The Nonlinear Structure of the Sorrow of War

Bao Ninh is a Vietnamese war veteran and the author of what is said to be â€Å"one of the most moving war novels of all time† (Gareth Smith), The Sorrow of War. In the epic tale, Bao tells the story of Kien in a nonlinear narrative, weaving in and out of stories of young love and war, each failing to complete its own objectives: to come home and live in peace with those they love. It compares the ‘sorrow of war' to the sorrow of love, both nostalgic as Kien looks back on what has been lost, and the heartbreak created.Bao compares the two sorrows by intertwining flashbacks and events occurring in the present. Bao writes very straight-forwardly when speaking of war, but leaves much to be explained when describing the seemingly complicated relationship of Kien and Phuong. The nonlinear structure, non-chronological sequence of events, and Bao's saving of key information until the very end of the novel, distorts the view of their relationship so that it appears to be a more hostile than loving. This technique creates character depth in Kien, describing why he becomes the man he does: sad and full of regret.In the novel Kien's best friend from the war, Oanh, is killed by a beautiful woman on the front lines. It is mentioned multiple times in the novel that Phuong had wanted to participate in fighting in the war, as she made clear the night before Kien left for war, stating â€Å"I'll see you to the gate of the battlefront, just to see what it's like† (136). This event is a major turning point in the tone that Kien and Phuong's relationship is discussed. This event is a reminder of the loss he suffered by leaving her as well as reminding Kien of all the things he loved about her, including her beauty and strength.Before the death of Oanh, Kien appears to be more focused on the negative aspects in their relationship, such as their breakup, the struggles he faces as she tries to move on with her life, and his losing battle with Post Traumatic Stress Disorder. Kien's post-war difficulties, particularly with Phuong, can be best described by the character himself as he ponders the difficulties he's faced in his life since the end of the war, â€Å"†¦Though now he often drowned himself in alcohol, though hundreds of times he pleaded with his inner self to calm down, he was constantly torn with pain recalling the post war times he had with Phuong.His life, after ten destructive years of war, had been punctured by the sharp thorns of love† (84). The idea that Phuong is the main reason Kien is so depressed after the war is introduced early on and is mentioned many times in the beginning of the novel. Generally, in the beginning of a book with a traditional structure, characters are still being introduced and are receiving information that is vital to the rest of the story. In the beginning of The Sorrow of War, Kien often reflects on ‘the love he knew had been within him seemed to have drained away' (31).The audienc e is generally in the traditional mindset. This gives the audience the false impression that Phuong was never as in love with him as he was with her, or at all, since she can move on with her life and watch him struggle to move on with his. This distorts the view of the relationship because Phuong is being mistaken for a cruel person, begging the question of how this could possibly be one of the greatest loves of all time. The idea that the person you love most does not love you back creates a deep empathy toward Kien, and gives him depth as a character because his levels of depression are justified.Kien often dwells on Phuong's unrequited love for him and his failed attempts to forget her, stating ‘he had tried desperately to forget Phuong, but she was unforgettable. He longed for her still† (71). Despite this, Kien's belief that â€Å"nothing lasts forever, including love and sorrow† (71) gives him faith that one day the pain will go away if he continues on his damaging path. This hope for the better despite the destructive path he has placed himself ironically shows his strength.The focus shifts from Kien's depression and his awful post-war relationship with Phuong to a discussion of their pure love before the war after Oanh's death. Before the war, Kien and Phuong were inseparable. The intensity of their relationship is best described through the narrator's mention of â€Å"neither of them had other close friends. Others seemed unable to penetrate their cocoon of friendship† (131). Phuong often refers to herself as Kien's wife, as Kien and the rest of Hanoi expects her to be. This part of the novel chronicles their shift from best friends to lovers, although their ove was never consummated.Kien would never accept Phuong's advances to make love to him. This is what makes their love so true and desirable, because it is innocent and pure. His denial of her, however, also distorts the view of the relationship because it now appears th at he does not want her or is not as attracted to her as she is to him, a feeling Phuong will later direct toward Kien. The love they share appears to be on some scale that is never even. With all this, Phuong is still viewed as the unkind woman she was previously regarded as.Her kindness is almost viewed as her having an ulterior motive because of the way she was described earlier in the novel. Before Kien leaves for war, Phuong tells him that â€Å"from now on I'll be a lover and wife to you; I'll never be angry at you, and remember, I'm not taking leave of my senses. Not yet†¦Ã¢â‚¬  (136). By Phuong says that she isn't taking leave of her senses, she is solidifying that she's thought what she said through and that she is making a promise to Kien rather than a statement. If Phuong had promised Kien that she would love him forever, it raises the question of why she left him later on in life.It also appears Phuong has contradicted herself. She promised she would never be angr y at him and later allows him to suffer without her. These questions are frequent because of the knowledge collected at the beginning of the novel. This promise is very misleading and is a large contributor as to why Kien feels the heartbreak he does later in life when Phuong is anything but a wife to him. It begs the question of how a love so pure and strong could disappear. It is almost as if key elements or events are being kept secret. And they are.After the explosion, rape, and murders at the Hanoi train station, Kien and Phuong continue their journey into the frontlines but not before they stop at a school house to rest. After harassment from a group of soldiers, including accusations that Phuong had cheated on Kien, Kien leaves her at the school without any notice. Later, he receives a letter from the men in the schoolhouse apologizing: â€Å"We had made a big mistake in kidding you about what she did†¦Contrary to what we told you, your girlfriend was not like that at a ll†¦She was very much in love with you† (226).This information is key to the story because it proves that Phuong was truly committed and in love with him after all, and he left her. Had the narrative been in chronological order, one would have sympathized much more with Phuong and would not have thought so harshly of her and the reasons she left and got over him would have been much more justified. The narrative instead gave a deep analysis as to why Kien is so depressed and how deep their love for each other was and continued to be.Upon, reading this letter it â€Å"warmed Kien's heart, consoling and cheering him, he began to hope for something like a miracle†¦He might have something wonderful to return to after all† (226), which was sadly not the case. The nonlinear structure of the story and non-chronological order of events not only distorts the relationship and creates character depth, but masterfully describes the sorrow of war, and the even deeper, sorr ow of love. By describing war's destruction on, not only countries, but on our most intimate relationships. Ninh presents the idea that after war, it is not possible to have love, which is the sorrow of both love and war.

