Financial Information Systems Essay Example for Free

Financial Information Systems Essay INTRODUCTION Financing is the important function of every business organizations, Computer based financial information systems(FIS) support financial managers in decisions concerning. The financing of business, the allocation and control of financial resources. What is finance ? Finance is the art and science of managing money. Virtually all individuals and organisations earn or rise money and spend or invest money. Finance is concerned with the process, institutions, markets and instruments involved in the transfer of money among and between individuals, business and governments. Major FIS Categories Include Cash investment management Capital budgeting Financial forecasting Financial planning Cash Management Collect information on all cash receipts and disbursements with in a company on a real time or periodic basis. This helps the business to deposit or invest excess funds more quickly. for cash flow forecasts. to determine cash collection programs and alternative financing or investments strategies with forecasted cash deficits or surplus. Online Investment Management Helps to financial management The process of buying, selling, or holding each type of security so that an optimum mix of securities is developed that minimizes risk and maximizes investment income for the business. Capital Budgeting Process of evaluating the profitability and financial impact of processed capital expenditures. Techniques in capital budgeting Payback Period (PBP) Net present value (NPV) Internal rate of return (IRR) Spreadsheets are heavily used for this process incorporates present value analysis of expected cash flows and probability analysis of risk to determine the optimum mix of capital. Financial Forecasting Planning Financial forecasts concerning to †¦ Economic situation Business operations Type of financing available Interest rates Stock and bond prices Software’s used in FIS 1.Sage Accpac ERP Sage Accpac ERP offers the freedom of choice, seamless integration, high performance, and reliability that forward-thinking companies rely on to increase profitability and gain competitive advantage. Advantages Completely Web-Based Easy To Use and Customize Total Investment Protection Designed for Global Business Hundreds of Industry-Specific Solutions 2.SAP The e-commerce functionality in the SAP ® Business One application will help you bring your business to the public with a set of Web design tools that enable you to build and customize your online store. Create an online catalog where customers, salespeople, and partners can easily access your  products. Manage everything from taxes to inventory to pricing through a Web-based interface, all synchronized with SAP Business One. 3.Greentree Greentree’s main users are medium sized businesses, but it is also successfully used by many larger organizations. The Green tree product is seamlessly scalable to support the whole spectrum of businesses from a small team to many hundreds of users. Features: Greentree is built around a core financial system, with seamless integration across distribution, job costing, manufacturing etc. The modular design will enable to implement a basic financial solution and add modules as the business grows or grows in complexity, or install a complete business management package from the outset. Greentree delivers both Windows-based and Linux-based software 4.Microsoft Dynamics AX Designed for mid-size and larger companies, It is a multi language, multicurrency enterprise resource planning (ERP) solution. Its core strengths are in manufacturing and e-business, and  it includes strong functionality for the wholesale and services industries. includes applications for financial management, customer relationship management, supply chain management, human resource management, project management, and analytics. It integrates with widely-familiar Microsoft products such as Microsoft SQL Server, BizTalk Server, Exchange, Office, and Windows. Employees can work with tools that they’re already familiar. Financial Management Microsoft Dynamics AX delivers a range of financial capabilities for companies to consolidate accounts with subsidiaries or distribution centres, no matter where they are located. 5.SAP Business One SAP Business One provides you with instant access to your critical business information – when you need it to run your business. This comprehensive application covers all your core operations, giving you keen insight, so you  can confidently make informed business decisions. Features: All aspects of business become more agile, including administration, customer relationship management, operations, distributions, and financials. Helps in Accounting and Financials, Budgeting, Banking, Financial Reporting, Customer Relationship Management (CRM), Business partner management.

The Evolution of Capital Punishment Essay -- Death Penalty

The Evolution of Capital Punishment Ever since there has been crime, there has been punishment. One form of punishment that has existed since the beginning of society is capital punishment. As crime and societies have evolved over time, so have capital punishment, its forms, and its reasons for use. Capital punishment is defined as the execution or death for a capital offense. (Hill & Hill 1995: 75) A capital offense is defined as being any criminal charge that is punishable by the death penalty. (Hill & Hill 1995: 75) A capital offense usually means that no bail will be allowed. Capital punishment has existed since the earliest civilizations such as the ancient Greeks, Romans, and even the English have existed. Death sentences were not only carried out centuries ago, but they were also given out as sentences in formal courts. In ancient Greece, the death penalty was ordered for what are known as minor crimes in modern day living. The rules of Rome were not much more merciful to say the least. Starting a fire or even disturbing the peace after dark could fuel such a verdict as death by fire or worse. And finally in England, there were over 200 offenses that could be punishable by death. (Landon 1992: 9) The English, were in fact, the main reasons as to why the death penalty exists in America. Capital punishment became a very important part of the written rules at the time of the first wave of colonists that arrived in America. The rules varied from colony to colony although the rules remained quite similar all the same. (Landon 1992: 10) The death penalty in very early America was the end result of a murderous conviction the majority of the time although it was put to use for many other crimes. Due to the fact that there was no separation of power between the church and the American government and the fact that a simple accusation could cost somebody their life, the 8th and then later on, the 14th amendments were created. The 8th amendment states that â€Å"Excessive bail or fines and cruel punishment are prohibited. Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.