Spanish Influence in Puerto Rico Essays - Americas, Spanish Empire

Spanish Influence in Puerto Rico Sarah Osorio Imperialism and Nationalism Final project Sarah Osorio John Poon Imperialism and Nationalism 11-18-17 Spain's Control of Puerto Rico For most of its history, Puerto Rico has been controlled by an outside power, and its people oppressed. While Puerto Rico is currently a U.S. territory, Spanish colonialism has had a significant impact on the island's development and identity. The history of the island itself is proof of this fact, demonstrating each step Puerto Rico took to reach its current state. By examining the stages of Spanish control that Puerto Rico experienced, we can determine how each stage affected the structure of Puerto Rico. Before Spain invaded Puerto Rico, the native population known as the Tainos inhabited it. At the beginning of the 1500's, the Tainos were conquered by the Spanish and, after a series of revolution attempts, virtually disappeared from Puerto Rican life. Those that were left fled to the interior of the island, which was empty for the most part. This part of the island became a refuge for the people who had fled from the approaching Spanish conquerors. This was the first stage in Puerto Rico's development. Spain was the most dominant oppressor of Puerto Rico, and its occupation of the island resulted in many social and economic changes. The native people were marginalized, and Spain took over Puerto Rico in order to turn it into a productive colony. In addition to this, the presence of the Spaniards in Puerto Rico added a different ethnic group to the island's native population. When the official slave trade began in 1518, African slaves were added to Puerto Rico's mixed ethnic heritage. This is the reason for all of the different skin toned people in Puerto Rico. Puerto Rico remained under Spanish control until 1898, but in the 1540's, Spain discovered silver mines in Mexico and Peru. Puerto Rico was virtually abandoned, becoming a frontier zone. Forced into labor, the peasants developed a passive, evasive attitude toward Spanish control. A reflection of this can be seen in Francisco de Valle Atiles article The Spiritual Life of the Jibaro. According to Valle Atiles, The speech of the peasant has the imperfections of those who never had any education; he still uses words that modern Spanish has forgotten, and the impurity and barbarism of his language are notorious. (Valle Atiles 95) This describes the life of the Puerto Rican peasant: poor, uneducated, and deemed inferior by their Spanish tyrants. However, the Puerto Rican peasants had pride in their own culture, and did their best to survive despite their oppressed status. They refused to be controlled by the Spaniards, even to the point of escaping the areas of the island most heavily developed by Spain and living in the uninhabited area. Between 1550 and 1560 Puerto Rico's position as the entry point to the New World began to attract people from countries other than Spain. For this reason, Puerto Rico became the target of many anti-Spain attacks. In 1598, England made an attempt to conquer Puerto Rico, only to be wiped out by an epidemic. San Juan became a Spanish enclave, and it was at this point that Puerto Rican society began to develop dualism. The people who fled to the interior of the island, the Spaniards living in San Juan, and those living in the coastal areas became more familiar with their own identities. In particular, those living in the interior of the island, known as jibaros, were characterized by their dislike of authority and desire for independence. Another aspect of Puerto Rican history that affected the development of the island's structure and identity was the emergence of the sugar and coffee industries. The sugar industry was the first market to emerge, and Spain went so far as to change their policies to encourage commerce on the island. With their new policy, foreign traders could trade with Puerto Rico, building a web of economic interdependence that had a huge effect of Puerto Rican economics. Spain wanted Puerto Rico to become a valuable asset in the sugar industry, and used this reason to tighten its grip on Puerto Rico. This also advanced the class divisions on the island. Although

A comparison between cardiac CT scanning and cardiac digital subtraction angiography (DSA) The WritePass Journal

A comparison between cardiac CT scanning and cardiac digital subtraction angiography (DSA) Abstract A comparison between cardiac CT scanning and cardiac digital subtraction angiography (DSA) ). This review aims to review the literature on coronary CT scanning and digital subtraction angiography, their clinical applications, techniques and comparative value in coronary artery assessment and diagnosis. Cardiac Digital subtraction angiography Coronary angiography is the conventional diagnostic procedure used in coronary artery disease. It is a minimally invasive technique, whereby a catheter is placed into the radial or femoral artery and is advanced through the arterial system to the coronary arteries. A contrast agent is then injected at the aortic root and allows visualization of the arteries using x-ray in real time at up to 30 frames per second. This allows a view of the extent, location and severity of coronary obstructive lesions such as atherosclerosis and enables prognostic indication (Miller et al., 2008). Coronary angiography also enables catheter placement either side of the lesion to assess pressure changes and determines the degree of flow obstruction (Miller et al., 2008). . Digital subtraction angiography (DSA) again works by introducing a contrast agent into the coronary arteries and taking x-rays in real time, however a pre image is taken by x-ray. This