Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score

© The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology.Aims: CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS). Methods and results: Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98). Conclusion: In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a 'gatekeeper' in this patient cohort, obviating the need for further more expensive tests.Peer reviewedFinal Published versio

Effects of the Master Principal Program on Perceived Principal Leadership Effectiveness in Arkansas

The purpose of this dissertation was to examine the perceptions of stakeholders of principals who were participating in the Master Principal Institution to determine principals’ leadership effectiveness in regard to the ISLLC 2008 Standards. This study surveyed stakeholders of principals who were participating in the Master Principal Institute. A quantitative, causal-comparative strategy was used in this study. Hypotheses 1-5 were tested by 2 x 2 factorial between-groups designs. The independent variables were level of school (Elementary or Secondary) and Master Principal Program phase (Phase I and II) for each of the hypotheses. The dependent variables for the hypotheses were the six ISLLC standards, respectively, as measured by the LEADS survey. The study used stakeholders of principals enrolled in Phase I and Phase II of the Master Principal Program facilitated by the Arkansas Leadership Academy. LEADS surveys were administered to stakeholders in schools of principals that were enrolled in the Master Principal Program. The surveys were administered within 72 schools in Arkansas. The data collected were from surveys given during 2015-2016 school year. A 2 x 2 factorial ANOVA was used to analyze the data collected for each of the six hypotheses. In all six hypotheses, no significant interaction effect existed. The main effect for Master Principal Phase was not found to be significant for any of the six hypotheses involving principals’ leadership effectiveness. The main effect for School Level was found to be significant for Hypotheses 1 and 2. There was a noticeable difference in teachers’ perceptions of their principals’ leadership effectiveness in ISLLC Standards 3, 4, 5, and 6, but these differences were not statistically significant in this study. The results of this study coincide with research from similar studies showing that elementary teachers hold a higher perception of principal leadership effectiveness compared to secondary teachers

The Dangerous/Endangered Modern Woman in Four Interwar Spanish Novels (1917-1936)

The Modern Woman was a figure perpetually discussed in the early twentieth century, as she embodied the increasingly public role and greater mobility of women in industrialized cities. A century later, historians and literary critics still explore the significance of this female archetype, who was at the center of debates regarding feminism and changing gender dynamics, because the Modern Woman’s defiance of social conventions opened the way for the independent lifestyle and freedoms of women today. Yet, still left unexplored is the image of the Modern Woman as both dangerous and in danger and what this contradictory depiction reveals about beliefs regarding the right of women to access spaces and employment traditionally reserved for men, which continue to manifest in prohibitive practices like sexual discrimination and harassment. Through the analysis of four novels—La rampa by Carmen de Burgos, La Venus mecánica by José Díaz Fernández, Eva Libertaria by Rafael López de Haro, and Cristina Guzmán, profesora de idiomas by Carmen de Icaza—this study elucidates the dichotomy of the dangerous/endangered Modern Woman in literature of Interwar-era Spain, between the end of World War I and the start of the Spanish Civil War. Representations of the Modern Woman exposed to danger often served as literary proof of her unsuitability for employment and the need for male protection to usher her back into the domestic realm. Less commonly, these depictions served to raise awareness of the exploitation, unfit work conditions, and insufficient wages that women experienced in the city, in works like La rampa and La Venus mecánica, which call for social and economic reforms, or revolution, to oppose patriarchal, capitalist institutions. In contrast, the frivolous Modern Woman is an agent of disorder who threatens to dismantle the traditional family structure in Eva Libertaria and Cristina Guzmán, profesora de idiomas. Furthermore, male anxieties about androgyny, unrestrained female sexuality, and the women’s emancipation movement are evident in La Venus mecánica and Eva Libertaria, in which female characters manipulate or emasculate men. These conflicting images reflect fears of rapidly changing gender roles and illustrate the difficulties that women faced in Spanish urban centers

