in clinical notes is not that well-structured. In either case there is no drop in performance of Q-Map because of the preprocessing steps done for data uniformity.

 Another major difference between the two systems can be seen in terms of the speed of system. MetaMap operates on data on disk while Q-Map is designed to operate in-memory which gives it a faster processing speed. There are a few drawbacks of this in-memory operations when the dataset being loaded is very large, but so far, we have created automatons with as many as 25 million nodes and have gotten maximum of 4GB size models, which are easily managed by the current machines.

Table I presents a few of real world discharge summaries and the medical concepts returned by both Q-Map and MetaMap.

In Table I, the concepts retrieved are grouped under the groups medicines, diagnosis and procedures for comparison purpose. This is done using the bucketing of sematic types associated with concepts and is easily available in Metathesaurus. From the table, it can be observed that the performance of Q-Map in retrieving concepts is on-par with that of the MetaMap.

Particularly, in row 3 of Table I it can be noticed that Q-Map outperforms MetaMap in retrieving concepts related to medical procedures. This points to a small advantage it has over MetaMap because of digesting the Metathesaurus data after preprocessing.

Another advantage of Q-Map is that addition and debugging of processes in Q-Map is much easier because it can work with any form of Knowledge Source and applied in various different fields. The program size is comparably lesser than MetaMap and language of choice is python, which is more easily adaptable than the prolog engine integrated Java source code of MetaMap.

In terms of processing speed, Q-Map is found to be much faster and takes only around 22.9ms to process a 110 word discharge summary as against MetaMap which takes around 11.9s (experiments performed on a machine with Intel i7 processor and 32GB DDR4 RAM). Also, while it is possible to reduce memory usage by limiting semantic types in Q-Map, no such adjustments are possible in MetaMap.

\section{Conclusion and Future Scope}

In this work, we presented Q-Map, a system for clinical data retrieval and compared its performance with MetaMap. Empirical evidence shows that the system works as well as MetaMap, occasionally outperforming it. It also shows major improvement in terms of memory management by limiting semantic types and speed of processing documents by order of 500.

The added advantages of configurability, easy debugging, memory usage management and speed of processing make it a worthy substitute of the popular tool, MetaMap.
Experiments on texts from various sources have shown that Q-Map works very well for finding clinical concepts in human written free text. Q-Map has various utilities in the domain and is currently being used to build intelligent systems to predict correct ICD codes from the human written discharge summaries. It has also proved to be useful in creating features used to build decision trees using XGBoost and Random Forest.

There are various improvements which can be incorporated to ensure better performance. Usage of deep learning models for concept aggregation would be more efficient than the current data driven approach used, but the unavailability of the data for training poses a challenge.

Q-Map also provides scope to augment the algorithm with semantic lookups in the text corpora along with the syntactic lookups which is implemented in the current version. Also, there is a scope to understand acronyms and abbreviations better. Though, the above enhancements could not be incorporated, Q-Map with its current version gives promising results and has advantages over its contemporary counterparts.

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redpajama_set_name: RedPajamaArXiv