Premature Rupture of Membranes Essay

When the fluid is lost the cord and fetus can be compressed causing decelerations in which the baby must be removed from the womb. For example, last week in clinical there was a 33 gestational week mother with PPROM who was a smoker and tested positive for opioids. The fetal monitor the night before had indicated decelerations throughout the night, one even lasting nearly 8 minutes. The nurse I was assigned to said that â€Å"she did not realize how close to delivery she was. If a deceleration cannot be brought up in 10 minutes, they are on their way to the OR to deliver! . As discussed in the article, infection is also a major problem with PPROM. The amniotic fluid creates a seal of sorts that is to protect the mother and infant from infection and other harmful things that could enter into the environment of the growing fetus. Once this is lost, infection is easily contracted. Usually infections associated with PPROM are bacterial. According to the article, these types of infection s cause a string of effects that virtually throw the mother into premature labor. Because of the infection, prostaglandins are released. These then cause uterine contractions. However, the metalloproteases that are also released cause the cervix to soften and relax. This is the cause of the membrane rupture according to the article. Race is also thought to play a role in the risk of PPROM. It says that â€Å"black and Hispanic women are at a higher risk in comparison to white women [for PPROM]†. Diagnostic procedures can also cause PPROM. These include carclage and amniocenteses. Because these procedures compromise the integrity of the amniotic sac; the risk for PPROM is increased greatly along with the risk for infection. Management of the PPROM patient depends on gestational age and severity of luid loss. It could be treatment such as medications or it could go as far as full bed rest until delivery. According to the article, 34 weeks ot gestation witn no other complications will often lead to antibiotics and corticosteroids to prolong the pregnancy and decrease the risk for infections. However, in some of the extreme cases that were seen, bed rest or delivery of fetus was seen. In clinical, one of the patients seen was on bed rest until delivery and constant fetal monitoring. In conclusion, infection tends to be the most common effect of PPROM. Smoking nd drug use are viewed as the most common causing risk factors, and fetal complications can range from poor formation of lungs and other physical features, low birth weight, to even fetal death. It is important to educate newly pregnant mothers on risk factors of PPROM, the effects that could occur with PPROM, and educate them on what they can do to prevent this from happening during their pregnancy.

The Requirement for Employers to Allow Maternity Leave under United Essay

The Requirement for Employers to Allow Maternity Leave under United Kingdom Law Is a Disadvantage to Women in the Workplace - Essay Example This paper illustrates that many have argued that maternity leave is disadvantageous for working women since it holds back women’s progress in the workplace. Under the present UK law, a working woman who gives birth to a child is allowed to take maternity leave up to a year. For six weeks they are paid 90 percent of their usual salary, but after that, they rules vary and it can be around  £ 135 per week or even less than that. But maternity leave is becoming a huge burden on many businesses and women. The legislation thus directs many employers not to employ women and the companies are reluctant to give jobs to women of childbearing age. This part of the legislation, which is called family-friendly legislation, is wrong and needs to be abandoned. Many ordinary women in ordinary jobs do badly when they take advantage of the family-friendly legislation. When they join their work it becomes difficult for them to return to their earlier earnings and they don’t get their p ension rights when they were away. But organizations display a good pretty picture of the facilities which they offer to their working new mother. But the reality is actually very different. The new mother has to abandon her job for a fixed term. After first six weeks, her income possibly falls huskily and it takes her time to return back to normal salary level. These statutory benefits and provisions create a perverse incentive for a short term to return to work against what might be a longer-term interest. It is important to understand that the decision whether to return to work or not is difficult and individual. This may include personal inclination, circumstances, family income, costs at home, job and childcare.

