UML Class Diagram or Entity Relationship Diagram : An Object Relational Impedance Mismatch

It is now nearly 30 years since Peter Chen’s watershed paper “The Entity-Relationship Model –towards a Unified View of Data”. [1] The entity relationship model and variations and extensions to ithave been taught in colleges and universities for many years. In his original paper Peter Chen looked at converting his new ER model to the then existing data structure diagrams for the Network model. In recent years there has been a tendency to use a Unified Modelling Language (UML) class diagram forconceptual modeling for relational databases, and several popular course text books use UMLnotation to some degree [2] [3]. However Object and Relational technology are based on different paradigms. In the paper we argue that the UML class diagram is more of a logical model (implementation specific). ER Diagrams on theother hand, are at a conceptual level of database design dealing with the main items and their relationships and not with implementation specific detail. UML focuses on OOAD (Object Oriented Analysis and Design) and is navigational and program dependent whereas the relational model is set based and exhibits data independence. The ER model provides a well-established set of mapping rules for mapping to a relational model. In this paper we look specifically at the areas which can cause problems for the novice databasedesigner due to this conceptual mismatch of two different paradigms. Firstly, transferring the mapping of a weak entity from an Entity Relationship model to UML and secondly the representation of structural constraints between objects. We look at the mixture of notations which students mistakenly use when modeling. This is often the result of different notations being used on different courses throughout their degree. Several of the popular text books at the moment use either a variation of ER,UML, or both for teaching database modeling. At the moment if a student picks up a text book they could be faced with either; one of the many ER variations, UML, UML and a variation of ER both covered separately, or UML and ER merged together. We regard this problem as a conceptual impedance mismatch. This problem is documented in [21] who have produced a catalogue of impedance mismatch problems between object-relational and relational paradigms. We regard the problems of using UML class diagrams for relational database design as a conceptual impedance mismatch as the Entity Relationship model does not have the structures in the model to deal with Object Oriented concepts Keywords: EERD, UML Class Diagram, Relational Database Design, Structural Constraints, relational and object database impedance mismatch. The ER model was originally put forward by Chen [1] and subsequently extensions have been added to add further semantics to the original model; mainly the concepts of specialisation, generalisation and aggregation. In this paper we refer to an Entity-Relationship model (ER) as the basic model and an extended or enhanced entity-relationship model (EER) as a model which includes the extra concepts. The ER and EER models are also often used to aid communication between the designer and the user at the requirements analysis stage. In this paper when we use the term “conceptual model” we mean a model that is not implementation specific.ISBN: 978-84-616-3847-5 3594Peer reviewe

The Use of UML Class Diagrams To Teach Database Modelling and Database Design

It is now nearly 30 years since Peter Chen’s watershed paper “The Entity-Relationship Model – towards a Unified View of Data”. [1] The entity relationship model and variations and extensions to it have been taught in colleges and universities for many years. In his original paper Peter Chen looked at converting his new ER model to the then existing data structure diagrams for the Network model. In recent years there has been a tendency to use a Unified Modelling Language (UML) class diagram for conceptual modelling for relational databases, and several popular course text books use UML notation to some degree [2] [3]. This paper looks at the usefulness of using UML class diagrams for teaching database design in undergraduate courses. In this paper we look specifically at two concepts which can cause problems for the novice database designer. Firstly transferring the concept of a weak entity from an Entity Relationship model to UML and secondly the notation for structural constraints in different diagramming notations. We also look at the mixture of notations which students mistakenly use when modelling. This is often the result of different notations being used on different courses throughout their degree. Peter Chen wrote in his original paper “The entity-relationship model can be used as a tool in the structured design of databases using the network model” today we could write “the UML class diagram can be used as a tool in the structured design of databases using the relational model”. Or can we

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially