Tuesday, October 29, 2019

Financial Planning Essay Example | Topics and Well Written Essays - 2000 words - 1

Financial Planning - Essay Example The role of three companies, like Colonial First State Investments Limited and Professional Investment Services Pty Ltd related to provide financial planning services has been sorted out in the assigned study. The of Financial planning in Australia begun in the years 80s, as during those years there were no Financial Planners as they were not existing then. This occurred due to the fact that as there was no prerequisites for the clients within the Marketplace to enable them get efficient financial advice. It was only network of insurance that existed during that period under review. The Financial Planning Association of Australia (FPA) is the peak professional body for Australia's financial planners, representing approximately 12,000 individuals and businesses (The Financial Planning Association of Australia (FPA). However, (Cowen, Blair, Taylor, 2006, p 4) reveals that "In the early 1980s, a leading Australian financial planning industry stalwart Gwen Fletcher visited the United States intent on pursuing discussions with the U.S. industry association, the International Association for Financial Planning (IAFP). These discussions related to the creation of either a new industry body for A ustralia or the establishment of an affiliated chapter of the IAFP. At a later meeting of dealers conducted by the Department of Corporate Affairs (the then-regulatory body issuing licenses to dealers of securities), the affiliation model was proposed but rejected. However, a new industry body consisting of an elite group of independent advisors was formed, the Association of Independent Professional Advisors (AIPA). It is important to note that this group excluded all banks and insurance companies from membership". Additionally, following the International Conference of IAFP held in Australia in the years 1982 and 1984 respectively, Australian IAFP was officially launched. (Cowen, Blair, Taylor, 2006, p 4) states that after the launching, "The IAFP in Australia was to be an open forum for individuals, dealers and fund managers alike. Following U.S. IAFP requirements, the newly formed Australian association sought and was granted a license for the CFP designation and subsequently established the Diploma of Financial Planning (DFP) course. This necessitated strong collaboration between the United States and Australian bodies with the College of Financial Planning in the United States providing much of the DFP educational materials and resources. The US IAFP oversaw and closely monitored the development of educational standards to ensure that the Australian DFP met the educational requirements for the CFP designation. This involved an ongoing process of quality assurance by the U.S. body". It is e stimated that there are about 5,500 financial planning practices in

Sunday, October 27, 2019

Automatic Quantification of the Myocardial Extracellular

Automatic Quantification of the Myocardial Extracellular Automatic Quantification of the Myocardial Extracellular Volume by  Cardiac Computed Tomography: Synthetic ECV by CCT Thomas A Treibel, MBBS1,2, Marianna Fontana, PhD,1,2, Jennifer A Steeden PhD2,3, Arthur Nasis, MD1, Jason Yeung, MBBS4, Steven K White, BSc, MBChB1,2, Sri Sivarajan4, Shonit Punwani, PhD4, Francesca Pugliese, PhD1, Stuart A Taylor, MD4, James C Moon, MD1,2, Steve Bandula, PhD4 1Barts Heart Centre, St Bartholomews Hospital, London, UK. 2Institute of Cardiovascular Science, University College London, London, UK. 3UCL Centre for Medical Image Computing, Department of Medical Physics, London, UK. 4Centre for Medical Imaging, University College London, London, UK. Manuscript Type: Original Manuscript Manuscript: 3924 words (all including) No conflict of interest declared. Funding: TAT and SB are supported by Doctoral Research Fellowships from the NIHR, UK (NIHR ­DRF ­ 2013-06-102 / NIHR ­DRF ­ 2011 ­04 ­008). MF and SKW are supported by Clinical Research Training Fellowships from the British Heart Foundation (grants FS/12/ 56/29723 and FS/10/72/28568). JCM is directly and indirectly supported by the University College London Hospitals NIHR Biomedical Research Centre and Biomedical Research Unit at Barts Hospital, respectively. FP: this work form part of the translational portfolio of the Cardiovascular Biomedical Research Unit at Barts, which is supported and funded by the NIHR. SAT is an NIHR senior investigator. This work was undertaken at University College London Hospital, which received a proportion of funding from the UK Department of Health National Institute for Health Research Biomedical Research Centres funding scheme. ABSTRACT [TT1] Background: The quantification of myocardial extracellular volume fraction (ECV) by Cardiac Computed Tomography (CCT) can identify changes in the extracellular space due to fibrosis or infiltration. Current methodologies require laboratory blood hematocrit (Hct) measurement which complicates the technique.   