† The 14th amendment then states that â€Å"All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or... ...t is awfully convenient to be able to go both ways on such a subject. It is fascinating to be able to notice the evolution of such an important subject in our history and how it is still changing. It is worth noting that the death penalty is not simply the most serious criminal punishment there is to offer, but is has and is still a social, moral, and legal problem in society. It was a problem 200 years ago and still is today. It is a subject that all people most likely will not be able to come to an agreement on, but it is one that will continue to evolve so all we can do for now is watch and see. Bibliography 1.  Ã‚  Ã‚  Ã‚  Ã‚  Hill, Gerald N., and Kathleen Thompson Hill. Real Life Dictionary of the Law. Los Angeles, General Publishing Group, Inc., 1995 2.  Ã‚  Ã‚  Ã‚  Ã‚  Zimering, Franklin E., and Gordon Hawkins. Capital Punishment and the American Agenda. Cambridge, Cambridge University Press, 1986 3.  Ã‚  Ã‚  Ã‚  Ã‚  Berns, Walter. For Capital Punishment: Crime and the Morality of the Death Penalty. New York, Basic Books Inc., 1979 4.  Ã‚  Ã‚  Ã‚  Ã‚  Landon, Elaine. Teens and the Death Penalty. Hillside, Enslow Publishers, 1992 5.  Ã‚  Ã‚  Ã‚  Ã‚  Herda, D.J. Furman v. Georgia. Springfield, Enslow Publishers, 1994

Batman: the Dark Knight Film Analysis

Batman: The Dark Knight Batman: The Dark Knight directed by Christopher Nolan is non-stop action thriller that continually did the unexpected. The film is based off of the original Batman comic book but additionally changes the perception of the everyday world as good to naturally bad. Throughout the movie, Batman stands for honesty and goodness while the Joker is a symbolism of chaos and evil. Both sides are forced to make quick-witted decisions in order to stop the opposing vigilante from doing his desired work. The citizens of Gotham are put in the heart of this circumstance and feel obligated to go against their values to stop the chaos. Numerous people habitually pursue their dreams and values but often become blinded from their true intentions by the world they exist in. To understand the circumstance the citizens of Gotham are placed in we must first understand each side they are being pulled from. First is the good side, represented by Batman/Bruce Wayne and played by Christian Bale. He stands for everything good and has one personal rule as a superhero that prevents him from killing any person. Batman believes the law must punish the immoral so he stays in the shadows of the night. The law depends on Batman to do the work they legally cannot do. So Batman makes it possible for the law to easily come across these criminals even when they run beyond national borders. These unlawful acts committed by Batman are easily looked past due to bright light always surrounding him. There are many scenes in which the lighting shows the goodness of Mr. Wayne. His underground office wear all his superhero work is done has a ceiling purely of bright white lights. No other part in the movie has this much lighting. Also, the bright Batman light on top of the building is a symbol of good around the city. When the light is shinning many criminals second guess crimes they have always committed. Furthermore, Bruce Wayne is always looking through the windows in his home that radiate with natural light. Batman’s suit may be completely black but this is in order to be a stealth hero through the night. When looking closer at these night time scenes each one consists of Batman standing in the darkness but always with a very bright light somewhere nearby. Secondly is the bad side, represented by the Joker and played by Heath Ledger. From first sight of the Joker you know he is wicked. He wears a purple suit coat, green vest, green tie, and a patterned gray shirt. His hair is always a mess and black make-up surrounds his eyes. These are all dark colors but they are not to hide in the darkness of the night such as Batman’s outfit. He is not trying to hide; he wants to prove people how evil he really is. The Joker also has a piercing voice that is not forgotten combined with an evil laugh that shows his true ecstasy. He has no limits and thrives to do the unexpected just to see how people will react. Christopher Nolan begins this movie with ordinary people wearing a Joker mask while they are robbing a bank. Each member of this mob is shot after they do their part of their job until the real Joker becomes the last one standing. This first scene in the film is pure evil and captivates the audience quickly although I believe the director is trying to create early signs of symbolism. These ordinary men believe if they wear this Joker mask they are some how something they never could be on their own. The next scene also symbolizes something similar to the robbery scene but on the opposite side of the spectrum. The mob is meeting when all of a sudden multiple want-to-be batmen try to engage in the action to stop the wickedness. They too are wearing costumes and masks just like Batman’s creating a clear relation between the outfit and super human power. The real Batman even states at the end of this scene when asked what is the difference between him and the other phony batmen, â€Å"I am not wearing hockey pads! † Early in the film it is evident people are trying to be something they are not causing themselves pain and in even some cases death. If the fake batmen wouldn’t have worn that attire they would have never stood up to the mob and created the clash that the real Batman was forced to fix. The abilities of the two vigilantes in the city captivated many people and they starting forgetting who they really were. The city in Gotham is in chaos. They no longer know what they stand for and are starting to wonder if fighting evil is, in fact, creating more evil. One man who stands strong even when the public is second-guessing is Harvey Dent played by Aaron Eckhart. He is the new district attorney and is respected by the entire city for stopping corruption all over the town. He is a clean-shaven man with blonde hair and blue eyes who presents himself as a very proper man. This mise en scene proves that this man is a good man. If he were unshaven, had dark eyes, and dark hair it would be hard to consider him a truly good man. The director realizes this may not be true with everyone but it is a typical stereotype in our society today. As the movie goes on the enemy, who is forcing him to second-guess his values, tests him time and time again. Being an honest man is no longer putting criminals away; they are always one step ahead. By the end of the film, the Joker crushes Harvey’s values and blinds him from what his true goals were in life. His two-sided face shows this visually after being burned in the explosion. Also, Harvey has a coin with a head printed on both sides. This coin never can land on tails but Harvey claims to people, â€Å"I make my own luck†. This symbolizes his values and how he believes he can accomplish anything at this point in the movie. After an explosion kills his girlfriend, he reclaims the coin but one side of the coin is now completely black. Harvey at this point, mad at the world, flips the coin to put others life up to chance. He no longer says he will make his own luck; the coin flip is now up to chance. The worldly things in life ruined Harvey to the point that he becomes better off dead. Once the noblest man in the city, Harvey Dent becomes caught between choosing the law or his own way in order to bring to an end wrongdoings. Alongside Harvey are the commissioner and the city police department. They too are uncertain of how to stop the turmoil in the city of Gotham. They are put directly in the middle between choosing Batman’s side or the Joker’s side, which is pure evil but made very appealing through his trickery. Members of the police department are overwhelmed with life and corruption floods through them. Some could use an extra few dollars here and there to have the easy way out but they failed to realize that taking shortcuts would always catch up to them in the end. The once good cops of Gotham soon can no longer be trusted due to the Joker blinding their true values. Not only are the once good people of Gotham confused, the mob is also. Due to all the imprisonment of mob leaders there wasn’t anyone â€Å"on top† of the streets. Criminals no longer knew whom they were working for or what they were working for. This is visually shown in the movie when the Joker burns all of the money that had been stolen by the mob earlier. He claims the money is not what brings the mob together; it is the brutality and wrongdoing throughout the city. The entire movie is filled with a confused mob. Even from the beginning the mob does not know what to do with their money or what criminal action to take next. The greatest visual symbolism in the movie is the Joker’s mask. It is often mistaken that â€Å"good† is happiness when really the evil is hiding underneath. The Joker’s makeup is white symbolizing purity and good along with his smile that is scarred into the sides of his lips. All the pain the Joker is feeling inside is covered by this phony smile and pure colored face. He even states an example of this when describing how he got the scars of his face, â€Å"why so serious? The Joker does not know who he really is or what he is trying to do. He is in confusion just as the rest of the city. Another illustration of visual symbolism is the boat scene toward the end of the movie. There are two ships, Liberty and Freedom, each having a completely different set of individuals. In this scene the director portrays the natural human and the confusion in each o f us. Did they not blow up the other ship because they cared for others or were they scared for their own sake? This proves once again that this city is in confusion and is blinded from the chaos that is happening. Luckily there were a few people who stood up for their values at this critical time and proved to everyone else that values will stand the test of time if you stay true to them. Each character in this movie had goals and values, whether it was to take crime off the streets, create chaos, or just be a good human being. When things didn’t go as planned or as usual these characters became tested to do what was right. Many fell to what they never wanted to be while Batman stayed strong throughout time. In the scene where Batman and the Joker are in the interrogation room and Batman is ready to kill. It is not an accident that the lighting is so bright. It reminds Batman what he stands for even in the darkest times and keeps him from breaking his one and only rule. He could have ended everything there with one punch but knew taking the short cut would not pay off in the end. This is what makes Batman the true superhero of the movie. We must put our wants and needs behind what is right in many situations in life in order to truly reach our goals. Bibliography Nolan, Christopher, Dir. Batman: The Dark Knight. Dir. Christopher Nolan. † Warner Bros: 2008, Film.

Maltreatment and diabetes - Free Essay Example

Sample details Pages: 26 Words: 7702 Downloads: 6 Date added: 2017/06/26 Category Health Essay Type Research paper Did you like this example? Study Rationale The primary goal of this study is to conduct an empirical investigation of the association between an early life stressor such as childhood maltreatment and subsequent diagnosis of Type II diabetes in adulthood. This study will specifically explore if a relationship exists between the type and severity of childhood maltreatment encountered and participants diabetes-related quality of life. To provide a context for the current study, background literature focusing on two dimensions that have received considerable attention in the psychological literature is first thoroughly reviewed: definition and effects of childhood maltreatment and the biopsychosocial aspect of Type II diabetes. Don’t waste time! Our writers will create an original "Maltreatment and diabetes" essay for you Create order The current studys purpose, hypotheses, method, and data analytic strategy will then be proposed. Background Information Childhood Maltreatment Childhood maltreatment refers to, any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child (Centers for Disease Control [CDC], n.d., para. 1). In their report, Child Maltreatment Surveillance, Leeb, Paulozzo, Melanson, Simon, Arias (2007) defined acts of commission as deliberate and intentional use of words or actions that cause harm, potential harm, or threat of harm to a child. Examples of acts of commission include physical, sexual, and/or psychological abuse. Acts of omission, on the other hand, are the failure to provide for a childs basic physical, emotional, or educational needs or to protect a child from harm (Leeb et al., 2007). Thus, acts of omission include physical, emotional, medical, or educational neglect, the failure to supervise or insufficient supervision, and/or exposure to a violent environment. According to the most recent publication by the U.S. Department of H ealth and Human Services (USDHHS) on childhood maltreatment, an estimated 905,000 children were determined to be victims of abuse or neglect (USDHHS, 2006). Specifically, 64.2 percent of child victims experienced neglect, 16.0 percent were physically abused, 8.8 percent were sexually abused, and 6.6 percent were emotionally or psychologically maltreated. The report suggests that rates of victimization by maltreatment type have fluctuated only slightly during the past several years. The long-term consequences of child maltreatment are significant and include the risk of alterations of brain structure and function, sexual risk taking behaviors, eating disorders, suicidal intent and behavior, lower self-esteem, adjustment problems, internalizing problems (i.e. anxiety and depressive disorders), externalizing problems (i.e. personality disorders and substance abuse), adult trauma, continuation of intergenerational violence and/or neglect, and developmental and cognitive