allows for the post images to be subtracted from the original mask image, eliminating bone and soft tissue images, which would otherwise overlie the artery under study (Hasegawa, 1987). Unlike conventional angiography, it is possible to conduct DSA via the venous system, through accessing the superior vena cava via the basillic vein (Myerowitz, 1982). This removes the risks associated with arterial cannulation (Mancini Higgins, 1985). The procedure can also be performed with a lower dose of contrast agent and be done more quickly therefore eliminating constraints of using too much contrast during a procedure (Myerowitz, 1982). Whilst DSA is the gold standard in arterial imaging of carotid artery stenosis (Herzig et al., 2004), the application of DSA to the coronary arteries is limited due to motion artefacts associated with each heartbeat and respiration (Yamamoto et al., 2009). There are numerous cardiac clinical applications of DSA, it can be used to assess coronary blood flow (Molloi et al., 1996), valvular regurgitation (Booth, Nissen DeMaria, 1985), cardiac phase (Katritsis et al., 1988), congenital heart shunts (Myerowitz, Swanson, Turnipseed, 1985), coronary bypass grafts and percutaneous coronary intervention outcomes (Katritsis et al, 1988; Guthaner, Wexler Bradley, 1985). However, others have suggested that the coronary arteries are not visualized well due to their small size, movement, their position overlying the opacified aorta and left ventricle, and confusion with other structures such as the pulmonary veins (Myerowitz, 1982). Cardiac CT Scanning Development of CT scanning in the 1990s enabled an increase in temporal resolution that was sufficient to view the beating heart, and they now provide a non-invasive technique for diagnostic and prognostic purposes. Cardiac CT scans have clinical applications that go beyond perfusion investigation, and can be used to assess structure and function of the heart (for example in electrophysiology disorders or congenital heart disease) due to its ability to provide anatomical detail (Achenbach Raggi, 2010). CT scans can be used to assess coronary artery disease with and without injection of contrast agent (Achenbach Raggi, 2010) by calcium scan or CT angiography. Coronary calcium CT scanning uses the evidence base that coronary artery calcium is a correlate of atherosclerosis (Burke et al., 2003) and is a strong prognostic predictor of the future development of coronary artery disease and cardiac events (Arad et al., 2000; Budoff et al., 2009; Achenbach Raggi, 2010). Calcium is easily depicted on CT scan due to its high CT attenuation, and is classified according to the Agatson score, which considers the density and area of the calcification (Hoffman, Brady Muller, 2003). Coronary CT angiography (CTA) allows visualization of the coronary artery lumen to identify any atherosclerosis or stenosis within the vessels. Patients are injected intravenously with a contrast agent and then undergo a CT scan. There are limitations regarding the suitability of patients for coronary CTA due to prerequisites of sinus rhythm, low heart rate and ability to follow breath-holding commands. Additionally, obesity presents a problem for patients that cannot fit into the scanner and affects the accuracy of the procedure. (Achenbach Raggi, 2010). Comparison of cardiac DSA and cardiac CT scanning The technical differences between cardiac DSA and cardiac CT scanning give rise to differences in the clinical indications for the procedures, their diagnostic efficacy and also different risks or relative benefits to the patients. Due to the nature of the images produced by coronary CTA and DSA, each lends itself to different indications for use. Whilst coronary DSA provides imaging of all aspects of perfusion, CTA used with contrast agent also provides this however has the additional advantage of being able to assess structure and function of the heart. Coronary CTA has been shown to have a high accuracy at detection and exclusion of coronary artery stenoses (Achenbach Raggi, 2010). In a multicentre trial conducted by Miller et al. (2008), patients underwent coronary calcium scoring and CT angiography prior to conventional invasive coronary angiography. The diagnostic accuracy of coronary CTA at ruling out or detecting coronary stenoses of 50% was shown to have a sensitivity of 85% and a specificity of 90%. This showed that coronary CTA was particularly effective at ruling out non-significant stenoses. Additionally, coronary CTA was shown to be of equal efficacy as conventional coronary angiography at identifying the patients that subsequently went on to have revascularisation via percutaneous intervention. This was shown by an area under the curve (AUC), a measure of accuracy of 0.84 for coronary CTA and 0.82 for coronary angiography. Miller et al.’s (2008) study included a large number of patients at different study sites, and additionally represented a large variety of clinical patient characteristics. The author’s claim that these factors contribute to the strength and validity of the study findings, and suggest that in addition to using patients with clinical indications for anatomical coronary imaging, should be used as evidence that coronary CTA is accurate at identifying disease severity in coronary artery disease. Miller et al. (2008) did however,, find that positive predictive and negative predictive values of coronary CTA were 91% and 83% respectively and therefore suggested that coronary CTA should not be used in place of the more accurate conventional coronary angiography. A low positive predictive value (in relation to the prevalence of disease) was proposed to be due to a tendency to overestimate stenosis degree as well as the presence of artefacts