The experiences of migrating a large scale, high performance healthcare network
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Lessons learned from migrating a large scale healthcare application from Windows to Unix at Partners Healthcare in Boston MA.
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Gate Control Theory: Tactile input via Aβ fibers inhibits pain transmission
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Electrical Stimulation: From surface electrodes to stereotactic thalamic implants
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Tic Douloureux: Trigeminal neuralgia characterized by sudden, stabbing facial pain
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Gastric Cancer: Artificial Intelligence, Synergetics, Complex System Analysis...Oleg Kshivets METHODS: We analyzed data of 806 consecutive GCP (age=57.1±9.5 years; tumor size=5.4±3.1 cm) radically operated (R0) and monitored in 1975-2025 (m=563, f=243; distal gastrectomies (G)=463, proximal (G)=166, total (G)=177, combined G with resection of pancreas, liver, diaphragm, duodenum, colon transversum, jejunum, cholecystectomy, splenectomy=341; T1=242, T2=223, T3=184, T4=157; N0=443, N1=109, N2=254; G1=225, G2=165, G3=416; early GC=168, invasive=638; only surgery=630, adjuvant chemoimmunotherapy-AT=176: 5-FU+thymalin/taktivin). Variables selected for prognosis study were input levels of 45 blood parameters, sex, age, TNMG, cell type, tumor size. Survival curves were estimated by the Kaplan-Meier method. Differences in curves between groups of GCP were evaluated using a log-rank test. Multivariate Cox modeling, clustering, SEPATH, Monte Carlo, bootstrap and neural networks computing were used to determine any significant dependence.
RESULTS: Overall life span (LS) was 2146.8±2350.4 days and cumulative 5-year survival (5YS) reached 58.6%, 10 years – 52.5%, 20 years – 40.2%, 30 years – 28%. 322 GCP lived more than 5 years (LS=4337.4±2377.7 days), 172 GCP – more than 10 years (LS=5966.5±2159.7 days). 291 GCP died because of GC (LS=649.9±347.1 days). AT significantly improved 5YS (67.5% vs. 56.9%) (P=0.047 by log-rank test). Cox modeling displayed that 5YS of GCP significantly depended on: phase transition (PT) in terms of synergetics N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G, prothrombin index, residual nitrogen, blood cells subpopulations, age, sex, GC cell dynamics, histology, tumor growth, bilirubin, chlorides, procedure type (P=0.000-0.021). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and healthy cells/CC (rank=1), PT early—invasive cancer (2); erythrocytes/CC (3), PT N0--N12 (4); leucocytes/CC (5), lymphocytes/CC (6), thrombocytes/CC (7), monocytes/CC (8), segmented neutrophils/CC (9), eosinophils/CC (10); stick neutrophils/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5-year survival of GCP after radical procedures significantly depended on: 1) PT “early-invasive cancer”; 2) PT N0--N12; 3) Cell Ratio Factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) GC cell dynamics; 9) GC characteristics; 10) tumor localization; 11) anthropometric data; 12) surgery type. Optimal diagnosis and treatment strategies for GC are: 1) screening and early detection of GC; 2) availability of experienced abdominal surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunotherapy for GCP with unfavorable prognosis.
BIOMECHANICS & KINESIOLOGY OF THEHIP COMPLEX.pptx
BIOMECHANICS & KINESIOLOGY OF THEHIP COMPLEX.pptxdrnidhimnd The cuplike concave socket of the hip joint is called the acetabulum and is located on the lateral aspect of the pelvic bone (innominate or os coxa).
Until full ossification of the pelvis occurs between 20 and 25 years of age.
The periphery of the acetabulum (lunate surface) is covered with hyaline cartilage.
This horseshoe-shaped area of cartilage articulates with the head of the femur and allows for contact stress to be uniformly distributed.
The inferior aspect of the lunate surface (the base of the horseshoe) is interrupted by a deep notch called the acetabular notch.
The acetabular notch is spanned by a fibrous band, the transverse acetabular ligament, that connects the two ends of the horseshoe.
The acetabulum is deepened by the fibrocartilaginous acetabular labrum, which surrounds the periphery of the acetabulum. The acetabular fossa is non-articular; the femoral head does not contact this surface.
The acetabular fossa contains fibroelastic fat covered with synovial membrane.
Taking the Lead in Timely Diagnosis of AD: Incorporating Biomarkers Into Rout...
Taking the Lead in Timely Diagnosis of AD: Incorporating Biomarkers Into Rout...PVI, PeerView Institute for Medical Education
Meeting dissolution requirements M.Pharmacy sem 2nd biopharmaceutics &pharmac...
Meeting dissolution requirements M.Pharmacy sem 2nd biopharmaceutics &pharmac...Swami ramanand teerth marathwada university
Defining and Delivering Person-Centric HIV Care in Key Populations
Defining and Delivering Person-Centric HIV Care in Key PopulationsPVI, PeerView Institute for Medical Education
A comparative study of onlay versus sublay mesh repair in the surgical manage...