The attenuation of blood (HUblood) is known to change with anemia. We hypothesized that the relationship between Hct and HUblood could be calibrated to rapidly generate a synthetic ECV without the need to formally measure Hct. Methods: This retrospective study received institutional review board approval. The association between Hct and HUblood was derived from forty non-contrast thoracic CT scans using regression analysis. Synthetic Hct was then used to calculate synthetic ECV, and in turn compared with ECV using blood Hct in a validation cohort with mild interstitial expansion due to fibrosis (aortic stenosis, n=28, ECVCT = 28 ±4%) and severe interstitial expansion due to amyloidosis (n=27; ECVCT = 54 ±11%, psynthetic ECV was correlated with collagen volume fraction (CVF) in a separate cohort with aortic stenosis (n=18). All CT scans were performed at 120kV and 160 mAs. Results: HUblood was a good predictor of Hct (R2=0.47; p), with the regression model (Hct = [0.51 * HUblood] + 17.4) describing the association. Synthetic ECV correlated well with conventional ECV (R2=0.96; p with minimal bias and 2SD difference of 5.7%. Synthetic ECV correlated as well as conventional ECV with histological CVF (both R2=0.50, p). Finally, we implemented an automatic ECV plug-in for offline analysis. Conclusion: Synthetic ECV by CCT provides instantaneous quantification of the myocardial extracellular space without the need for blood sampling. KEYWORDS: Computed tomography; Myocardial tissue characterization; Extracellular matrix; Myocardial extracellular volume fraction; Myocardial fibrosis; cardiac amyloidosis. LIST OF ABBREVIATIONS AL amyloidosis = Immunoglobulin light-chain amyloidosis AS = Aortic stenosis CCT = Cardiac computed tomography CMR = Cardiovascular magnetic resonance CVF = Collagen volume fraction ECV = Extracellular volume fraction HU = Hounsfield units INTRODUCTION Extracellular volume fraction (ECV) quantification by cardiac computed tomography (CCT) 1-5 and cardiovascular magnetic resonance (CMR) 6, 7 is a promising new imaging biomarker for interstitial expansion due to myocardial fibrosis and cardiac amyloid deposition. Emerging data suggests ECV predicts outcome as well as left ventricular ejection fraction 8, 9 and there is increasing interest in targeting the interstitium during the development of heart failure therapy.10 Current methodologies for ECV quantification require blood hematocrit (Hct) measurement, which adds a layer of complexity and is potentially a barrier to easy clinical implementation. Alternatively, for CMR, Treibel et al. recently proposed a synthetic ECV technique, removing the need for Hct measurement by utilizing the relationship between relaxivity of blood and lab measured Hct.11 It is unknown if a similar approach can be used for CCT, although a relationship between anemia and unenhanced blood attenuation has been observed.12-17 For example the aortic ring sign and dense intra-ventricular septum on unenhanced thoracic CTs suggest underlying anemia.17-19 We hypothesized that the relationship between Hct and unenhanced blood attenuation (HUblood) could be used to estimate a synthetic Hct, permitting immediate synthetic ECV calculation without blood sampling. We used existing patient cohorts1, 4 to investigate how synthetic ECV (a) compares to conventional ECV, and (b) correlates with the reference standard collagen volume fraction. We also tested implementation of an automated synthetic ECV measurement plug-in within the open-source DICOM viewer OsiriX.20 MATERIAL AND METHODS This study is a retrospective analysis of prospectively acquired data, received local ethical approval and conformed to the principles of the Helsinki Declaration. The study received no industry support.   