leading to false positive interpretation (Achenbach Raggi, 2010). Other research providing comparison between coronary CTA and conventional coronary angiogram has highlighted variability in results. A meta-analysis conducted by Gorenoi, Schonermark and Hagen (2012) investigated the diagnostic capabilities of coronary CTA and invasive coronary angiography using intracoronary pressure measurement as the reference standard. The authors found that CT coronary angiography had a greater sensitivity than invasive coronary angiography (80% vs 67%), meaning that coronary CTA was more likely to identify functionally relevant coronary artery stenoses in patients. Despite this,, specificity of coronary CTA was 67%, compared to 75% in invasive coronary angiography, meaning that the technique was less effective at correctly excluding non-diagnoses than invasive coronary angiogram. This research appears to contradict the power of cardiac CTA at excluding diagnoses of coronary artery stenosis as suggested by Miller et al. (2008), he study did combine evidence from over 44 studies to provide their results and therefore had a large statistical power. The authors interpret the results in light of the clinical relevance of cardiac imaging, suggesting that patients with a higher pretest possibility of coronary heart disease will likely require invasive coronary angiography for revascularisation indicating that coronary CTA may be a helpful technique in those patients with an intermediate pre-test probability of coronary heart disease that will therefore not require invasive angiography. Goldberg et al. (1986) investigated the efficacy of DSA in comparison to conventional coronary angiography in 77 patients. They found that the two angiograms agreed within one grade of severity in 84% of single cases and 90% of multiple cases, identifying both patent and lesioned arteries. The results led the authors to conclude that there was no significant difference between the two methods and that DSA could be used in selective coronary angiography to find results comparable to that of conventional angiography. In addition to being a small study into the efficacy of DSA, the study also had several sources of inherent variability that should be considered when interpreting the results. These included differing sizes of digital imaging screen and non-use of calipers, meaning that the interpretation of the images could vary throughout the study. The authors also suggest that whilst showing strong support for the use of DSA in coronary artery disease, the technique may not actually p ermit better prognostic determinations or clinical judgements that are better than conventional angiography, and therefore the further implementation of the techniques may not be founded or necessitated. More recently, there has been further research looking at the effectiveness of DSA as a way of measuring coronary blood flow. Whilst motion artefacts have proven a problem in lots of past research (Marinus, Buis Benthem, 1990; Hangiandreou, 1990), recent research has developed methods to minimise these. Moilloi and colleaues (1996) showed that using a motion-immune dual-energy digital subtraction angiography, absolute volumetric coronary blood flow could be measured accurately and thus provide an indication of the severity of any arterial stenosis.This may provide further suggestion for clinical implementation of DSA. Although these studies provide evidence for the efficacy of cardiac DSA and CTA, they often make comparisons to conventional angiography. This is useful as a baseline comparison, however it is difficult to make comparisons between the two procedures directly due to less available evidence making direct comparisons. Lupon-Roses et al. (1985) conducted a study investigating both coronary CTA and venous DSA. The study looked at the efficacy of both techniques at diagnosing patency of coronary artery grafts compared to the control conventional angiography. CT was shown to diagnose 93% of the patent grafts and 67% of the occluded grafts whereas DSA correctly diagnosed 98% and 100% of patent and occluded grafts respectively. Interestingly, the DSA picked up the 11 grafts that were misdiagnosed by CTA and the CTA picked up the 2 grafts misdiagnosed by the DSA. This data may suggest that individually, DSA has a better profile for diagnosis of coronary artery occlusion, however if the two procedures are used in combination exclusion of patent arteries and diagnosis of occluded arteries would be effective (Lupon-Roses et al., 1985). Coronary DSA and CTA are both non-invasive procedures (unlike the conventional coronary angiography where a wire is placed in the coronary vasculature). With the only invasive part of the procedure being the injection of the contrast material into a vein. This presents a significant advantage to both procedures over that of conventional angiography, and may even permit investigation on an outpatient basis (Meaney et al., 1980). Similarly, both DSA and coronary CTA are favoured because of their intravenous approach, eliminating the risks of bleeding or arterial injury from an intra-arterial catheterization and being able to be used in those with limited arterial access. However, although the intravenous approach used in cardiac DSA makes it favourable, it does lead to difficulty with visualisation of the coronary arteries due to the overlying iodinated pulmonary and cardiac structures (Mancini Higgins, 1985). Therefore,, intra-arterial DSA is also sometimes used (Yamamoto et al., 200 9). As with all CT scanning, coronary CTA carries with it a dose of ionizing radiation (Brenner Hall, 2007). Studies have estimated that for diagnostic CT scanning, patients are on average exposed to 12mSv of radiation during the