disabilities (Anda, Felitti, Bremner, Walker, Whitfield, Perry, Dube, Giles, 2006; Arata, Langhinrichsen-Rohling, Bowers, OFarrill-Swails, 2005; Bardone-Cone, Maldonado, Crosby, Mitchell, Wonderlich, Joiner, Crow, Peterson, Klein, Grange, 2008; Johnson, Sheahan, Chard, 2003; Kaplow Widom, 2007; Kaslow, Okun, Young, Wyckoff, Thompson, Price, Bender, Twomey, Golding, Parker, 2002; Lewis, Jospitre, Griffing, Chu, Sage, Madry, Primm, 2006; Medrano, Hatch, Zule, Desmond, 2002; Smith, 1996; Sobsey, 2002; Taft, Marshall, Schumm, Panuzio, Holtzworth-Munroe, 2008). A consistent relationship between abuse history and poorer overall health has also been demonstrated in a stratified, epidemiological sample of both men and women within the United States (Cromer and Sachs-Ericsson, 2006). Childhood Maltreatment and Physical Health Problems A consistent dose-relationship between abuse history, poorer overall health, and sustained losses in health-related quality of life has been well established (Cromer Sachs-Ericsson, 2006; Golding, 1994; Corso, Edwards, Fange, Mercy, 2008). Childhood sexual abuse has been associated with physical complaints such as migraine, irritable bowel syndrome, fibromyalgia, and chronic pain (Goldberg, Pachas, Keith, 1999; Goodwin, Hoven, Murison, Hotopf, 2003; Ross, 2005; Walker, Keegan, Gardner, Sullivan, Bernstein, Katon, 1997). Furthermore, using data from the National Corbidity Study, a nationally representative general population study, Arnow (2004) found that abused children were likely to have pelvic and musculoskeletal pain as adults, and utilize health care services at a greater proportion in adulthood. However, a major limitation of these studies is exclusion of emotional and/or psychological abuse experienced in childhood. Additionally, results regarding the incidence of types of childhood maltreatment and diabetes have been mixed. Diabetes Diabetes is a chronic disease characterized by the deficiency or resistance to insulin, a hormone needed to convert sugar, starches and other food into energy needed for daily living. As such, insulin deficiency compromises the body tissues access to essential nutrients for fuel or storage. According to the American Diabetes Association (ADA), there are 23.6 million children and adults in the United States, or 7.8% of the population, who have diabetes, many of which unaware that they have the disease (ADA, n.d., para. 2). Diabetes occurs in two primary forms. Type I diabetes is characterized by absolute deficiency and typically occurs before the age of 30. Type II diabetes, however, is typified by insulin resistance with varying degrees of deficiencies in the bodys ability to secrete insulin. Sedentary lifestyle and diet have been linked to the development of Type II diabetes. Other risk factors for this type of diabetes include obesity, pregnancy, metabolic syndrome, and variou s medications. Physiologic and emotional stress has also been thought to play a key role in the development of Type II diabetes specifically. Prolonged elevation of stress hormones, namely cortisol, glucagon, epinephrine, and growth hormone, increases blood glucose levels, which in turn places increased demands on the pancreas. Such stress ultimately leads to the inability of the pancreas to keep up with the bodys need for insulin and high levels of glucose and insulin circulate in the bloodstream, setting the stage for Type II diabetes (Diseases, 2006). Role of Stress in the Onset of Diabetes Animal Studies Researchers have found that both a history and presence of existing stressors play a significant role in the onset and course of diabetes. Through the use of animal studies, researchers have been able to prospectively test the influence of stress on both types of diabetes. For example, Lehman, Rodin, McEwen, and Brinton (1991) investigated whether an environmental challenge promoted the expression of diabetes in bio-breeding rats. Researchers introduced a triad of stressors to the animals over a 14-week period, including rotation of the cage, vibration, and restraint in individual containers. They found that the administration of these stressors repeatedly increased the likelihood of the rats developing Type I diabetes as indicated by elevated blood sugar levels (Lehman et al., 1991). One of the first observations that stress could contribute to the expression of Type II diabetes was made during metabolic studies of the native North African sand rat (psammonys obesus). Once fed with laboratory chow and allowed to become obese, the North African sand rat will eventually develop Type II diabetes in response to an environmental stressor (Surwit, Schenider, Feinglos, 1992). Notably, Mikat, Hackel, Cruz, and Lebowitz (1972) administered an esophageal intubation of saline in an effort to control the dietary intake of the sand rat. This tube feeding resulted in an alteration of glucose tolerance and precipitated the onset of Type II diabetes in these rats. Similar research was done on the genetically obese (ob/ob) mouse, which is used as a prototype of Type II diabetes in humans because of its pattern of obesity, hyperinsulinemia, hyperglycemia, insulin resistance, and glucose intolerance (Surwit, Feinglos, Livingston, Kuhn, McCubbin, 1984). To study the effects of environmental stress and sympathetic nervous system arousal on plasma glucose in ob/ob mice, Surwit et al. (1984) designed two experimental conditions. In the first condition, 15 ob/ob mice were shak en in their cage at a rate of 200 strokes per minute for five minutes. In the second condition, 16 ob/ob mice were injected with epinephrine bitartrate, a chemical whose effects mimic those of the stress response. Plasma glucose levels in mice from both conditions were found to be significantly elevated. The researchers concluded that environmental stress was partially responsible for the expression of the diabetic phenotype in this animal model of diabetes. Role of Stress in the Onset of Diabetes Human Studies Data gathered on the impact of life events on Types I diabetes in a human sample has yielded inconsistent results. An early study by Grant, Kyle, Teichman, and Mendels (1974) examined the relationship between the occurrence of life events and the course of illness in a group of 37 diabetic patients. Using Holmes and Rahes Schedule of Recent Events (SRE), a scale in which 43 significant recent life events are assigned a numeric value of life change units as a measurement of life stress, Grant et al. (1974) found that of the 26 participants who had a positive correlation between undesirable life events and illness, 24 had a positive correlation between undesirable events scores and diabetic condition. This data suggests that negative events were primarily responsible between life events and changes in diabetic condition since the inclusion of neutral and positive events did not increase the magnitude of the correlations. Despite the significant results, this study had a number of lim itations, including the utilization of a small sample size, difficulty in establishing reliable criteria for assessing subtle changes in the diabetic condition, lack of sufficient time to elapse between assessments for significant life changes to occur, and the lack of delineation of the types of diabetes studied (i.e. Type I vs. II). However, in a more recent meta-analysis, Cosgrove (2004) found no evidence to support the hypothesis that life events cause or precipitate Type I diabetes. Using an electronic and manual literature search of appropriate key words (namely, diabetes and depression, diabetes and depressive, diabetes and life events, diabetes and stress) in the literature up to July 2003, Cosgrove (2004) aimed to establish whether there might be a link between depression, stress, or life events and the onset of Type I diabetes. A total of nine papers were found from the electronic and manual search. It was concluded that when the number and severity of life events was c ompared to controls in all nine reviewed studies, no differences were detected in the diabetics (Cosgrove, 2004). Though data from small, older studies and large, randomized studies showed that early losses in childhood increase the risk of developing Type I diabetes, no evidence was found to support the hypothesis that life events cause or precipitate this diagnosis. Meta-analyses with more recent studies have not been found studying the relationships between stressful life events in both types of diabetes. As such, it is unknown whether links have since been found by other researchers. More consistent evidence was found supporting the notion that stressful circumstances precipitate Type II diabetes. In their study of environmental stress on Type II diabetics, McCleskey, Lewis, and Woodruff (1978) measured glucagon and glucose levels on 25 patients who were undergoing elective surgery, a physical stressor. Ten samples were obtained during pre-operative, intra-operative, and post -operative periods for each patient. It was found that throughout the sampling period, diabetic patients had two times the amount of glucagon (a hormone produced by the pancreas that stimulates the increase of blood sugar levels) in their body compared to their non-diabetic counterparts (McCleskey, Lewis, Woodruff, 1978). This effect was also found in Pima Indians, who have an approximately 60% chance of eventually developing Type II diabetes, compared with 5% of the Caucasian population (Surwit, Schenider, Feinglos, 1992). The effects of a simple arithmetic task on blood glucose levels were studied in both Caucasian and Pima Indian samples. Surwit, McCubbin, Feinglos, Esposito-Del Puente, and Lillioja (1990) found that blood glucose was consistently higher during and following the stressful task in ten of 13 Pima Indians, concluding that altered glycemic responsivity to behavioral stressors anticipates the development of Type II diabetes in individuals who are genetically pred isposed to the disease (Surwit et al., 1990). Results from The Hoorn Study further illustrated the effects of stress on Type II diabetes. Mooy, De Vries, Grootenhuis, Boutner, and Heine (2000) analyzed data from a large population-based survey of 2,262 adults in the Netherlands upon which the researchers were able to explore whether chronic stress is positively associated with the prevalence of Type II diabetes. Analysis of data confirmed their hypothesis; a high number of rather common major life events that are correlated with chronic psychological stress, such as death of a spouse or relocation of residence, were indeed found to correspond to a significantly higher percentage of undetected diabetes (Mooy et al., 2000). Because the study was conducted in the Netherlands on a Caucasian, middle-aged population, it is uncertain whether these findings are generalizable to other demographics in different geographic regions. Childhood Maltreatment and Diabetes Thus far, with the exception of one study, the research discussed has demonstrated a positive correlation between a variety of recent or current environmental stressors, such as anesthesia, surgery, cognitive tasks, death of a loved one, and other significant losses, and the onset of Type I and/or II diabetes in animals and human beings. However, the literature is somewhat limited as to the relationship between a past environmental stressor, namely childhood maltreatment, and Type II diabetes in adulthood. Numerous researchers examined the prevalence of medical problems in abused populations and have reported that diabetes is one of the most common health conditions among those who have experienced maltreatment. For example, using data drawn from the National Comorbidity Study conducted in the early 1990s, Sachs-Ericsson, Blazer, Plant, and Arnow (2005) examined the independent effects of childhood sexual and physical abuse on adult health status in a large community sample of 5 ,877 men and women. Sachs-Ericsson et al. (2005) found that childhood sexual and physical abuse was associated with the one-year prevalence of serious health problems for both men and women. Specifically, participants who experienced any form of childhood abuse were more likely to report having a medical condition, including AIDS, arthritis, asthma, bronchitis, cancer, diabetes, high blood pressure, kidney or liver disease, neurological problems, stroke, gastrointestinal disorders, or any other serious health problem (Sachs-Ericsson et al., 2005). Though data from this epidemiological study likely represents the U.S. demographics, a number of limitations exist. Specifically, the researchers did not report the prevalence of each disorder endorsed and thus, the actual incidence of diabetes in the population sample is unknown. Furthermore, Sachs-Ericsson et. al (2005) did not look at additional forms of maltreatment, such as verbal abuse, emotional abuse, and neglect. Similarly, Wal ker, Gelfand, Katon, Koss, Von Korff, Bernstein, and Russo (1999) found a significant association between childhood maltreatment and adverse adult health outcomes. In particular, the researchers administered a survey to 1,225 women randomly selected from the membership of a large HMO in Washington State. Results indicated that women with childhood maltreatment histories were more likely to have an increased number of physician-coded ICD-9 diagnoses, grouped together as high blood pressure, diabetes, dermatitis, asthma, allergy, acne, and abnormal menstrual bleeding. Though the group of women in this study who reported threshold levels of sexual maltreatment had the poorest health outcomes, a major limitation of this study is the uncertainty as to whether additional forms of maltreatment were concomitantly experienced. Specifically, the authors do not establish whether sexual abuse solely was the cause of poorer health or is largely due to multiple forms of maltreatment in girls who were not properly protected in their early families. Moreover, Walker et al. (1999) do not differentiate between types of diabetes. Gender differences have been established in the association between physical abuse in childhood and overall health