Poverty and Social Violence in Latin America Term Paper

Poverty and Social Violence in Latin America - Term Paper Example These acts of violence and injustice through the lifestyle of communities as well as countries make it hard to penetrate positive change in those societies. Measures no matter how strong, are mostly used for containing and limitation purposes rather rehabilitation process. As far as history goes, the only way to spread the message has been written or visual context. Now having the newer media available in all parts of the world, it has reached and given opportunity to not only present one’s ideas but to also spread a message. Films such as Bus 174, City of God, and Los Olvidados etc are amongst their time from 50’s onwards have tried to share the changing stories of Latin America. The purpose of books such as Child of Dark show reality of the times regarding the social stratification present in the society. Each of the depiction of reality has been related to fight poverty to become amongst the ones who can live the rest of their lives in ease. Much like a jail, all of the films have tried to portray a life more or less confined under boundaries where the only way to survive is through someone others fortune. Having a downstream injustice present based in all parts of the hierarchy the films try to show the system failing to control its own public and being biased towards making choices. The ambitions lay towards the stability of life in most of the films but either failing to reach that goal due to fact that when one is caught in the vicious cycle of poverty and crime, there is no way out of it.

Discussion week 9-2 Essay Example | Topics and Well Written Essays - 250 words

Discussion week 9-2 - Essay Example In view of the assignment given prior to the lesson (essay outlining the role of different people in society), the instructor will then evaluate the students understanding before the lesson and after the discussion (mentioned below). On the other hand, informal presentation will come in handy while carrying out some activities during this same lesson. I mentioned in the lesson plan that the lesson is predominantly a discussion; therefore, judicious review is a major strategy. This aspect ensures that information delivery is clear and concise while providing for students’ active involvement in information gathering and rehearsal. The power point presentation as a visual aid will further accentuate this method. Structured discovery will also work well in this same lesson. This is because the lesson is safe in view of environment and potential discoveries and failure is not imminent. The instructor first outlines a few of the objectives (occupations in society); the students are already consciously aware that people need to make a living by having an occupation. After this, it is up to the student to create a connection to other objectives, for instance, differences in occupations, benefits of different types of occupations and gender disparity in different types of

Why is the 1980s the pop decade that receives the most negative Essay

Why is the 1980s the pop decade that receives the most negative critical press, and is it justified - Essay Example Technology wise, the trend was also fast-emerging. The improvement of telecommunications played a key role in the success of the current technology. Scientifically speaking, there were several vital breakthroughs in science which led to further improvements in the succeeding years. There was also a recorded tremendous increase in the world’s population and is actually one of the periods with the largest recorded rate of increase. The fashion and style aspect also rocketed during this period in time and there were many things which made the people, most especially the youth, go gaga and engrossed to their icons to the extent of imitating them in how they look, what they do and all sorts. There are many other factors which made many people and even historians consider this era as a highly celebrated one in terms if the aforementioned reasons and events. However, as the saying goes, for every swing of the pendulum, there is always a counter-swing. This is because there are also several aspects which made people look at this era as an uncalled for- something which is ridiculed because of several negative implications that it brings to the people. One aspect which suffered bittersweet treatments is the entertainment industry, more specifically the music industry. It was this specific industry which is home to one of the most celebrated yet criticized icons. The music industry was considered to be at its peak during this period. Much advancement such as technology, style, genres and other matters emerged during this time. Pop music during those times was more of the dance tunes and even reached the age of rock and rap because of the advancement. Because of the great acceptance of the public to music, many musicians became icons which gained international fame and respect. To name some are Michael Jackson and Madonna- who were both

Precautionary Principle Essay Example | Topics and Well Written Essays - 3500 words

Precautionary Principle - Essay Example Such specific status of the precautionary principle makes it a very interesting and highly relevant field of analytical inquiry. The formal concept of 'precautionary principle' originated in Germany in the 1930s. Initially, this concept applied to socio-legal practices such as household management: German word 'Vorsorgeprinzip' translated into English as 'precaution principle' (O'Riordan & Cameron 1994, p. 10). By the 1970s the concept of 'Vorsorgeprinzip' developed into an essential principle of German environmental law and was used to justify the actions meant to address such problems as global warming, sea and air pollution, and others. At the centre of early conceptions of precautionary principle was the idea that society should take efforts to prevent environmental damage by careful forward planning, blocking the flow of human activities potentially hazardous for environment or "long term planning to avoid damage to the environment, early detection of dangers to health and the environment through comprehensive research, and acting in advance of conclusive scientific evidence of harm" (LaFranchi 2005, p. 681). Since the 1970s the precautionary principle has proliferated in international and domestic conventions, treaties, and political statements dealing with environmental issues in which the science is uncertain. Thus, the precautionary principle was introduced in 1984 at the First International Conference on Protection of the North Sea; it was also integrated into the Bergen declaration on sustainable development, the Maastricht Treaty on the European Union, the Barcelona Convention, and the Global Climate Change Convention. Sweden and Denmark were the first states after Germany to seriously implement the precautionary principle in their environmental and public health policy (Hanson 2003). Since the late 1980s, the precautionary principle in some or other form has become unalienable aspect of domestic statutes and policies in Australia too. Current Approaches and Definitions Despite relatively long history of use, no universally accepted definition of the precautionary principle has been proposed up to date. Perhaps the most widely quoted definition of the precautionary principle is the one formulated at the 1992 UN Conference on Environment and Development: "In order to protect the environment, the precautionary approach shall be widely applied by States according to their capabilities. Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation" (Rio Declaration on Environment and Development, 1992, Principle 15). Although this definition is used more commonly than others it is not universally accepted: there are many alternative definitions. The precautionary principle can also be defined as "... a willingness to take action in advance of

Race and your community Research Paper Example | Topics and Well Written Essays - 1500 words

Race and your community - Research Paper Example It shall present my account of how human interactions in my community have been racialized. This analysis is being undertaken in the hope of coming up with a thorough and analytical assessment of the race in relation to the community, in the hope of clearly establishing the trends and patterns of human behavior. First and foremost, I am of Romanian, African-American, and Indian descent. As a child, our family moved around a lot and because of this, I was exposed to and I grew up in a mixed community. When, I joined the service, I was still in a mixed community – living and being exposed to Caucasians, African-Americans, Asians, Europeans, and other races. At present, I am still in a mixed community, being exposed to different races and cultural groups. Some of the members of my community look like me. My features are predominantly African-American and some of the members of my community look the way I do. My coloring is not as dark as those who are of pure African-American descent and so, I am slightly different from them in this regard. About 35 percent of my community is of African-American descent. About forty percent of the community is Caucasian and I do not look like them at all because of my stronger African-American features. The leaders within my community are sometimes ambivalent to people like me. Most of the leaders are Caucasians (whites) and they seem to treat people who look like me with suspicion. One time, I complained with the leaders about a Caucasian neighbor who liked to play loud music at most times of the night. They spoke to the neighbor, but they did not do so with firm authority. After a few days of quiet, my neighbor resumed his loud music. In order to avoid any trouble, I just tried my best to ignore the loud antics of my neighbor. I saw however how differently I was treated by the leaders when it was my neighbor’s turn to complain when I

Case 11-1 SHOULD YOU HIRE A FORMER EMPLOYEE Essay

Case 11-1 SHOULD YOU HIRE A FORMER EMPLOYEE - Essay Example 2. How valid were David Heard’s concerns about the effect of returning employees on the company’s culture? David Heard’s concerns were valid in terms of affecting the company’s culture when a former employee who left the organization is eventually rehired. For a small organization, the camaraderie is more close-knit and the company’s culture would somehow dictate the firm’s overall sentiments, values and beliefs in terms of embracing a returning employee. If the culture is more of acceptance and the skills of the former employee are indeed worthy to be kept (especially if the position is still vacant), then, there would not be any potential dilemma. However, if the culture shuns employees who had not been loyal to their organization’s thrusts, then, accepting or rehiring a returning employee would prove to be difficult and would compromise the work behavior of others who were deemed loyal for considerable lengths of time. 3.