procedure, the equivalent of 600 x-rays (Hausleiter et al., 2009). Estimates of radiation doses associated with conventional coronary angiography are lower than that of coronary CTA at 7mSv (Einstein et al., 2007). Additionally, DSA technique reduces the radiation dose from that of conventional coronary angiography as the vessels are visualised more clearly (Yamamoto et al., 2008). The dangers of radiation exposure are increased risk of developing cancer, skin injuries and cateracts (Einstein et al., 2007). It is therefore important that the benefits of conducting the procedure greatly outweigh the risk of radiation exposure. CT calcium scanning provides a low radiation dose at around 1mSv (Hunold et al., 2003). Cardiac CT calcium scanning does not require administration of a contrast agent, unlike in coronary CTA and DSA that use iodine based contrast agents. The risks associated with contrast agent include nephrotoxicity and risks of hives, allergic reactions and anaphylaxis (Maddox, 2002). The amount of contrast agent used is partly dependent on the length of the procedure and how clearly the arteries can be visualised. For this reason, both cardiac CTA and DSA use less contrast agent that conventional coronary angiography (Brant-Zawadzki, et al., 1983). CT calcium scanning of the coronary arteries is therefore recommended in those with less likelihood of coronary artery disease (NICE, 2010). Both coronary CTA and DSA require interpretation by trained physicians, and the importance of training and achieving intra-rater reliability should not be underestimated (Pugliese et al., 2009). Conclusion Overall, both coronary CT and DSA have been demonstrated as effective procedures for the imaging of the coronary arteries in CAD (Achenbach Raggi, 2010; Miller et al., 2008; Moilloi et al., 1996; Goldberg et al., 1986). Whilst cardiac CT scanning does provide a wider range of clinical applications, allowing assessment of perfusion as well as cardiac structure and function (Achenbach Raggi, 2010), coronary DSA has many applications that allow assessment of coronary blood flow (Molloi et al., 1996; Katritsis et al, 1988; Booth, Nissen DeMaria, 1985; Guthaner, Wexler Bradley, 1985; Myerowitz, Swanson, Turnipseed, 198). Both cardiac DSA and CTA procedures have their advantages. As non-invasive procedures, these techniques pose less risk to patients, and enable the possibility of outpatient investigation, to be used to rule out diagnoses and to avoid inappropriate invasive coronary angiogram (Gorenori et al., 2012). Additionally, intravenous access is preferential to arterial cannulation for the contrast infusion, removing the risks associated with bleeding or intra-arterial injury. Cardiac DSA exposes the patient to a lower dose of radiation that coronary CTA (Hausleiter et al., 2009; Yamamoto et al., 2008; Einstein et al., 2007), which is beneficial at reducing the risk of genetic mutations and cancer. Cardiac CTA and DSA also have their common disadvantages. The use of contrast agent may present side effects for the patient including kidney damage and risk of allergic reactions and anaphylaxis (Maddox, 2002). For this reason, calcium CT scanning can be useful in patients that are not at high likelihood of coronary artery disease (NICE, 2010b). Additionally, both cardiac DSA and CTA are subject to motion artefacts from respiration and heart beats, which can cause difficulties with interpretation (Achenbach Raggi, 2010; Yamamoto et al., 2009). In the case of cardiac CTA, this excludes a subset of patients that are unable to follow commands and those who have high heart rates. Overall, cardiac CTA and cardiac DSA are effective, non-invasive imaging techniques for assessment of coronary artery disease. Whilst they are not the gold standards in cardiac monitoring, they can provide important diagnostic information without exposing patients to the risks of invasive angiography. Due to this, their use should be weighted against clinical need, the risks of the procedures, and the suitability of the patient. Interpretation of cardiac CTA and DSA imaging should be by trained individuals. References Achenbach, S., Raggi, P. (2010) Imaging of coronary atherosclerosis by computed tomography. European Heart Journal. 31:1442 Arad, Y., Spadaro, L. A., Goodman, K., Newstein, D., Guerci, A. D. (2000). Prediction of coronary events with electron beam computed tomography.Journal of the American College of Cardiology,  36(4), 1253-1260. Booth, D. C., Nissen, S., DeMaria, A. N. (1985). Assessment of the severity of valvular regurgitation by digital subtraction angiography compared to cineangiography.  American heart journal,  110(2), 409-416. Brenner  D. J., Hall  EJ.  Computed tomography: an increasing source of radiation exposure.  Ã‚  N Engl J Med.  2007;357(22):2277-2284 Budoff, M. J., McClelland, R. L., Nasir, K., Greenland, P., Kronmal, R. A., Kondos, G. T., Blumenthal, R. S. (2009). Cardiovascular events with absent or minimal coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA).  American heart journal,  158(4), 554-561. Bugiardini, R., Manfrini, O., Pizzi, C., Fontana, F., Morgagni, G. (2004). Endothelial function predicts future development of coronary artery disease a study of women with chest pain and normal coronary angiograms.Circulation,  109(21), 2518-2523. Burke, A. P., Virmani, R., Galis, Z., Haudenschild, C. C., Muller, J. E. (2003). Task force# 2- what is the pathologic basis for new atherosclerosis imaging techniques?.  