A comparative study of onlay versus sublay mesh repair in the surgical manage...Sona Thesis Consultancy
The experiences of migrating a large scale, high performance healthcare network
- 1. The experiences of migrating a large scale, high performance healthcare network Larry Williams Corporate Manager, Partners HealthCare
- 2. In the next half hour… Partners Healthcare System overview Caché platform architecture & metrics The need to migrate Phased migration approach Benchmark testing and results Discoveries and production enhancements
- 3. Partners Healthcare System Founded in 1994 Brigham & Women’s Hospital Massachusetts General Hospital Now includes: Community physician network (1200 + 3500 MD’s) PCHi 3 community hospitals 2 rehab hospitals 3 specialty institutions Enterprise-wide Information Systems 1100 employees Annual budget FY05 approximately $160 million
- 4. Anchor Hospitals & Airport BWH MGH Logan Airport 10 km 6 km
- 5. Acute Care Hospitals MGH BWH Newton- Wellesley Community Physician Practices
- 6. Partners Domain Devices Internet 12,000 Printers 32,000 Desktops Firewall ~30,000 other devices 1,450 Servers Closely Managed Assumed Managed
- 7. Windows Production Architecture 3.5 TB
- 8. Enterprise Integration Over 30% are to and from Caché database Change from prior year Daily Average Est. Annual Transactions # of Interfaces 196 170 192 167 37% 4,659,035 1,330,962,017 2007 40% 3,399,211 1,240,712,044 2006 45% 2,431,917 887,649,802 2005 1,673,515 610,833,080 2004
- 10. Gigabytes in Use
- 11. Annual Database Growth Rate
- 12. Database Utilization Average Database References per day in Billions
- 13. The Need to Migrate - Availability Monthly Downtime Current State Business need
- 14. Additional Business Requirements Increase availability and reliability Decrease database risk from 5 single points of failure More robust hardware and OS Many less servers and OS instances to manage Clustering and automated failover Reduce monthly maintenance needs, updates once or twice per year -------------------------------------------------------- Improve Performance 64 bit OS, more memory for cache Caché 5.0.20 to Caché 2008.1, significantly improved ECP performance Increase Scalability 91 Terabytes available on EMC SAN DMX3 On-demand addition of processor cores
- 15. Caché Migration Decision Making Process Only considered first tier vendors and support (IBM, HP) HP assumed much more risk with Professional Services Existing HP business yields more leverage & visibility with regional office More headroom in HP configuration Price was not a distinguishing factor
- 16. Phased migration approach Proof of Concept (benchmark testing) Completed 10/15/07 Phase 1 – Database tier 4 of 5 servers migrated, anticipated completion 4/14/08 Phase 2 – Application tier Big Bang migration 12/14/08 Phase 3 – Disaster Recovery January 2009
- 18. Database Benchmark Load Testing Results Goals Simulate current Production user counts & transaction loads Verify support for load increases up to 300% Benchmark Environment Isolated LAN, new DMX3 SAN 20 new Windows blade servers (10 app servers, 10 script ‘players’) Scripts for 8 apps (represent heaviest use, Web/Telnet/VB apps) 2 batch jobs (screensaver simulation, NullGen LMR functions) Conclusions Able to simulate production load, 1.5x and 3x load 2 HP rx8640 can handle growth projections 0.66 0.15 0.32 LMR avg Caché app time (in sec.) 40,000 40,000 11,806 LMR transactions (5 min. period) 135,000 30,000 35,000 Database Global Refs / sec. Benchmark full script load Benchmark “paced” script load Production peak (8/21, 11:20 am) Metric
- 19. Design and Configuration Considerations Database configuration simulation testing 1 to 5 Caché database instances were assessed 1 vs. 5 ECP channels per Caché instance were assessed Number of active cores were accessed (4 active, 2 reserved) Results and unexpected discoveries Identify 5 Caché database instance as optimal design configuration Journal synch bottleneck the biggest issue High Transaction Journal deamon maintains ECP durability to guarantee transaction (1 per Caché instance) Maintain same data distribution across 5 DB instances Determine 1 ECP channel per instance optimal Additional channels did not improve throughput, still have only 1 Journal Deamon
- 20. Benchmark Discoveries led to Production Improvements References to Undefined globals using $Data and $Get These commands require network round trip Use of $increment Each call to $I requires network round trip Excessive use of Cache locks Forces more than 1 round trip Use of large strings Strings that require more than 3900–4000 bytes to represent the string value are big strings and never cached on the ECP client. Lesson Learned - Each trip to the database server results in overhead caused by a Journal Synch. Increasing the Journal Synch rate causes bottlenecks in the ECP channel which increase the risk of long transactions .
- 21. 75% reduction in long running transaction
- 23. Monthly Average Caché Web Transaction Time
- 24. Application Models Old New Browser client Web server Cache Cache VB client .Net server Cache Cache .Net client Browser client Web server Cache Web Services Browser client .Net client Scalability/Connection pooling, robustness/error handling, Vism Managed Obj. Vism.ocx Managed Obj. Cache Web Services WebLink
- 25. The experiences of migrating a large scale, high performance healthcare network Larry Williams Corporate Manager, Partners HealthCare