The True Meaning of the American Dream Essay Example for Free

The True Meaning of the American Dream Essay The American Dream has been all about a greater national vision, however as time has progressed, the American Dream has shifted from a greater national vision to individual material success. These cultural aspects of the American Dream complement each other and have an underlying relationship. One often â€Å"†¦winces a bit†¦Ã¢â‚¬  at the phrase the American Dream â€Å"†¦ because it has become such a clichà ©.† (Source 7) Everyone does not know the true meaning of the American Dream because one interprets it in their own way. But the true meaning of the American Dream is that it is the dream of opportunity. The American Dream accentuates a greater national vision because it is the opportunity for something that will not only benefit you, but it will also benefit others. â€Å"It is not a dream of motor cars and high wages merely†¦Ã¢â‚¬  (Source 1). A greater national vision gives the American Dream a deeper meaning. For example according to Martin C. Jischke (Source 1)’ James Truslow Adams view of the American Dream is that it is a â€Å"dream of a land in which life should be better and richer and fuller for everyone, with opportunity for each according to ability or achievement.† The American Dream is more than a dream and with â€Å"†¦talent and hard work† (Source 3) one is bound to find opportunity anywhere in the world. For once the American Dream â€Å"had meant something nobler† (Source 7), but over time it has become the want for individual material success. When one comes from a background of having nothing, he/she begins to become eager for success and wants to get something for themselves. This eagerness causes them to work hard and eventually they would be able to â€Å"†¦improve their lot in life†¦Ã¢â‚¬  according to W. Michael Cox and Richard Alm in By Our Own Bootstraps. There has been thousands of people who did not have much, but they soon became very well known around the world. For instance â€Å"Bill Gates in computer software†¦Oprah Winfrey in entertainment†¦Michael Jordan in sports†¦Ã¢â‚¬  (Source 3) All of these people had the â€Å"opportunity† to become who they are today and they took that chance, but only to become successful. These cultural aspects of the American Dream complement each other because every person achieves their meaning of the American Dream by first experiencing individual material success, and then seeing that it’s a deeper meaning, which is the greater national vision. Martin C. Jishke would be the perfect example of how the cultural aspects complement each other because after he had completed college, which no one had ever done in his family, his meaning of what the American Dream is became a greater national vision. He had seen that it was more to the American Dream than just achieving your goal to only benefit yourself. The underlying relationship between these two cultural aspects of the American Dream is that in order to know the greater national vision of it, you have to achieve individual material success. Due to how the American Dream is interpreted many people believe that it does not exist anymore. But those people are greatly mistaken because it still exists the meaning has just changed over time. One would agree that as the years continue to pass by the definition of the American Dream will change, but there will always be an underlying relationship between the old meaning and the new meaning. Nothing ever stays the same.