Journal of the American College of Cardiology,41(11), 1874-1886. Einstein, A. J., Moser, K. W., Thompson, R. C., Cerqueira, M. D., Henzlova, M. J. (2007). Radiation dose to patients from cardiac diagnostic imaging.Circulation,  116(11), 1290-1305. Goldberg HL, Moses JW, Fisher J, Tamari I, Borer JS (1986). Diagnostic accuracy of coronary angiography utilizing computer-based digital subtraction methods; Comparison to conventional cineangiography. Chest 90, 793–797, Gorenoi, V., Schà ¶nermark, M. P., Hagen, A. (2012). CT coronary angiography vs. invasive coronary angiography in CHD.  GMS health technology assessment,  8,  Doc02-Doc02.. Guthaner, D. F., Wexler, L., Bradley, B. (1985). Digital subtraction angiography of coronary grafts: optimization of technique.  American journal of roentgenology,  145(6), 1185-1190. Hacker, M., Jakobs, T., Hack, N., Nikolaou, K., Becker, C., von Ziegler, F., Tiling, R. (2007). Sixty-four slice spiral CT angiography does not predict the functional relevance of coronary artery stenoses in patients with stable angina.  European journal of nuclear medicine and molecular imaging,34(1), 4-10. Hangiandreou N. J.  (1990) Coronary Blood Flow Measurement Using Digital Subtraction Angiography and First Pass Distribution Analysis. Madison, Wis: University of Wisconsin-Madison; Thesis. Hasegawa, B. (1987). Physics of Medical X-Ray Imaging 2nd Edition. Medical Physics Publishing Corporation. Hausleiter, J., Meyer, T., Hermann, F., Hadamitzky, M., Krebs, M., Gerber, T. C., Achenbach, S. (2009). Estimated radiation dose associated with cardiac CT angiography.  Jama,  301(5), 500-507. Herzig, R., BuÃ…â„¢val, S., KÃ…â„¢upka, B., Vlachov, I., Urbnek, K., MareÃ… ¡, J. (2004). Comparison of ultrasonography, CT angiography, and digital subtraction angiography in severe carotid stenoses.  European Journal of Neurology,  11(11), 774-781. Brant-Zawadzki, M., Gould, R., Norman, D., Newton, T. H., Lane, B. (1983). Digital subtraction cerebral angiography by intraarterial injection: comparison with conventional angiography.  American Journal of Roentgenology,  140(2), 347-353. Hoffmann, U., Brady, T.J., Muller, J. (2003). Cardiology patient page. Use of new imaging techniques to screen for coronary artery disease. Circulation 108 (8): e50–3. Hunold, P., Vogt, F. M., Schmermund, A., Debatin, J. F., Kerkhoff, G., Budde, T., Barkhausen, J. (2003). Radiation Exposure during Cardiac CT: Effective Doses at Multi–Detector Row CT and Electron-Beam CT 1.Radiology,  226(1), 145-152. Katritsis, D., Lythall, D.A., Cooper, I.C., Crowther, A., Webb-Peploe, M.M. (1988) Assessment, of coronary angioplasty: Comparison of visual assessment, hand†held caliper measurement and automated digital quantitation.  Catheterization and cardiovascular diagnosis,  15(4), 237-242. Kaufmann, P. A., Gnecchi-Ruscone, T., Schfers, K. P., Là ¼scher, T. F., Camici, P. G. (2000). Low density lipoprotein cholesterol and coronary microvascular dysfunction in hypercholesterolemia.  Journal of the American College of Cardiology,  36(1), 103-109. Liu, J. L. Y., Maniadakis, N., Gray, A., Rayner, M. (2002). The economic burden of coronary heart disease in the UK.  Heart,  88(6), 597-603. Lupà ³n-Rosà ©s, J., Domingo, E., Marinez-Vzquez, J. M., Là ³pez-Moreno, J. L., Montaà ±, J., Permanyer-Miralda, G., Soler-Soler, J. (1985). Direct non-invasive techniques for assessing coronary bypass graft patency.  The International Journal of Cardiac Imaging,  1(3), 181-188. Maddox, T. G. (2002). Adverse reactions to contrast material: recognition, prevention, and treatment.  American family physician,  66(7), 1229. Mancini, J. G. B., Higgins, C. B. (1985). Digital subtraction angiography: a review of cardiac applications.  Progress in cardiovascular diseases,  28(2), 111-141. Marinus, H., Buis, B., Van Benthem, A. (1990) Pulsatile coronary flow determination by digital angiography.  International Journal of Cardiac Imaging, 5, 173-182 McClure, K. H., McGivern, J. P., Stultz, M. R., Whitehurst, T. K. (2009).  U.S. Patent No. 7,481,759. Washington, DC: U.S. Patent and Trademark Office. Meaney, T. F., Weinstein, M. A., Buonocore, E., Pavlicek, W., Borkowski, G. P., Gallagher, J. H., Maclntyre, W. J. (1980, August). Digital subtraction angiography of the human cardiovascular system. In  Application of Optical Instrumentation in Medicine VIII  (pp. 272-278). International Society for Optics and Photonics. Miller, J. M., Rochitte, C. E., Dewey, M., Arbab-Zadeh, A., Niinuma, H., Gottlieb, I., Lima, J. A. (2008). Diagnostic performance of coronary angiography by 64-row CT.  New England Journal of Medicine,  359(22), 2324-2336. Molloi, S., Ersahin, A., Tang, J., Hicks, J., Leung, C. Y. (1996). Quantification of volumetric coronary blood flow with dual-energy digital subtraction angiography.  Circulation,  93(10), 1919-1927. Myerowitz, P. D. (1982). Digital subtraction angiography: present and future uses in cardiovascular diagnosis.  Clinical cardiology,  5(12), 623-629. Myerowitz, P. D., Swanson, D. K., Turnipseed, W. D. (1985). Applications of digital subtraction angiography in cardiovascular diagnosis.  The Surgical clinics of North America,  65(3), 423-437. National Institute for Health and Care Excellence. (2010a). Unstable angina and NSTEMI: The early management of unstable angina and non-ST-segment-elevation myocardial infarction. CG94. London: National Institute for Health and Care Excellence. National Institute for Health and Care Excellence. (2010b). Unstable angina and NSTEMI: Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. CG95. London: National Institute for Health and Care Excellence. Pugliese, F., Hunink, M. M., Gruszczynska, K., Alberghina, F., Malagà ³, R., van Pelt, N., Krestin, G. P. (2009). Learning curve for coronary CT angiography: what constitutes sufficient training?.  Radiology,  251(2), 359. Yamamoto, M., Okura, Y., Ishihara, M., Kagemoto, M., Harada, K., Ishida, T. (2009). Development of digital subtraction angiography for coronary artery.  Journal of digital imaging,  22(3), 319-325.

Introduction of My Firm Essay Example | Topics and Well Written Essays - 500 words

Introduction of My Firm - Essay Example timation of property value in comparison with other properties), guide the seller or buyer through the process, necessary paperwork preparation for ‘Sale by Owner’ sellers, appraisal of real estate, exchanging property, property auctioning, leases and contracts preparation and consultancy. Under supply will mean lower prices. As a recent example, negotiators saw fast appreciation as well as a frenzied response by the consumers within the real estate market in US from year 2002 to 2005. The response had been caused by the reason that real estate demand happened to be at all time high at the same time as supply was limited. This demand and supply lead to rapid appreciation, where sellers of homes received multiple offers in a matter of days or even hours (ALTOS, 2014). There was a time within the same period when Southern California homes sold at 18% on average above listed price, the outcome of this market condition within which demand outstripped supply. In July 2014, there were just more than 1,400,000 residential properties within the market which is low. In 2013 houses for sale inventory raised and it is now increasing slightly throughout the country. ALTOS estimates that in 2015 supply will rise by 10% or about 1,600,000 active for sale properties will be availabl e in the market as at July 2015. That means that prices for properties will go down with time (ALTOS, 2014). In 2010, the required time for sale was t peak indicating high demand hence prices changed significantly. In 2012 and 2013 when there was high demand, only few properties required price reductions. Property crises throughout the United States are poised for a 5th consecutive year for recovery (ALTOS, 2014). There is still low supply while demand remains healthy due to expanding economy as well as other factors. Both demand and supply conditions are moving to healthy conditions, from extreme bullish conditions (ALTOS, 2014). A significant trait of demand curve happens to be the sensitivity

Film Analysis Essay Example | Topics and Well Written Essays - 1000 words - 5

Film Analysis - Essay Example This is because, from the film, the freedom aspects of people living in the slum environment and communities raise the planning concerns in the movie. The freedom that is experienced in the slum regions is not something to be happy of, due to dense population; this is because it makes the population to be close physically (Linklater & Kim, 64). The densely populated areas in the urban setting make the development process of such regions to be minimal; this has an amicable influence on the development process. The issues behind planning in Before Sunset shows the stance of the public; where individual interest is the main agenda. The planning politics finds its roots with the water related issues and the welfare of the people around the site. The United States environment fits will the desires of the citizens. Analysis of Before Sunset involves the rapid integration of both speed and time. The shape of the city is prescribed in such a way that people and pedestrians can freely move from one location to the other and choose the location where the want to live and work. The building and the firm also move freely within the city and likewise they chose where to localize. From the film, it is evident that there are two bodies that utilized the land. The residence and the businesses. The land belonged to the property owners who rented them to highest bidders. From the film, it is evident that one of the challenges that the city faces is the open space. Cities need to consider in improving the current open spaces by adding to the open space amount. In the film majority of the city was densely populated where the green space ration and the center resident were favorable. Therefore, it is crucial to understand that while the challenge of open space need to be handled at individual level, cities need to consider this in their planning at the scale of metropolitan cities. The two elements of time

European Convention on Human Rights

European Convention on Human Rights The European Convention on Human Rights and the supreme court in matters relating to its jurisdiction, the European Court of Human Rights, are no longer a matter of external control, following their incorporation into domestic law via the Human Rights Act 1998.   The European Convention on Human Rights provides that the judgement of ECHR shall be final and that parties to it will abide by the Court’s decisions.   The institution resides in Strasbourg and is responsible for all matters relating to the interpretation and application of the Convention.   In relation to the ‘necessary in a democratic society’ provision, five of the Convention’s Articles specify the phrase in their text, although it is assumed that the Convention as a whole upholds its importance.   This essay examines the European Court of Human Rights (hereinafter ECHR) and its interpretation, and relative importance, of the phrase, ‘necessary in a democratic society’ in r elation to the Convention.   Due to limitations in word count, the contents of this essay are not exhaustive. The inception of communications has seemingly created an increase in challenges relating to Article 8 of the Convention.   In Malone v UK, the ECHR found a breach of Article 8 of the Convention, relating to the right of privacy.   More specifically, it was found that telephone tapping by the police and authorised by the UK Government and condoned by the High Court was in breach of right to privacy, contained in Article 8 of the Convention.   This Article provides: There shall be no interference by a public authority with the exercise of this right except such as is accordance with the law and is necessary in a democratic society in the interests of national security. It was held by the ECHR that tapping was against the Convention because it was not in accordance with law but governed by an unregulated decision.   The reason why it could not be necessary in a democratic society was that there were no constitutional safeguards against misuse of the power.   The Court concluded that the law was unclear and stated that, ‘the minimum degree of legal protection to which citizens are entitled under the rule of law in a democratic society is lacking.’ This case thus initiated new Government legislation to control telephone tapping by the police.   The legislation comes in way of the Interception of Communications Act 1985 which limits telephone tapping to cases where the Home Secretary has issued a warrant and, to safeguard against arbitrary use, the warrant can only be issued in three distinct circumstances, one being serious crime.   Furthermore, a tribunal and Commissioner will review how the Home Secretary has exercised his power s on an annual basis.   