problems in adulthood. Analysis of data from 16,000 individuals interviewed in the National Violence Against Women Survey found that female abuse victims were at greater risk for health problems than their male counterparts (Thompson, Kingree, Desai, 2004). Furthermore, women with maltreatment history tend to have more distressing physical experiences, have an increased number of physician-coded diagnoses, and were more likely to engage in multiple health risk behaviors, including obesity a significant risk factor associated with Type II diabetes (Trickett, Putnam, Noll, 2005; Walker, Gelgand, Katon, Koss, Von Korff, Bernstein, Russo, 1999). Moreover, sexual assault history throughout ones lifespan was also associated with chronic di sease (i.e. diabetes, arthritis, and physical disability) in a sample of women from Los Angeles (Golding, 1994). Conversely, in their sample of 680 primary care patients, Norman, Means-Christensen, Craske, Sherbourne, Roy-Byrne, and Stein (2006) found that the experience of trauma significantly increased the odds of arthritis and diabetes for men, while trauma was associated with increased odds for digestive disorders and cancer in women. Although the data suggests that childhood maltreatment is related to adverse health outcomes in adulthood, they do not address as to why associations differed by gender. Analyzing data from the Midlife Development in the United States Survey (MIDUS), Goodwin and Weisberg (2002) sought to determine the association between childhood emotional and physical abuse and the odds of self-reported diabetes among adults in the general population. Their results revealed that self-reported diabetes occurred in 4.8% of its representative sample of 3,032 adul ts aged 25-74 years. Childhood abuse was associated with significantly increased odds of self-reported diabetes, which persisted after adjusting for differences in socio-demographic characteristics and mental health status (Goodwin Weisberg, 2002). Moreover, individuals who specifically reported maternal emotional abuse and maternal physical abuse had significantly higher rates of diabetes (Goodwin Weisberg, 2002). Furthermore, data gathered from a sample of 130 patients (65 abused, 65 non-abused controls) drawn from an adult primary-care practice in a small, affluent, predominantly Caucasian community in northern New England revealed that patients with a history of victimization were more likely to report diabetes or endorse symptoms of this illness than non-abused participants (Kendall-Tackett Marshall, 1999). Specifically, four patients in the abused group reported diabetes, with none in the control group. Interestingly, those patients in the abused group did not have a sig nificantly higher family history of diabetes than those in the non-abused group and a higher percentage of patients in the abused group reported having three of more symptoms than did those in the control group. Kendall-Tackett and Marshall (1999) assert that although only four people identified themselves as having diabetes, this number should be interpreted in the broader context of incidence of diabetes in the general population. Nonetheless, this finding could have been due to chance and many of the symptoms endorsed could have been related to other diseases (Kendall-Tackett Marshall, 1999). Additional limitations include the failure to differentiate between the types of abuse endured and the use of a non-empirically validated measure to gather data. Furthermore, the researchers did not specify which type of diabetes the participants were diagnosed with and did not indicate the severity of the disease. Data from the Adverse Childhood Experiences Study (ACE), however, found a lternative results. Researchers Felliti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, and Marks (1998) mailed questionnaires about adverse childhood experiences to 9,508 adults who had completed a standardized medical evaluation at a large HMO in California. It was found that abuse and other types of household dysfunction were significantly related to the number of disease conditions, with the exception of diabetes. Specifically, when those who had experienced multiple forms of childhood maltreatment were compared to those with no experiences, the odds-ratio for the presence of diabetes was a non-significant 1.6 (Felliti et al., 1998). The researchers believe that their estimates of the long-term relationship between adverse childhood experiences and adult health are conservative. Specifically, it is likely that, consistent with well-documented longitudinal follow-up studies, that reports of childhood abuse were underestimated due to the premature mortality in persons with mu ltiple adverse childhood exposures (Felliti et al., 1998). Similarly, in a sample of 1,359 community-dwelling men and women aged 50 years or older, Stein and Barrett-Connor (2000) found no relationship between sexual assault history in participants lifetime and reported rates of diabetes. Rather, a history of sexual assault was associated with an increased risk of arthritis and breast cancer in women and thyroid disease in men (Stein Barrett-Connor, 2000). In this study, the researchers posit that the possibility of response bias is a major limitation. Namely, Stein and Barrett-Connor (2000) consider the likelihood that previously assaulted respondents have a greater tendency to visit doctors, leading to the increased opportunities for health conditions to be detected. Additional limitations include the lack of consideration for other types of abuse encountered in childhood. The Link between Childhood Maltreatment and Diabetes The above findings provide support for the hypothesis that childhood maltreatment may be associated with increased likelihood of the diagnosis of a medical condition, with the inclusion of diabetes in some studies. An essential question posed by this observation is by what mechanisms are adverse childhood experiences linked to health risk behaviors and adult diseases? A number of researchers have found that psychological stress, in particular, has been associated with the onset of Type II diabetes. This impact of stress on the etiology and course of Type II diabetes can be considered via the metabolic pathways by means of obesity and/or activation of the hypothalamic-pituitary-adrenal (HPA) axis, the gene-environment interaction, and the correlation of coping with diabetes and stressors. The stress response is a physiological coping response that involves the HPA axis, the sympathetic nervous system, the neurotransmitter system, and then immune system. There is growing evidence that victims of various forms of abuse and stressors often experience biological changes, particularly in the neuroendocrine system implicated in the stress response, as well as the brain (Glaser, 2000; Goenjian, Pynoos, Steinberg, Endres, Abraham, Geffner, Fairbanks, 2003; King, Mandansky, King, Fletcher, Brewer, 2001; McEwen, 2000). The HPA axis is the primary mechanism studied in the literature on the neurobiology of stress and is