All participants provided informed and written consent. Exclusion criteria were uncontrolled arrhythmia or impaired renal function (estimated glomerular filtration rate ECV CCT Protocols. The CCT protocol consisted of three steps: first, a low dose non-contrast scan to obtain baseline attenuations; second, contrast administration with a contrast-enhanced 1-minute acquisition and a 5 minute delay to allow blood to myocardial contrast equilibration; third, a repeat scan to re-measure blood and myocardial attenuations. CCT examinations were performed on a 64-detector row CT scanner (Somatom Sensation 64; Siemens Medical Solutions, Germany).1, 4 A topogram was used to plan CT volumes from the level of the aortic valve to the inferior aspect of the heart, typically a 10 cm slab. Cardiac scans (tube voltage, 120 kV; tube current-time product, 160 mAs; section collimation, 64 detector rows, 1.2-mm section thickness; gantry rotation time, 330 msec) were acquired with prospective gating (65%-75% of R-R interval), and reconstructed into 3-mm-thick axial sections with a B20f kernel. All pre- and post contrast acquisitions were performed and reconstructed with the same parameters and matched the level of the pre-contrast scan. The iodinated contrast material used was iohexol (Omnipaque 300; Nycomed Amersham, Oslo, Norway; 300 mg of iodine per milliliter) at a standard dose of 1mL/kg and injection rate of 3ml/sec without a saline chaser. Image Analysis. CCT image analysis was performed using a free and open-source Digital Imaging and Communications in Medicine viewer (OsiriX v4.1.2; Pixmeo, Bernex, Switzerland) independently by two experienced readers blinded to all other study data. For Hct estimation, regions of interest (ROIs) were placed in in a single axial slice in the center of the right atrium. The mean area of these ROIs were 4.8 ±1.2cm2. ROIs were drawn in the myocardial left ventricular septum and blood pool in the contrast-enhanced 1-minute acquisition in axial sections and propagated to the pre-contrast and post contrast acquisitions. Myocardial and blood attenuation values (pre-and post contrast only) were used to calculate the ECV fraction from the ratio of the change in blood and myocardial attenuation (ΆHU) corrected by the blood volume of distribution (1 Hematocrit): ECV   =   (1 Hematocrit) x (ΆHUtissue / ΆHUblood) Synthetic Hematocrit and ECV Methodology 1. Derivation of synthetic Hematocrit To derive a regression model predicting hematocrit from pre-contrast HUblood, clinical unenhanced CT scans of the thorax were retrospectively analyzed (120 kV; reconstructed at 5mm slice thickness and B70F soft tissue kernel). These were consecutive clinical CT scans of the thorax for investigation of malignancy, fibrosis or infection. Datasets were included if the patients had a contemporaneous paired laboratory measured Hct (within 20 days, median 8 days). HUblood was analyzed in a single axial slice through the center of the right atrium. This was chosen to minimize beam-hardening artifact from the spine (compared to aortic blood pool) and partial voluming of papillary muscles in the left or right ventricular blood pool. Synthetic Hct was obtained from the equation describing the linear regression line between laboratory HUblood and Hct. 2. Creation of a synthetic ECV Equation Blood hematocrit was substituted by the derived synthetic Hct to derive a synthetic ECV: Synthetic ECV   =   (1 synthetic Hct) x (ΆHUtissue / ΆHUblood) 3. Validation of synthetic ECV For validation, we used existing patient cohorts to investigate how synthetic ECV (a) compares to conventional ECV with laboratory blood hematocrit,4 and (b) correlates with the reference standard collagen volume fraction.1 3a. Clinical Validation Cohort In order to test synthetic ECV across a range of ECV values, the cohort used by our group to validate ECV by CT in amyloidosis was chosen; this comprised of two sub-groups with differing degrees of extracellular volume expansion: I. patients with cardiac amyloidosis (typically high ECV), comprising of 26 patients with systemic amyloidosis (21 males, age 55 ±10 years; 18 with transthyretin amyloidosis; 8 with systemic AL amyloidosis) with varying degrees of cardiac involvement; II. A comparator group of 27 age- and sex-matched patients with severe aortic stenosis (19 male, age 68 ±8 years) who typically exhibit only mild ECV elevation. Scans were performed between January and December 2013. In the clinical cohort, contrast administration was performed using a bolus only approach with a 1 mL/kg bolus of iohexol and post-contrast imaging at 1 minute (for segmentation) and 5 minutes (for post contrast analysis), as validated by our group previously.4 3b. Histological Validation Cohort For histological validation, the performance of synthetic ECV against a histological measure of fibrosis, the collagen volume fraction (CVF), was tested in a second smaller cohort of patients with severe AS, who underwent intra-operative biopsy (no overlap with clinical cohort). This cohort had been used by our group to validate ECV by CT again histology:1 Consenting severe AS patients (n = 17, median age 71 ±10 years, 76% male) underwent CCT between July 2010 and February 2012. Biopsies were obtained