The main findings of this case were reiterated in Kruslin v France and Huvig v France, where it was decided that there were insufficient safeguards in the law and that, accordingly, the Convention was violated. A very different approach was reached by the court in Klass v Federal Republic of Germany. In that case, German legislation was challenged for authorising the inception of mail and telecommunications.   It was held that, whilst the right to privacy was infringed, the inceptions were justified due to the ‘necessary in a democratic society’ provision, contained in paragraph 2.   It was said that surveillance of citizens was legitimate to the extent that it was ‘safeguarding the democratic institutions’ of the State.   As there were no adequate guarantees against abuse, Article 8 was not violated.   It can be observed from these cases that their relationship to Article 8 of the Convention is markedly similar, yet, they have been decided differently.   The cases symbolise the importance of the phrase relating to the necessity of a democratic society but show how, according to its own discretion, the court can manipulate the case one of two ways:   ei ther by stating the importance of a democratic society in safeguarding the State and thus authorising the surveillance of citizens, or; offering protection to the same citizens because this is what is needed in a democratic society.   It seems that the cases were decided upon according to the likelihood of relative threat, as the Convention states, ‘in the interest of national security, public safety or the economic well being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.’ Article 10 of the Convention provides for the right to freedom of expression.   These freedoms are subject to ‘formalities, conditions, restrictions and penalties, as are prescribed by law and necessary in a democratic society.’   At this point, it is perhaps worthwhile to note that the ECHR applies what is known as the margin of appreciation, so that Member States have a measure of national discretion in the way they give effect to general standards set out in the Convention.   An example is the ECHR’s decision in favour of the United Kingdom’s decision to ban the film, Visions of Ecstasy, under its blasphemy law, in spite of the Director’s claim that it violated his right to freedom of speech. The Court ruled by seven votes to two that the refusal of the Director’s claim was justified under Article 10(2) as being necessary in a democratic society.   The Board of Film Classification believed that the film would infringe the criminal l aw of blasphemy.   It was stated however that although the law of blasphemy did not treat all religions equally, it did not detract from the legitimacy of the Director’s aim, and it was consistent with the aims of Article 9 of the Convention.   The Court ruled that while the law of blasphemy was invoked rarely, there was not sufficient consensus with Member States to conclude that the blasphemy legislation was ‘unnecessary in a democratic society and incompatible with the Convention.’   The restriction was justified on the basis of excessive interference to Christians, which could amount to blasphemy. The United Kingdom’s record in relation to cases taken against it in the ECHR is not promising.   In 2000, the United Kingdom came second to Turkey in this vein. These decisions are extremely important because they are now binding precedents in the law of the United Kingdom.   Although the case of Wingrove may have pleased the United Kingdom with the imposition of the margin of appreciation, there have been a number of controversial cases in which the decisions have gone against it.   One example was the decision that the rights of suspected IRA terrorists had been violated by their summary execution in Gibralter.   It follows that the ‘necessary in a democratic society’ provision, is capable of being argued either way.

Big Fish Film Study Creative Assignment

Creative Writing Assignment 1. At the end of the film Will reconciles with his dying father. Write the eulogy that Will delivers at his father's funeral. Consider what Will would say about what kind of father Ed was, what kind of man he was, what lessons he taught, or the type of man Will strives to be. Losing a loved one is one of the most difficult things we can go through, so much more is it is a parent. No words can express what I am feeling right now and I’m sure that in time I will be able to accept the facts.My father was one of those creative and story telling types. His creative sorties were the truth in our house. I used to love listening to the invogorating sroties he would tell me every night before bed. He would tell me that everything he said he did was true and not to let anyone tell me otherwise. As I grew older, I slowly drifted apart from him, not caring about the nonsense he called his life. I soon learned that the most important thing that i had was my fami ly, weather we included him in it or not he would always be my dad.Though he may never have said it out loud but I believe he told these stories to be remembered. I am the person i am today because of eveything his legends taught me. As most of you may know my father always had something to say. I remember when we were little and my father was gone on business quite often, at that point in time is when we got totally separated that we could barely carry on a conversation as friends let alone family. About 3 months ago when my father got very ill and my wife and i came to stay with my parents we grew much closer again.He told me stories i had heard many times befoare and ones i had not yet heard. I discovered that the purpose of these legends is to be passed on throughout the generations, to be remembered adn to teach us a little something about life and ourselves. He showed strength until the end and still had some enlightening words for us. I promise that I will continue what my fa ther has started, and i will tell adventerous stories whenever i can. I know I’ll be filling huge shoes but I think I can do it.Let’s just remember everything that my father shared with us. And let’s be happy that he has finally in a better place. Critical Responses 1. â€Å"You are a big fish in a small pond, but this here is the ocean† –old Edward Bloom I believe that in this quote the fish represents Sandra, Ed’s wife. When Edward is in Spectre and he sees a naked woman where Jenny sees a fish. I also think that the fish is not real but a metaphor; it is whatever you want the most, and at the time Edward was looking for Sandra. 2. â€Å"And that was the lesson I learned that day†¦ he day my son was born. Sometimes the only way to catch an uncatchable woman, is to offer her a wedding ring. † –Edward Bloom In this text the fish represents Sandra as well because everyone says that the fish is uncatchable, which is true bec ause it isn’t real. Sandra was the uncatchable fish at one point because at first Edward didn’t know who she was and when he finally found her and she was engaged. When Edward offered Sandra a wedding ring that is where we see him actually catching the fish because she is now catchable.