Early Childhood Inclusion: Teacher Perception of the Supports Needed to Fully Include Children with Special Needs

Inclusion of children with disabilities in early childhood settings remains a goal for many early care and education centers and professionals. In this study, the perceptions of supports needed to accomplish this goal were examined. Early childhood teachers from a university-based child care center, which is inspired by the schools in Reggio Emilia, Italy, were interviewed and asked to explore their feelings and thoughts on fully including children with disabilities in their classrooms. An examination of their perceptions led to the identification of four major themes: a) everyone is valuable in the classroom community, b) additional training is needed, c) support from administrators, peers, specialists, and therapists, d) experience fosters success. From these themes the researcher found that teachers felt support from administrators(staffing, policies and procedures, time for meetings), peers, and on-site consultants, additional training, and an over arching philosophy of accepting differences were crucial to successful inclusion. The participants also indicated that all new teachers, whether in pre-service or through in-service should have access to these supports and be provided with information about the benefits and positive experiences of others who have included a child with a disability into their classroom. This study will add to the continuing discussion of early childhood inclusion and provide additional information for programmatic decision making within a particular setting

Normative Disruptions: The Diegetic Reading of Anachronism in Twentieth-Century American Novels

Much of the discourse on literary anachronism remains fixated on questions of error and intent: Anachronisms are assumed to be flawed attempts to recreate the historic real, and scholars who deal with them tend to insist an anachronism can only be meaningful if it was placed intentionally by an author for a specific purpose. This is not only a reductive understanding of what anachronisms are, it limits the range of critical and theoretical approaches by which an anachronism can be discussed. This dissertation addresses this problem by asserting a new way of approaching anachronism that bypasses the question of authorial intent entirely. This dissertation contends that anachronisms should be read, not as errors in history, but as wholly accurate depictions of a different history which, instead of being subordinated to the historic real, can be compared to it as a distinct reality. The first chapter demonstrates the process of reading an anachronism diegetically by applying it to William Faulkner’s Absalom, Absalom! Subsequent chapters complicate the same process by exploring anachronisms that deviate from our understanding of anachronism in key ways. Chapter Two uses Kurt Vonnegut’s Timequake to examine the potentials for an anachronism that does not depend on historicism to reveal its divergence. In Chapter Three, anachronistic racial attitudes in Harry Turtledove’s The Guns of the South allow us to consider how the discussion of anachronism is complicated by an absence of agreed-upon historic facts. Finally, Chapter Four reads Margaret Mitchell’s Gone with the Wind as the narrative of an attempt to construct an anachronism, and consequently analyzes the effects of an anachronism that is attempted by the characters, within the diegesis of a work. This dissertation represents the beginning of a larger project, considering new articulations and applications of a misunderstood temporal paradox.English, Department o

USING GIS TO DELINEATE HEADWATER STREAM ORIGINS IN THE APPALACHIAN COAL-BELT REGION OF KENTUCKY

Human activity such as surface mining can have substantial impacts on the natural environment. Performing a Cumulative Hydrologic Impact Assessment (CHIA) of such impacts on surface water systems requires knowing the location and extent of these impacted streams. The Jurisdictional Determination (JD) of a stream’s protected status under the Clean Water Act (CWA) involves locating and classifying streams according to their flow regime: ephemeral, intermittent, or perennial. Due to their often remote locations and small size, taking a field inventory of headwater streams for surface mining permit applications or permit reviews is challenging. A means of estimating headwater stream location and extent, according to flow regime using publicly available spatial data, would assist in performing CHIAs and JDs. Using headwater point-of-origin data collected from Robinson Forest in eastern Kentucky along with data from three JDs obtained via a Freedom of Information Act (FOIA) request to the U.S. Army Corps of Engineers (USACE), headwater streams in the Appalachian Coal Belt were characterized according to a set of spatial parameters. These characteristics were extrapolated using GIS to delineate headwater streams over a larger area, and the results were compared to the National Hydrography Dataset (NHD)