and stained with picrosirius red for histological measurement of collagen volume fraction (CVF) as previously described.21 In the histology cohort, contrast administration followed primed iodinated contrast material infusion (bolus plus maintenance infusion) with a 1 mL/kg bolus of iohexol followed by a maintenance infusion of at a rate of 1.88 mL/kg per hour for 25 minutes, when the post contrast imaging was performed.1 4. OsiriX Plugin To facilitate offline analysis and to exemplify future inline automation by scanner manufacturers, an automatic synthetic ECV plug-in was developed for OsiriX. Statistical analysis Analyses were performed using SPSS (Chicago, IL, USA, version 22). All data are presented as mean  ± SD. Normal distribution was assessed by using the Kolmogorov-Smirnov test. Differences were assessed using unpaired, two-sided student t-tests (significance level p). Agreement between conventional and synthetic ECV was analyzed using the Bland-Altman method. The significance of the difference between two correlation coefficients was tested using the Fisher r-to-z transformation. RESULTS[TT2] Step 1. Derivation cohort 40 thoracic CT scans with contemporaneous Hct samples within 20 days (mean 8 ±7 days) of the scan were included (n=40, 53% male, age 60 ±20 years) with a broad range of Hct (mean 38.2 ±6.0%; range 24.7-50.7%) and HUblood (mean 40 ±8; range 20-55). The linear regression equation was:   (sHct = [0.51 * HUblood] + 17.4) with R2=0.47 p (Figure 1). Step 2. Creation of the synthetic ECV Equation Blood hematocrit was substituted by the derived synthetic Hct to derive a synthetic ECV: Synthetic ECV   =   (1 ([0.51 * HUblood] + 17.4)x (ΆHUtissue / ΆHUblood) Step 3. Validation Step 3a. Clinical cohort Baseline characteristics of twenty-six systemic amyloidosis and twenty-seven AS patients are shown in Table 1.In this cohort, Hct were mean 41.4 ±3.8% (range 29.3-47.4%) and HUblood mean 40.2 ±3.9 (range 29.3-50.1). Synthetic ECV, calculated using the regression model to derive HCT,and conventional ECV were highly correlated (R2=0.96; p) with a 5.7% SD of differences and minimal bias (2.4%) on Bland-Altman analysis (Figure 2). ECVCT was significantly higher in amyloid patients with definitive cardiac involvement than aortic stenosis (54 ±11% versus 28 ±4%, p Step 3b. Histology cohort Baseline characteristics of the histology cohort are described in Table 2.The mean histological CVF of the 17 biopsies was 18  ± 8% (range 5% to 40%), Hct were 40.2 ±4.6% (range 29.4-46.4%) and HUblood 37.7 ±4.2 (range 29.5-45.1). Synthetic and conventional ECV both correlated well with collagen volume fraction (R2 = 0.50, p vs. R2 = 0.50, p ; Figure 3) and did not differ statistically on Fisher r-to-z transformation (p = 0.8). Step 4. Automatic synthetic ECV plug-in in OsiriX Example output of the OsiriX plugin are shown in Figure 4, and the code is provided in the supplementary data. This plugin involves three simple steps: I. Manual segmentation of the blood pool in the pre- and post-contrast images; II. The plug-in automatically estimates blood hematocrit using the attenuation relationship defined above; III. The plug-in produces a three-dimensional myocardial ECV volume, where each image voxel represents an ECV value. Reproducibility Inter- and intra-observer agreement was excellent for myocardial (ICC = 0.92 and ICC = 0.94, respectively) and blood pool (ICC = 0.96 and ICC = 0.99, respectively) attenuation measurements. Similarly for ECV, excellent agreement was found (ICC = 0.95 and ICC = 0.98, respectively). Repeat sampling variability was tested in 44 patients who underwent two samples a median of 4 hours apart. Test:retest variability of laboratory hematocrit was higher than expected (n=44, variability 10% with hct:hct R2=0.86.11 DISCUSSION Identifying interstitial heart disease is important for diagnosis and prognosis,10 and myocardial extracellular volume fraction (ECV) can be measured non-invasively by CCT.1-4 However, its measurement is complicated by the necessity for venous blood sampling, image analysis and then offline ECV calculation. This process is cumbersome and a major obstacle for implementing this technique into routine clinical practice. In this manuscript, we simplify the technique by calculating ECV without blood hematocrit. This development arose out of a need to simplify ECV measurement to make it more clinically applicable. We utilize the relationship between hematocrit and blood attenuation (the attenuation of blood decreases with anemia)12-14, 17-19 to derive a synthetic hematocrit for immediate synthetic ECV calculation without blood sampling. We show that synthetic ECV was highly correlated to conventional ECV, and had a similar association to the histologic reference standard of CVF. The implementation of an offline automated processing tool provides a significant aid to workflow, allowing for ECV measurement in routine clinical practice.   