MRI as a Breast Cancer Screening Tool

MRI as a Breast Cancer Screening Tool Chapter 1 Introduction In the United States, one in eight women will be diagnosed with breast cancer, accounting for 26% of all cancer cases in women (Jiao, 2014). The standard of care for women over the age of 40 is mammography. It has been shown to increase life expectancy by detecting breast cancer through a quick and easy x-ray. Magnetic resonance imaging, which is more sensitive to breast cancer is costlier and produces more false-positive results, therefore it is not used as often. When mammography is the only test being done, breast cancer is more likely to go undetected in patients with dense breasts and those with small lesions. In high-risk women, MRI has been shown to detect breast cancer in earlier stages than mammography. MRI screening is successfully reported between 77% and 91% (Jiao, 2014). Most detections from MRI are located within axillary lymph nodes during stage 1 breast cancer. A patient may simply refuse yearly mammograms, when she goes five years later breast cancer may be in the fi nal stage whereas MRI could’ve detected it years earlier. Women are recalled more often for additional diagnostic testing when screened less frequently and recalled less often when screened more frequently (Orel, 2005). The American Cancer Society recommends MRI testing for women with the BCRA1 & BCRA 2 genes or a lifetime risk of 20% or greater for breast cancer (Saslow, 2007). Women who inherit the BRCA1 or BRCA2 gene have a 45% to 65% chance of developing breast cancer (Plevritis, 2006). BRCA 1 gene carriers are at a greater risk for developing breast cancer at an aggressive pace. Tumors in women screened with mammography alone are larger and more likely to have metastasized to axillary nodes (Taneja, 2009). MRI is approximately ten times more expensive than mammography making its cost effectiveness a critical consideration (Jiao, 2014). Due to its lower specificity than mammography increased costs are related to biopsies and additional exams. Estimated lifetime costs for 10,000 women would be higher by $10.6 million with MRI in combination with mammography than with mammography alone. In 2009, the costs billed to Medicare for a bilateral mammography was $49.76 while a bilateral MRI was $965.57 (Jiao, 2014). The price per quality adjusted life year would be $310,616 when MRI was performed with mammography (Fieg, 2009). MRI screening is most cost effective if the cost of MRI decreased or the cost of mammography decreased, when the risk of breast cancer increases, when mammography performance worsens, and if greater quality of life is accomplished (Orel, 2005). MRI becomes cost effective when patients with high-risk profiles are treated. If cancer was detected early enough, chemotherapy can be reduced. MRI is also needed for surveillance when breast conserving therapy results in recurrences. MRI would yield an additional 106 years of life per 10,000 women (Fieg, 2009). Women with BRCA1 and BRCA2 start mammograms at the age of 25 which makes MRI more cost effective and would decrease their radiation dose. Given the aggressive nature of breast cancer, screening with MRI whether alone or with mammography is cost effective and will prolong life expectancy (Berg, 2012). Contrast enhanced MRI is proven to detect breast cancer in the earliest stages compared to ultrasound and mammography. Statement of the Problem and Professional Significance Is MRI effective as screening tool for breast cancer? Which modality is the most effective study for diagnosing breast cancer? Are imaging modalities other than MRI a waste of time and money for patients? Mammography is seen as the first step in preventing breast cancer when a patient turns 40. For some patients, it might already be too late. Mammography is quick and low cost but does not detect breast cancer in patients with dense breasts or small lesions. MRI is considered the gold standard in imaging but is used with fewer women. As the population grows and rates of cancer increase, patients are demanding precise diagnosis and early detection for cancer. What factors should stand out to differentiate who receives MRI vs. mammography? By gathering medical history and diagnosis from several women receiving breast MRI’s, data will be examined to determine whether or not breast MRI’s were needed for proper diagnosis and if testing detected further malignancies. Research Hypothesis 1. It is hypothesized that MRI will be more effective in detecting breast abnormalities than Ultrasound or Mammography. This can be tested by comparing the results of their MRI with results of previous tests.    2. It is hypothesized that at least 50% of patients will feel more confident regarding their diagnosis following a MRI scan. This can be tested by having patients rank how they felt before and after having the test and talking with a radiologist on staff (using a scale of 1-10). 3. It is hypothesized that patients will not have had a mastectomy or received radiation until an MRI is performed. By surveying patients to determine who was and wasn’t diagnosed prior to MRI and what measures they took to prevent the malignancy from spreading I can determine these results.    4. It is hypothesized that patients positive for breast cancer will have at least one lesion undetected on mammography or ultrasound because of its small size or position in the axillary region.   This can be tested by comparing MRI test results with other imaging modalities. 5. It is hypothesized that 10% of participants will have had inconclusive results. This can be determined by whether the radiologist recommends a breast biopsy. MRI can produce false-positives, which cause the radiologist to compare results with past imaging. 6. It is hypothesized that at least 50% of the participants were recommended to have an MRI after inconclusive testing in other modalities. This information will be obtained through obtaining previous medical history in the survey. Definitions Breast cancer Uncontrolled growth of breast cells resulting in a malignant tumor (Medical Dictionary Online, 2018). Malignant Cancerous tumor that can spread to other parts of the body. Benign Tumor that is not dangerous to health. Quality adjusted life year Used to assess the value for money of medical intervention. One QALY = one year of perfect health (Science Direct Online, 2018). Probabilistic sensitivity analysis Technique used in economic modeling that allows the modellar to quantify the level of confidence in the output of the analysis (Science Direct Online, 2018). National comprehensive cancer network Not-for-profit alliance of leading cancer centers devoted to patient care, research, and education. BRCA 1 breast cancer type 1 susceptibility protein- Identified in 1990 and is on chromosome 17, increases likelihood of cervical, uterine, and colon cancer (National Cancer Institute, 2018). BRCA 2 breast cancer type 2 susceptibility protein- Identified in 1994 and is on chromosome 13-, increases likelihood of stomach cancer, gallbladder cancer, and melanoma (National