Cardiac Masses on Cardiac CT: A Review

Cardiac masses are rare entities that can be broadly categorized as either neoplastic or non-neoplastic. Neoplastic masses include benign and malignant tumors. In the heart, metastatic tumors are more common than primary malignant tumors. Whether incidentally found or diagnosed as a result of patients’ symptoms, cardiac masses can be identified and further characterized by a range of cardiovascular imaging options. While echocardiography remains the first-line imaging modality, cardiac computed tomography (cardiac CT) has become an increasingly utilized modality for the assessment of cardiac masses, especially when other imaging modalities are non-diagnostic or contraindicated. With high isotropic spatial and temporal resolution, fast acquisition times, and multiplanar image reconstruction capabilities, cardiac CT offers an alternative to cardiovascular magnetic resonance imaging in many patients. Additionally, cardiac masses may be incidentally discovered during cardiac CT for other reasons, requiring imagers to understand the unique features of a diverse range of cardiac masses. Herein, we define the characteristic imaging features of commonly encountered and selected cardiac masses and define the role of cardiac CT among noninvasive imaging options

Clinical risk factors and atherosclerotic plaque extent to define risk for major events in patients without obstructive coronary artery disease: the long-term coronary computed tomography angiography CONFIRM registry.

AimsIn patients without obstructive coronary artery disease (CAD), we examined the prognostic value of risk factors and atherosclerotic extent.Methods and resultsPatients from the long-term CONFIRM registry without prior CAD and without obstructive (≥50%) stenosis were included. Within the groups of normal coronary computed tomography angiography (CCTA) (N = 1849) and non-obstructive CAD (N = 1698), the prognostic value of traditional clinical risk factors and atherosclerotic extent (segment involvement score, SIS) was assessed with Cox models. Major adverse cardiac events (MACE) were defined as all-cause mortality, non-fatal myocardial infarction, or late revascularization. In total, 3547 patients were included (age 57.9 ± 12.1 years, 57.8% male), experiencing 460 MACE during 5.4 years of follow-up. Age, body mass index, hypertension, and diabetes were the clinical variables associated with increased MACE risk, but the magnitude of risk was higher for CCTA defined atherosclerotic extent; adjusted hazard ratio (HR) for SIS >5 was 3.4 (95% confidence interval [CI] 2.3-4.9) while HR for diabetes and hypertension were 1.7 (95% CI 1.3-2.2) and 1.4 (95% CI 1.1-1.7), respectively. Exclusion of revascularization as endpoint did not modify the results. In normal CCTA, presence of ≥1 traditional risk factors did not worsen prognosis (log-rank P = 0.248), while it did in non-obstructive CAD (log-rank P = 0.025). Adjusted for SIS, hypertension and diabetes predicted MACE risk in non-obstructive CAD, while diabetes did not increase risk in absence of CAD (P-interaction = 0.004).ConclusionAmong patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors. An interaction was observed between risk factors and CAD burden, suggesting synergistic effects of both

Economic Analysis of Flood Detention Storage by Digital Computer

The objective of this study was to develop a digital computer procedure for preliminary analysis of the economic justification of reservoir detention storage for flood control and to present a sample study illustrating its application. A computer program called the University of Kentucky Flood Control Planning Program III was developed and tested on the flood plain of the South Fork of the Licking River in northeastern Kentucky. Given a specified reservoir site and a downstream flood plain divided into planning units, Program III selects the economically efficient combination of reservoir detention storage and the associated combination of channel improvement, flood proofing, land-use management, and residual flooding for each downstream planning unit. The Program does not attempt final measure design but isolates those combinations of measures for which detailed data collection and analysis is warranted. This study presents a description of the basic Program logic and the results of its application along the South Fork, Licking River, as well as a FORTRAN IV listing of the computer program and a listing of the input data used in the South Fork, Licking River analysis