Automated synthetic ECV can be implemented inline on CT scanners with test performances approaching that of conventional ECV measurement. ECV quantification by CT, despite it lower signal to noise ratio, has key advantage over CMR: The CT approach is cheaper and widely available, can be completed in 5 minutes, and the scanner design can accommodate patients with obesity and claustrophobia (CMR is not suitable in around 10% of patients due to claustrophobia or many cardiac pacemakers).22 Furthermore, ECV by CCT can provide high-resolution 3D ECV volumes with whole heart acquisition and limited cardiac motion. Finally, the concentration of iodine has a linear relationship with th e CT attenuation value, which is not affected by fast exchange mechanism like CMR T1 mapping (depending on cell size and contrast dose, fast transcytolemmal water-exchange may reach its limits), which do not apply to CT.23, 24 ECV (by CMR or CT) allows quantification of a key pathophysiological pathway in heart failure: interstitial expansion due to diffuse myocardial fibrosis (or in rare cases by deposition of amyloid fibrils).1-4 As the CMR field is showing, ECV is diagnostic in certain diseases, tracks myocardial remodelling and predicts outcome.25, 26 Interstitial expansion can be global (hypertension, aortic stenosis) or focal (hypertrophic or dilated cardiomyopathy), therefore high spatial resolution and whole heart coverage is important. Due to the aforementioned advantages of CT over CMR, ECV by CT will undoubtedly receive greater attention as part of comprehensive assessment of the heart by CT coronary angiography, perfusion and myocardial tissue characterization. Limitations[TT3] The study has limitations. In the derivation cohort, the mean interval between Hct samples and CT 8 days. Normal within-subject variation in Hct between 1 day and 1-2 months in a healthy adult is actually very low (3%), but together with an analytical variation (3%) this may explain a relative change of >10% between two successive Hct values.27 The control cohort used in this study comprised of patients with AS rather then healthy volunteers, but, given the exposure to ionizing radiation and contrast, patients with AS were deemed as adequate control cohort, avoiding exposure of healthy volunteers. For the same reasons, variability of repeat synthetic ECV was not tested. Development and validation were performed using a single scanner platform, therefore this regression model is only valid for 120 kV and an X-ray tube used in a specific CT vendor. Spectrum of the X-rays emitted by a CT X-ray tube substantially varies among CT vendors. In addition, low KV scans are increasingly used to reduce radiation exposure to the patients. Consequently, multiple regression models for different KV settings as well as for different CT vendors should be carefully prepared for synthetic ECV by CCT. Other factors that may affect the attenuation of blood such as temperature28 and other blood constituents such as macromolecules, fat and iron require further investigation. The 64-slice-CT-system employed here reflects commonly available systems, but did not offer iterative reconstruction algorithms, dual energy acquisition and larger detector arrays that allow acquisition of whole heart, isotropic volumes of in one heart beat and at low radiation dose. In single-source 64 detector rows CT, myocardial CT attenuation is not homogenous due to artifacts, especially in the inferior wall and lateral wall. In the current study, we only included data from ROIs in the left ventricular septum. The accuracy of synthetic ECV should be validated in other segments in LV myocardium, if synthetic ECV by CT is more widely available and used in patients. Furthermore, 3D image registration and processing, reduces the errors of whole heart ECV maps.29 CONCLUSION Synthetic hematocrit derived from the relationship between blood hematocrit and blood attenuation allows quantification of the myocardial extracellular volume fraction by cardiac computed tomography without the need for blood sampling. ECV shows great potential, allowing myocardial tissue characterization with negligible effect on workflow and radiation dose. However wider adoption requires simplification and automation of the established technique synthetic ECV offers this. REFERENCES 1.Bandula S, White SK, Flett AS, et al. Measurement of myocardial extracellular volume fraction by using equilibrium contrast-enhanced CT: validation against histologic findings. Radiology. 