Cancer Institute, 2018). Ultrasound Imaging test using high frequency sound waves. MRI Imaging test that used magnets to generate a detailed picture. Mammography Images produced from low dose radiation. Gadolinium Chemical element of atomic number 64, injected into patients as contrast during MRI. Ductal carcinoma in situ (DCIS) Presence of abnormal cells inside a milk duct in the breast (Medical Dictionary Online, 2018). Mastectomy Surgical operation to remove a breast. Stereotactic biopsy Procedure that uses mammography to precisely identify and sample an abnormality within the breast. Limitations and Delimitations This study will survey twenty women (all ages) who are scheduled for breast MRI’s at Geisinger Community Medical Center during September-November 2018. I will conduct surveys with the patient prior to their MRI. Breast MRI’s will be conducted on a 1.5T, Siemens machine. All patients will be scanned using the same protocol for imaging regardless of medical history. External limitations are obtaining a medical history, incompletion of the patient’s MRI, lack of intravenous access for contrast, claustrophobia, and no show appointments. I will rely on patients to give me a detailed, accurate medical history. Assumptions During a typical work day in MRI at Geisinger Hospital a breast MRI is completed once. Within a typical month at least 20 scans are completed. This should allow me to survey enough patients over a six-week period. Permission for this study will come from patients who allow me to ask questions regarding their medical history and diagnosis. In accordance with HIPAA, I will keep all patient names and identifying information anonymous. Chapter 2 Introduction The purpose of this research project is to determine if MRI is effective as an imaging tool for diagnosing breast cancer. By surveying women, who have been diagnosed or are currently being diagnosed, collecting medical history, and analyzing data, imaging modalities will be examined to determine the most reliable, accurate, and timely way to diagnose breast cancer. If MRI is more efficient than mammography and ultrasound, time and money spent on those modalities could be eliminated. Women can be treated faster, and cancer could be diagnosed earlier when proper testing is ordered. Breast cancer during stage one is treatable, thousands of lives could be changed when it is diagnosed in a timely manner. Cancer is the overall most common cause of death in America with breast cancer being the most common type (Jiao, 2014). One in eight women will be diagnosed with breast cancer during their lifetime making it a very costly disease. Standard protocols for screening are determined by the American Cancer Society. Screening mammography is recommended for women with a 25-30% lifetime risk of breast cancer (National Cancer Institute, 2018). This includes women treated for Hodgkin disease and those with a family history of breast or ovarian cancer. Screening mammography typically starts at age 40 unless preexisting conditions are present, screening begins at age 25. The Gail, Claus, and Tyrer-Cusick models are used to estimate breast cancer based on family history. Breast cancer genes 1 and 2 (BRCA) are found in 1/500-1/1,000 women. Women of Jewish ethnicity have a 1/50 risk (National Cancer Institute, 2018). Those who test positive have a 65% chance of breast cancer by 70 years old (Saslow, 2007). What are American Cancer Society Guidelines? Recommendations for women at average risk of breast cancer are women between 40 and 44  have the option to start screening with a mammogram every year. Women ages 45 to 54  should get mammograms every year. Women 55 and older  can continue with mammograms every year or switch to having mammograms every other year (American Cancer Society, 2018). Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. Not all types of breast cancer cause a lump in the breast. Many breast cancers are found on screening mammograms which can detect cancers at an earlier stage, before the mass can be felt, and before symptoms develop. Women who are at high risk for breast cancer based on certain factors should get and MRI and a mammogram every year, starting at age 30 (American Cancer Society, 2018). This includes women who have a lifetime risk of breast cancer of about 20% to 25% or greater, have a known BRCA1 or BRCA2 gene mutation, have a first-degree relative (parent, brother, sister, or child) with a  BRCA1 or BRCA2 gene mutation, had radiation therapy to the chest when they were between the ages of 10 and 30 years, or have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes. (American Cancer Society, 2018). The American Cancer Society recommends against MRI screening for women whose lifetime risk of breast cancer is less than 15%. MRI in this case would be less cost-effective and timelier for patients to get done. How does MRI detect breast cancer? There are three imaging modalities that can effectively detect breast cancer. MRI, mammography, and ultrasound are commonly used in different combinations. MRI uses magnetic fields to produce cross-sectional images of breast tissue. Hydrogen atoms in fat and water contribute to the signal that is produced (Pilewskie, 2014). Gadolinium, IV based contrast, is administered to detect lesions and cancer. Subtraction images are obtained to differentiate fat from enhancing lesions. MRI produces high quality imaging from signal to noise ratio and high spatial resolution (Pilewskie, 2014). MRI is safe for all women (unless contraindicated by pregnancy) and doesn’t use radiation. A drawback to MRI is false positives that are produced and additional testing that this creates. On the other hand, additional testing leads to a higher number of cancer detected. The more women who are being closely watched and recommended for further tests, the greater their likelihood of being diagnosed earl y. In a study in the UK involving high risk populations, 4% found MRI â€Å"extremely distressing† and 47% reported having disturbing thoughts about it six weeks after (Saslow, 2007). Due to the psychological distress of MRI, other testing needs to be considered. Imaging Limitations Unlike other imaging tests, MRI candidates need to be screened for metal before considering the test. Pacemakers, aneurysm clips, specific stents and filters, and neuro-stimulators are not allowed in the machine. Body habitus and claustrophobia are also factors to consider. A small, loud environment can cause emotional distress and anxiety for a patient, some patients will refuse MRI testing. Breast MRI testing should be completed with and without contrast. Gadolinium, MRI contrast, can only be injected in patients with a glomerular filtration rate of >60. Patients on dialysis, with impaired kidney function, diabetes, high blood pressure, or certain allergies may not be able to receive contrast, making the test inconclusive. MRI results can also be misleading. False-negatives and false-positives occur from technical limitations, patient characteristics, quality assurance failures, human error, and heightened medical concern. A false negative exam looks normal even though the patient has breast cancer. They are more likely to occur in younger patients with dense breasts. MRI is commonly used for dense tissue to differentiate benign and malignant lumps. A false positive test looks abnormal even though the patient doesn’t have cancer. False positives occur in half of women getting mammograms over a ten-year period (Gillman, 2014). MRI’s and MRI guided biopsies are usually recommended for more accurate diagnosis. A patient’s need for definitive findings may increase testing ordered. According to the American Medical Association, 7% of women are biopsied only because of MRI findings. The call back and biopsy rates of MRI are higher than mammography in high risk populations due to the increased sensitivity of MRI (Gillman, 2014). MRI is also able to obtain images for women with breast implants. 