estimated through the non-invasive measurement of cortisol in saliva samples. During psychological stress, cortisol is elevated beyond normal levels in response to adrenocorticotropic hormone from the pituitary, mobilizing energy stores, and facilitating behavioral responses to threat (Diseases, 2006). In the presence of prolonged stress, especially in which the individual has difficulty coping, this physiological response may occur to an atypical extent and prove harmful. Dienstbier (1989) asserts that prolonged and/or extreme stress can create a vic ious cycle of pathology, as individuals with a history of abuse may become even more vulnerable in the face of new victimization because they become threat-sensitized, resulting in either an over- or under-reaction of the HPA system to new stressors. As Vaillancourt, Duku, Decatanzaro, Macmillan, Muir, and Schmidt (2008) cite, this process is best illustrated by Cicchetti and Rogoschs (2001) study of maltreated children attending a summer day camp. These authors found that in comparison to non-abused children, children who had been both sexually and physically abused, in addition to emotionally maltreated or neglected, exhibited higher morning cortisol levels, whereas a subgroup of children who had only been physically abused exhibited lower levels. Recent evidence suggests that increased cortisol concentrations may contribute to the prevalence of metabolic syndromes, such as Type II diabetes. For example, in their assessment of 190 Type II diabetic patients who volunteered from a population study of 12,430 in suburban Germany, Oltmanns, Dodt, Schultes, Raspe, Schweiger, Born, Fehm, and Peters (2006), sought to assess the relationship between diabetes-associated metabolic disturbances and cortisol concentrations in patients with Type II diabetes. The target population comprised of men and women born between 1939 and 1958 who completed a postal questionnaire about their health status. Results demonstrated that in patients with Type II diabetes, those with the highest cortisol profiles had higher glucose levels and blood pressures (Oltmanns et al., 2006). Their findings suggest that HPA axis activity may play a role in the development of Type II diabetes-associated metabolic disturbances. Cartmell (2006) proposes a model by which this may occur. Namely, high levels of cortisol decreases metabolism of glucose and increase mobilization and metabolism of fats. This decreased metabolism of glucose contributes to increased blood glucose levels. Furthermore, increa sed blood fat levels contribute to insulin resistance. This increase level of blood glucose and fats are characteristic symptoms of diabetes (Cartmell, 2006). Researchers Chiodini, Adda, Scillitani, Colleti, Morelli, Di Lembo, Epaminonda, Masserini, Beck-Peccoz, Orsi, Ambrosi, and Arosio (2007) extended the literature by studying HPA axis secretion of cortisol and chronic diabetic complications. An evaluation was conducted on HPA activity in a sample of 117 Type II diabetic patients with and without chronic complications and in a sample of 53 non-diabetic patients at a hospital in Italy. Chiodini et al. (2007) found that in diabetic subjects without chronic complications, HPA axis activity was comparable with that of non-diabetic patients, whereas in diabetic subjects with chronic complications, cortisol level was increased in respect to both diabetic subjects and control subjects. Though the design of their study did not look for a cause-effect relationship, Chiodini et al. (200 7) purport that higher levels of cortisol, either due to a constitutive HPA axis activation or secondary to a chronic stress condition, may predispose an individual to the development of chronic diabetic complications. Type II diabetes is now a well-recognized syndrome characteristic of hyperglycemia, insulin resistance, obesity, dyslipidemia, and hypertension (Sridhar Madhu, 2001). One theory that purports the biological plausibility of a stress-diabetes association has been formulated by Swiss researcher, Dr. Per BjÃÆ'Â ¶rntorp. BjÃÆ'Â ¶rntorp (1997) postulated that stress could be responsible for sympathetic nervous system activation, hormone abnormalities, and obesity. This theory states that perceived psychological stress with a defeatist or helplessness reaction leads to an activation of the HPA axis. This in turn results in endocrine abnormalities, including increased cortisol and decreased sex steroid levels that disrupt the actions of insulin. In addition, this horm onal imbalance causes visceral adiposity, which plays an important role in diabetes and cardiovascular disease by contributing to the development of insulin resistance (Cartmell, 2006). Researchers of The Hoorn Study described above tested BjÃÆ'Â ¶rntorps theory and found only partial support (Mooy et al., 2000). Specifically, the accumulation of visceral fat did not seem to be the major mediating factor between stress and diabetes and fasting insulin concentration, which is an approximation of insulin resistance, was not higher in the individuals in their sample who had experienced more stressful events. Study Significance The significance of this study is its potential to provide medical practitioners with information regarding the impact of past psychosocial factors, such as childhood maltreatment, on the current physical health of Type II diabetics. Diabetes and its complications affect a significant portion of the United States population and has become the fifth leading cause of death in the country (Florida Department of Health, 2008). As researchers continue to look for the cause(s) of diabetes and methods to treat, prevent, or cure the disorder, it is vital that practitioners take a holistic and comprehensive approach to assessing the diabetics life. As long as abuse and other potentially damaging experiences in childhood contribute to the development of risk factors, then these childhood exposures should be recognized as the basic causes of morbidity and mortality in adult life (Felliti et al., 1998). Major limitations of past literature include lack of specificity of type of diabetes, famil y history, and self-reported diabetes without data on physiological measures. In addition to replication, future studies should include detailed studies on diabetes-type, a ruling-out of serious medical conditions that could potentially act as confounds, and identify maltreatment subtypes experienced. This study aims to uncover a relationship between childhood maltreatment and adult physical health, namely with Type II diabetes, so as to assist with screening and intervention. If doctors caring for adults who suffer from a medical condition associated with diabetes are unaware of this relationship, they will neither obtain early maltreatment history nor make appropriate patient referrals leading to higher health care utilization and poorer outcomes (Arnow, 2004; Springer, Sheridan, Kuo, Carnes, 2003). Research Questions and Hypotheses This study aims to answer the following questions: Is a history of childhood maltreatment