2013;269:396-403. 2.Nacif MS, Kawel N, Lee JJ, et al. Interstitial myocardial fibrosis assessed as extracellular volume fraction with low-radiation-dose cardiac CT. Radiology. 2012;264:876-883. 3.Nacif MS, Liu Y, Yao J, et al. 3D left ventricular extracellular volume fraction by low-radiation dose cardiac CT: assessment of interstitial myocardial fibrosis. J Cardiovasc Comput Tomogr. 2013;7:51-57. 4.Treibel TA, Bandula S, Fontana M, et al. Extracellular volume quantification by dynamic equilibrium cardiac computed tomography in cardiac amyloidosis. J Cardiovasc Comput Tomogr. 2015. 5.Kurita Y, Kitagawa K, Kurobe Y, et al. Estimation of myocardial extracellular volume fraction with cardiac CT in subjects without clinical coronary artery disease: A feasibility study. J Cardiovasc Comput Tomogr. 2016;10:237-241. 6.Ugander M, Oki AJ, Hsu LY, et al. Extracellular volume imaging by magnetic resonance imaging provides insights into overt and sub-clinical myocardial pathology. Eur Heart J. 2012;33:1268-1278. 7.Banypersad SM, Fontana M, Maestrini V, et al. T1 mapping and survival in systemic light-chain amyloidosis. Eur Heart J. 2015;36:244-251. 8.Wong TC, Piehler K, Meier CG, et al. Association Between Extracellular Matrix Expansion Quantified by Cardiovascular Magnetic Resonance and Short-Term Mortality. Circulation. 2012;126:1206-1216. 9.Wong TC, Piehler KM, Kang IA, et al. Myocardial extracellular volume fraction quantified by cardiovascular magnetic resonance is increased in diabetes and associated with mortality and incident heart failure admission. Eur Heart J. 2014;35:657-664. 10.Schelbert EB, Fonarow GC, Bonow RO, Butler J, Gheorghiade M. Therapeutic targets in heart failure: refocusing on the myocardial interstitium. J Am Coll Cardiol. 2014;63:2188-2198. 11.Moon JC, Treibel TA, Schelbert EB. T1 mapping for diffuse myocardial fibrosis: a key biomarker in cardiac disease? Journal of the American College of Cardiology. 2013;62:1288-1289. 12.New PF, Aronow S. Attenuation measurements of whole blood and blood fractions in computed tomography. Radiology. 1976;121:635-640. 13.Black DF, Rad AE, Gray LA, Campeau NG, Kallmes DF. Cerebral venous sinus density on noncontrast CT correlates with hematocrit. AJNR. American journal of neuroradiology. 2011;32:1354-1357. 14.Collins AJ, Gillespie S, Kelly BE. Can computed tomography identify patients with anaemia? The Ulster medical journal. 2001;70:116-118. 15.Lan H, Nishihara S, Nishitani H. Accuracy of computed tomography attenuation measurements for diagnosing anemia. Jpn J Radiol. 2010;28:53-57. 16.Jung C, Groth M, Bley TA, et al. Assessment of anemia during CT pulmonary angiography. Eur J Radiol. 2012;81:4196-4202. 17.Kamel EM, Rizzo E, Duchosal MA, et al. Radiological profile of anemia on unenhanced MDCT of the thorax. Eur Radiol. 2008;18:1863-1868. 18.Wojtowicz J, Rzymski K, Czarnecki R. Severe anaemia: its CT findings in the cardiovascular system. Eur J Radiol. 1983;3:108-111. 19.Doppman JL, Rienmuller R, Lissner J. The visualized interventricular septum on cardiac computed tomography: a clue to the presence of severe anemia. Journal of computer assisted tomography. 1981;5:157-160. 20.Jalbert F, Paoli JR. [Osirix: free and open-source software for medical imagery]. Revue de stomatologie et de chirurgie maxillo-faciale. 2008;109:53-55. 21.Flett AS, Flett AS, Hayward MP, et al. Equilibrium contrast cardiovascular magnetic resonance for the measurement of diffuse myocardial fibrosis: preliminary validation in humans. Circulation. 2010;122:138-144. 22.Rosmini S, Treibel TA, Bandula S, et al. Cardiac computed tomography for the detection of cardiac amyloidosis. J Cardiovasc Comput Tomogr. 2016. 23.Moon JC, Messroghli DR, Kellman P, et al. Myocardial T1 mapping and extracellular volume quantification: a Society for Cardiovascular Magnetic Resonance (SCMR) and CMR Working Group of the European Society of Cardiology consensus statement. J Cardiovasc Magn Reson. 2013;15:92. 24.Coelho-Filho OR, Holland DJ, Mongeon FP, et al. Role of Transcytolemmal Water-Exchange in Magnetic Resonance Measurements of Diffuse Myocardial Fibrosis in Hypertensive Heart Disease. Circulation. Cardiovascular imaging. 2013;6:134-141. 25.Banypersad SM, Banypersad SM, Sado DM, et al. Quantification of Myocardial Extracellular Volume Fraction in Systemic AL Amyloidosis: An Equilibrium Contrast Cardiovascular Magnetic Resonance Study. Circulation. Cardiovascular imaging. 2013;6:34-39. 26.Wong TC, Wong TC, Piehler KM, et al. Myocardial extracellular volume fraction quantified by cardiovascular magnetic resonance is increased in diabetes and associated with mortality and incident heart failure admission. European Heart Journal. 