3D and 2D images are acquired in all planes, whereas mammography could miss an area of interest and compromise the breast implant.    Economic Impact   Cancer treatment can be impacted by lack of insurance, proximity to health care facilities, and availability of services. According to  Cancer Facts & Figures 2018, â€Å"Uninsured patients and those from many ethnic minority groups are substantially more likely to be diagnosed with cancer at a later stage, when treatment can be more extensive, costlier, and less successful.† (American Cancer Society 2018). Without routine mammograms, breast cancer can go undiagnosed and impose much higher costs when it’s found in a later stage. Early detection can potentially eliminate radiation, chemotherapy, mastectomy, and breast reconstruction. In 2009, the average Medicare reimbursement for a bilateral mammogram was $49.76, a bilateral MRI $965.57, and mastectomy $13,590.03 (Moore, 2009). These procedures drastically differ in costs therefore insurance companies use cost effectiveness and quantity adjusted life years as means in determining which patient will benefit from costlier studies. MRI screening becomes more cost effective as the cost of MRI decreases or the cost of mammography increases. It is also more cost effective for patients with higher risk profiles such as BRCA1 & BRCA2 genes. MRI combined with mammography would produce 106 years of life per 10,000 women compared with mammography alone (Taneja, 2009). The drawback is that MRI in addition to mammography would increase lifetime health care costs for those 10,000 women by $10,600,000 (Taneja, 2009). What does insurance cover? Breast cancer is the costliest cancer to treat. In 2010, it cost $16.5 billion in the United States to treat breast cancer. A major concern when ordering breast MRI’s is that insurance will deny it or charge a high co-pay. MRI’s cost more due to radiologist, facility, contrast, and technology fees. According to a survey by the American Cancer Society, many patients are cutting prescriptions, not going to their doctor, and not getting preventive services due to the high costs. Yearly mammograms are covered by insurance companies. The average cost of a breast MRI in the United States is $1,325 with prices ranging from $375 to $2,850. Patients with health insurance are responsible for paying their deductible, copay, and coinsurance amounts. The amount of each of these costs depends on their health plan. Patients without health insurance are responsible for 100% of mammogram and MRI costs. Case Study In a study published by the New England Journal of Medicine, titled MRI evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer, 969 women with a diagnosis of unilateral breast cancer and no abnormalities on mammography went for a breast MRI. MRI detected clinically occult breast cancer in the contralateral breast tissue in 30 women (Lehman, 2007). Biopsies were performed on 121 of the 969 women whose MRI showed breast cancer (Lehman, 2007). Of those 121, 30 were tested positive. MRI was able to detect cancer that was missed by mammography and clinical exam. Within the 969 women, 33 tumors were diagnosed with 30 being from MRI. The three others were diagnosed from a mastectomy specimen before a biopsy could be performed. Those three samples contained ductal carcinomas in situ and measured 1, 3, and 4 mm in diameter. The most common types of invasive cancer found on MRI was ducal carcinoma (67%), invasive lobular carcinoma (22%), and tubular carcinoma (Le hman, 2007). 96.7% of cancer found was stage 0 or 1. The overall high accuracy of MRI is due to technology and interpretation of results. Contrast enhanced MRI aids in distinguishing benign from malignant patterns. This study also showed that screening MRI can improve on mammography by detecting cancer in women at high risk especially those with aggressive cancers. When ordering MRI, cost effectiveness continues to be a major concern. In the article, American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography, benefits of MRI’s sensitivity in detecting lesions is noted but without data on the recurrence and survival rates, MRI is not recommended as a screening exam. The article compares study results from six published studies, sensitivity for MRI is consistently higher than mammogram and ultrasound while specificity was lower than mammogram and ultrasound. High sensitivity means MRI correctly identifies a patient with cancer. Low specificity means MRI is not able to correctly reject a patient without cancer as accurately as other modalities. MRI has higher error but in calling back more patients and performing more biopsies, it diagnoses cancer more accurately. With this being said, the article does not recommend MRI as a screening tool unless women are at an increased risk of breast cancer, have a fami ly history, or carry the BRCA gene (Stephens, 2011). Conclusion Women who present with signs and symptoms of breast cancer or have a family history should be screened with MRI in addition to mammography. It is not acceptable to deny patients imaging studies that can prolong their life. Breast cancer is 100% treatable when caught early. Due to advances in technology and a growing healthcare system, facilities are more readily available to treat women. Patients no longer need to wait months for tests or results. Steps should be taken to reduce anxiety associated with MRI cancer screening and wait time. Patients should be informed about the likelihood of false-negative and false-positive findings. Whether or not patients need to go through additional imaging, the chance of early detection outweighs the stress of additional testing. MRI is a very useful imaging test that can save lives if performed. Patients who want to be proactive in their treatment should be encouraged to get routine imaging tests done and educate themselves on different stages of breast cancer, so they understand the process they are going through. By creating high resolution imaging, MRI proves to be the most effective study for diagnosing breast cancer. MRI is able to detect smaller masses and abnormalities than other imaging tests miss. 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