associated with diabetes-related quality of life? If so, is a decrease in diabetes-related quality of life associated with an increase in the types of childhood maltreatment experienced? It is hypothesized that the more types of abuse endured during childhood (i.e. physical, emotional, and/or sexual, neglect, and/or the witnessing of family violence), the more chronic and severe an individuals diabetes will be and the greater impact of their illness on their reported quality of life. Method Participants Data will be collected from individuals with Type II diabetes, recruited from psychiatric practices located in Plant City and Tampa, Florida. Participants will be recruited from these sites due to likelihood that patients receiving psychiatric care have a history of childhood maltreatment. Participants will be included in the study if they are aged 40 and older, as non-insulin dependent diabetes appears after this age. Participants will be excluded from the study if they have additional existing physical conditions which may negatively impact their quality of life, as discussed in the Measures section. A projected sample size of 100 total participants has been chosen, using a sample size calculation provided by a statistics consultant. Procedure Details regarding the study will be posted in the form of a flyer (Appendix D) in the waiting rooms of the psychiatric practices. Patients interested in participating in the study will inform the front office staff, who will provide the prospective participant with a packet including informed consent and all measures. Specifically, the informed consent will include the purpose of the research, the procedures to be followed, risks and discomforts as well as potential benefits associated with participation, and alternative procedures or treatments, if any, to the study procedures or treatments. Once potential participants have read the consent document, have their questions are answered, and agree to participate in the research, the informed consent document will be signed, dated, and stored in a secure location. Participants will then be asked to fill out the questionnaires either in the waiting room or in a more private location of the office as they wait for their appointment. Once completed, participants will place the questionnaires in an attached blank envelope and placed in a collection box. A notation will be made in their chart signifying that they have completed the study so as to avoid duplicates. Potential subjects will also be given a copy of the informed consent document so they can carefully review the document and discuss the research with the significant others and/or physician and develop questions to ask at their next psychiatric appointment and subsequent meeting with the researcher. Measures Once informed consent has been obtained, each participant from either group is to complete a demographics questionnaire, as well as two measures that explore maltreatment in childhood and diabetes quality of life. These measures are to be self-administered and anonymous. The demographics questionnaire (Appendix A) will inquire about participants age, height, and weight. This information will be used to obtain a measure of their body mass index (BMI). The BMI provides a standardized measure, and thus, reliable indicator of body fatness for most people and is used to screen for weight categories, such as obese, that may lead to health problems (CDC, n.d., para. 2). Since obesity is known to be a significant predictor leading to poorer quality of life (Sundaram, Kavookjian, Patrick, Miller, Madhavan, and Scott, 2007), it is important for the purposes of this study to exlude those participants who fall into this weight categories so as to avoid confounding variables. The demographic s questionnaire will also include exclusionary criteria consisting of a variety of chronic physical conditions. In their research on comorbidity of chronic diseases, Rijken, van Kerhof, Dekker, and Schellevis (2005) note that the presence of multiple comorbid conditions complicates the question how a specific disease is related to quality of life and other outcome variables. It has been found that arthritis, osteoarthritis, cardiovascular diseases, chest pain, stroke, respiratory diseases, and cancer significantly reduces the quality of life in patients with Type II diabetes (Bowker, Pohar, Johnson, 2006; Maddigan, Feeny, Johnson, 2005; Miksch, Hermann, Rolz, Joos, Szecsenyi, Ose, Rosemann, 2009; Rijken et al., 2005; Stone, Khunti, Squire, Paul, 2008; de Visser, Bilo, Groenier, de Visser, Meyboom-de Jong, 2002). Therefore it is vital for patients with these comorbid conditions to be excluded from the present study so as to accurately ascertain the impact of childhood maltreatme nt on their diabetes-related quality of life. Maltreatment status is to be measured using the Childhood Trauma Questionnaire (CTQ; Bernstein et al, 2003; Scher et al., 2001). The CTQ is a self-report instrument that consists of five subscales assessing emotional, physical, and sexual abuse, as well as emotional and physical neglect. Rather than duration and intensity of traumatic experiences, the extent of the maltreatment is measured using a score that is calculated for each subscale and reflects the total number of items endorses. Each subscale score is categorized into four groups: none or minimal, low to moderate, moderate to severe, and severe to extreme (Bernstein and Fink, 1998). The CTQ has been well validated in both clinical and non-clinical populations. Furthermore, it has excellent reliability (.70-.93) for all subscales, with the lowest reliability for physical neglect and the highest for sexual abuse (Bernstein and Fink, 1998; Paivio and Cramer, 2004). The Diabet es-39 questionnaire (D-39; Appendix C; Boyer Earp, 1997) specifically asks patients to indicate the impact of items on their quality of life and elicits responses that reflect the individual burden of diabetes and its impact on the overall life of the patient. The instrument consists of 39 items and covers five dimensions of the patients lives: energy and mobility (15 items), diabetes control (12 items), anxiety and worry (4 items), social burden (5 items), and sexual functioning (3 items). Reliability of the D-39 instrument as measured by Cronbachs coefficient alpha ranged from 0.82 to 0.93. In a review of health outcome measures for diabetes, Garratt, Schmidt, and Fitzpatrick (2002) note that this instrument has good evidence for reliability, and internal and external construct validity. Proposed Data Analytic Strategy To measure the degree of relationship between childhood maltreatment and diabetes-related quality of life, two continuous variables, the Pearsons product moment correlation coefficient r will be calculated. The coefficient of determination, or r2, will also be calculated so as to ascertain how much of the variability (if any) in diabetes-related quality of life is explained by the variability in childhood maltreatment. 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