2013. 27.Thirup P. Haematocrit: within-subject and seasonal variation. Sports Med. 2003;33:231-243. 28.Bydder GM, Kreel L. The temperature dependence of computed tomography attenuation values. Journal of computer assisted tomography. 1979;3:506-510. 29.Nacif MS, Liu Y, Yao J, et al. 3D left ventricular extracellular volume fraction by low-radiation dose cardiac CT: assessment of interstitial myocardial fibrosis. J Cardiovasc Comput Tomogr. 2013;7:51-57. FIGURES Figure 1: Derivation of synthetic hematocrit from the attenuation of blood Thoracic CT scans (n=40, 53% male, age 60 ±20 years) with contemporaneous hematocrit samples (mean interval 8.8 ±7.3 days) of the scan were used to create a regression line between hematocrit (Hct; 38.2 ±6.0%; range 24.7-50.7%) and blood attenuation (HUblood; 40.7 ±8.0; range 19.5-55.2). The regression line between Hct and HUblood was linear (R2=0.47 p) with a regression equation for synthetic Hct = [0.51 * HUblood] + 17.4). Figure 2: Validation of synthetic ECV vs conventional ECV in AS and Amyloid Synthetic ECV, calculated using the regression model,and conventional ECV were highly correlated (R2=0.96; p) with a 5.7% SD of differences and minimal bias (2.4%) on Bland-Altman analysis (right image). Figure 3: Histological Validation of Synthetic ECV Synthetic and conventional ECV both correlated well with collagen volume fraction (R2 = 0.50, p vs. R2 = 0.50, p ) and did not differ statistically. Figure 4: OsiriX Plugin workflow To facilitate offline analysis and allow future inline automation, an automatic synthetic ECV plug-in was developed for Osirix. Following manual segmentation of the blood pool in the pre- and post-contrast images, the plug-in automatically estimates blood hematocrit using the attenuation relationship defined above, and produces a three-dimensional myocardial ECV volume from pre- and post-contrast CCT data.

Friday, October 25, 2019

Free Will and Determinism Views Essay -- Free Will, Determinism

The aim of this essay is to prove the reliability of and why Libertarianism is the most coherent of the three Free Will and Determinism views. It refers to the idea of human free will being true, that one is not determined, and therefore, they are morally responsible. In response to the quote on the essay, I am disagreeing with Wolf. This essay will be further strengthened with the help of such authors as C.A. Campell, R. Taylor and R.M. Chisholm. They present similar arguments, which essentially demonstrate that one could have done otherwise and one is the sole author of the volition. I will present the three most common arguments in support of Libertarianism, present an objection against Libertarianism and attempt to rebut it as well as reject one main argument from the other views. As a result, this essay will prove that one is held morally responsibly for any act that was performed or chosen by them, which qualify as a human act. The Libertarian view contends that one’s actions are not predetermined but rather that people have free will, a precondition for moral responsibility. Basically, human acts are not determined by antecedent causes. Libertarianism is one of the views under Incompatibilism along with Hard Determinism. The opposite of these views is Compatibilism. An example of Libertarianism is: right now, one has the choice to either stop or continue reading this essay. Under this claim, the fact that one can choose between either is not determined one way or the other. Campbell’s view on Libertarianism is quite simple. He suggests that one needs to judge people by their inner acts or intentions to understand free will. To have freedom one must have a precondition of moral responsibility as well as a categorical ana... ...ime or space. Nevertheless, as I stated earlier, for something to be determined I believe that God is required. So, by saying that one needs to eliminate a God and other requirements to have free will, then one falsifies determinism, thus making this view incorrect. All in all, each view about the philosophy of free will and determinism has many propositions, objections and counter-objections. In this essay, I have shown the best propositions for Libertarianism, as well as one opposition for it which I gave a counter-objection. Additionally, I have explained the Compatabalistic and Hard Deterministic views to which I gave objections. In the end, whether it is determinism or indeterminism, both are loaded with difficulties. Nonetheless, I have provided the best explanation for free will, determinism and to the agent being morally responsible for their human actions.