Elderly Drivers Informational Essay

Informational Essay Currently there is an extremely important issue that the public should understand more about due to its enormous impact on many citizens. This issue pertains to the safety concern surrounding the elderly while operating a motor vehicle past the age of 70 years old. This debate whether old people should be allowed to drive is often brought up by younger drivers, the reality is that all able bodied people who are physically and mentally healthy should be able to drive but as we grow older it is inevitable that our health will decrease.There are many different arguments on this subject and seems to be a widely spoken debate amongst road users regarding each of their opinions on the possible changes to be made addressing this concern. We can examine the argument by first generally summarizing each side of the argument and their position with supporting evidence of each sides common claims. One of the most common claims made by advocates for the elderly drivers are as following even though the initial licensing procedures vary greatly in the United States.However, those who tend to favor the allowance of elderly citizens to drive on their own, likely believe it is an insult to senior citizens ability to drive and do not support the newly suggested regulations in order for any citizen over the age of 70 to be considered for their license renewal. Most states generally allow license renewal if there are no suspensions on the driver’s license and may require appearing in person. Aside from the general requirements previously stated there are two aspects of the license renewal process that seem to vary substantially among states.Which are the length of time between renewals as well as some additional requirements that may possibly be imposed on older motor vehicle operators. Such legal requirements currently exist in 28 states as well as the District of Columbia who, specifically states that an applicant shall not be required to retake the wri tten exam or road test based solely on advanced age. This regulation is imperative in exemplifying current licensing laws in the other states and their positions held regarding this matter. Some of the more southern states even allow certain privileges or rewards for elderly drivers.For instance, in both Oklahoma and Tennessee, the license renewal fees are reduced for drivers that are 60 years of age or older. Tennessee in particular also permits current drivers past the age of 65 and over to retain a driver’s license which will be indefinitely valid without an expiration date. The laws created by these states contribute to the increase in older drivers and supports their rights. The ability to drive represents a freedom and independence from relying on anyone else, and allows us to feel self-sufficient and capable.It is the belief of many that older drivers should be allowed to drive without any verification of his/her competency and that the elderly should be able to operat e a vehicle independently at their own discretion on the road and renew their driver’s license, without first screening for safety requirements. A survey conducted on www. surveycentral. org, showed a 76. 5% majority of those surveyed in a research study voted that older people should be able to drive if they can pass a driving test.The parties who wish to not enforce further driving laws pertaining to elderly people also believe that a loss of mobility to an elderly person tends to diminish their sense of independence and self-confidence leaving them feeling stranded or alone and ultimately leads to a decrease in the overall quality of life. The author Liisa Hakamies-Blomqvist in her essay â€Å"Older Road Users† supports this position with statistical evidence and research when she reports the following statement: â€Å"Older drivers do not have a higher accident risk than others.They do however have a higher risk of being injured or killed in accidents because of w ith their age there is increasing physical frailty†( Hakamies-Blomqvist, 1997). The license renewal of the elder drivers may pose a problem among older citizens who will soon be approaching this age of evaluation, that are not likely to be cohesive with this proposal for various reasons. The fact that they are soon approaching this period in their life as they are getting older, and certain rights are undoubtedly being taken away from them with mandatory evaluations/examinations can be seen as a human rights issues.However, the main concern held in this matter lies in the safety and well-being of all vehicles including passengers and drivers. According to a recent study by Carnegie Mellon University in Pittsburgh and the AAA Foundation for Traffic Safety, based on data from 1999-2004 displays statistics to support the claim that laws should be enforced and can be seen in the following surprising fatality rates for drivers: â€Å"Which begin to climb after age 65, and from age s 75 to 84, the rate of about three deaths per 100 million miles driven is equal to the death rate of teenage drivers.Even worse for drivers 85 and older, the fatality rate skyrockets to nearly four times higher than that for teens† (AAA Foundation for Traffic Safety, 2004). Various statistics show similar results when comparing fatalities and crash rates involving elderly drivers and is a concern for many people. This concern is exemplified by the following statement by Barbara Harsha, executive director of the Governors Highway Safety Association. It's a huge problem, and we really don't have any solutions to it yet,† â€Å"We need to keep moving on it and try to find solutions as quickly as possible†(Harsha, 2004). This is a continuing problem and will only increase in severity as the boom of newly aged senior citizens grows rapidly, and will inevitably be driving on the road with us. This seems like an issue we should be addressing as citizens, however we have n’t been able to come up with any compromise or solution to resolve this problem as of yet.As far as seeing a visible improvement in statistics from any changes made in this effort seem that the only measure scientifically proven to lower the rate of fatal motor vehicle accidents involving elderly drivers is to require the seniors to appear at motor vehicle departments in person to renew their licenses. Research demonstrates that senior citizens who drive are involved in more fatal car accidents than any other driving age group. However, while senior drivers do pose a risk, losing the right to drive may also possibly lead to isolation or depression.Even though many states have implemented various restrictions on senior drivers in an attempt to fix the problem, there have been no successful results overall regarding this issue and so far all attempts seem to be inadequate to fully address the issue and resolve this situation. Therefore, the current challenge that seems to be f acing the community regarding transportation safety is how to provide the elderly with the easy mobility that they are used to having, while at the same time focusing on safety as a main priority.