Thursday, October 24, 2019

Comparing Values Essay

1. What values underlie your desire to help others? The value which underlies my desire to help others is too simply to put myself in other shoes that are going through difficult situations. I would step in and try to give them as much support as they would need. I prefer to do good thing for other without looking for some sort of recognition coming from it. I just want to be able to help those in need. Good things come to those who are kind to others. This why I can see myself as being a good human service worker I am a caring person and I love helping others. 2. What social issues do you feel strongly about? The social issues I feel very strongly about are abuse. I think no matter what type of abuse it is this should not be happening. Although this occurs every day to someone it is hard to grasp why people do these thing to themselves as well as to others. 3. Which client behaviors would you have trouble accepting? I would have trouble accepting client’s behaviors that are abuse to themselves and others. Especially, if it is dealing with a person who is abusive to a child. This will touch home because I am a parent and I cannot see anyone harm a child. 4. Which of your values would you like to change? The values which I would like to change would be I guess money. Sometime I put too much into trying to make more money. I just should accept the pay I am getting. You have to sometimes crawl before you can walk to get what you want in life. 5. What would you like to accomplish in human services? The things I would like to accomplish in human services are to give all my clients the best services I can give them. I want to be able to be my client support system. I will find my client all the necessary resource he or she needs to help their situation. 6. How do you go about solving personal problems? Solving personal problems can be difficult. If you are dealing with someone who has wrong you. I feel the best way to try resolve the situation is tried to talk to the other person. I would try to let they know how I am feeling and try to listen to the side and just try to resolve the problem as best as we both can and just move forward. 7. Do you readily seek help from others when you need it? Sometimes I do seek others help when I need help. I am human I have problems to. I general seek help or knowledge from those who are older and have experience many things in life. Rather, this is my manager are family member we all can learn something are get help from other sometimes in lives.

Wednesday, October 23, 2019

Executive Summary on Purell

Purell Instant Hand Sanitizer is a portable hand washing solution that cleanses hands without the need for soap and water. India currently has a problem with pollution in its water; we see this as an opportunity to increase our profits while also providing benefits that will help the Indian population achieve one of its strategic goals. Extensive research provides evidence that marketing Purell Instant Hand Sanitizer in could increase our profit margin as a company and allow us to grow our business. With a population over 1. 1 billion and limited competition; this market potentially could give us 5-7% growth each year for the next 7 to 10 years. Being that we are one of the first to enter this market, we will enjoy the benefits of being a pioneer in this industry. With such a huge market, we are hoping to have a 40% to 50% market share before additional competition start focusing on India. The purpose of this report is to recommend marketing Clean Hands, Inc product, Purell Instant Hand Sanitizer, in India. Purell Instant Hand Sanitizer is a portable supplement to routine hand washing. This is helpful because of all the diseases that are found in the waters of India. It is reported that 80 percent of disease that currently affects the people of India, is caused by unsanitary water and the lack of people washing or keeping their hands clean. Purell kills 99. 9percent of most common germs. Therefore, Purell is and effective tool that promotes proper health and prevents the spread of disease. In the documents to follow we are going to discuss the international business plan, which includes our policy commitment statement, our background analysis, our market research summary along with our action steps. Than we are going to go into detail about our marketing plan, which explains our method of entry into the market, as well as issues we might encounter.