Abdominal Aortic Aneurysm Ultrasound Screening Programme

Abdominal Aortic Aneurysm Ultrasound Screening Programme Susmi Suresh Role of the National Abdominal Aortic Aneurysm Ultrasound Screening Programme in Improving Health Outcomes: a systematic review Abstract Background: Abdominal Aortic Aneurysm (AAA) is one of the common conditions that affect men aged 65 and older. Described as a ticking bomb(1), rupture of such an aneurysm results in fatal bleeding and death. Early detection allows appropriate treatment to be given to patients as an effort to reduce mortality rates. The National Abdominal Aortic Aneurysm Screening programme, an initiative of Public Health England, offers screening to men in the prevalence group by following its objective of reducing mortality rates of preventable illnesses(2). Ultrasonography is the chosen imaging modality due to its high sensitivity and specificity(3). The aim of this study is to examine current literature on AAA and to understand whether screening programmes are effective enough to reduce mortality rates of AAA. Quality of life (QoL) as a health outcome will also be examined and evidence analysed, to see whether screening programmes affect patients quality of life. Method: A thorough search of prominent databases was carried out and the search-results underwent application of inclusion and exclusion criteria developed for this review. Four major randomised controlled trials were identified. Following data extraction, quality assessment was carried out using the CASP tool. Risk of bias was checked using the Cochranes tool for assessing risk of bias. All of these ensured a valid conclusion to be drawn.   Results: The four chosen RCTs were the MASS trial, the Chichester trial, the Viborg trial and the WA trial. The Mass and Chichester trials were conducted in the UK whereas the Viborg and WA trials were carried out in Denmark and Australia, respectively. The data pool of 125595 people added to the reliability of the findings of this review. A significant reduction in mortality rates of AAA was found in the intervention groups following an ultrasound screening of the abdominal aorta(4-7). QoL was looked at as the secondary outcome in the MASS trial which concluded that there was no adverse effect on QoL(4). Conclusion: The review showed evidence on reduced AAA mortality rates in men aged 65 and older following ultrasound screening. No adverse effect in patients QoL was found. The NAAASP is a commendable initiative of Public Health England and it is suggested that similar screening programmes be introduced through an evidence-based healthcare. Introduction       An aneurysm forms when a section of a weakened arterial wall dilates permanently. The walls of an artery can weaken and dilate due to cardiovascular diseases like arteriosclerosis, inflammation of the arterial wall or trauma. When this dilation occurs in the abdominal aorta, which runs from T12 to L5, it is considered to be an Abdominal Aortic Aneurysm (AAA)(8). Several studies have found smoking, hypertension and alcohol consumption to be the major risk factors of AAA(9). A family history of AAA is also considered to be a risk factor(10). AAA is age and sex-dependent as concluded by a retrospective prevalence study that looked at a cohort of 100,000 men and women each. The prevalence among men was found to increase rapidly after the age of 55 and that among women increases after the age of 70(11). Therefore, women are considered to be at low risk of developing AAA and hence screening programmes focus on a male population of 65 years or older(12). Patients are mostly asymptomatic and where symptoms do present, these could be abdominal pain, flank pain, back pain, groin pain, or syncope. A palpable pulsating abdominal mass could also be found during examination. An aneurysm once formed, grows in size until it bursts, leading to fatal bleeding. Only 2 in 10 people with a ruptured aneurysm survive if not treated with emergency AAA repair surgery(13). The survival rate among those who receive surgery is 94%(14). AAAs are detected using an ultrasound scan (US), which is considered to be the most effective screening modality with high sensitivity (98%) and specificity (99%) rates(15). The US is safe, cheap, quick, and non-invasive, and provides results immediately. It is widely accepted as a valid screening method and the aorta can be visualised in 99% of patients(15). Compared to CT scans which can sometimes overestimate the diameter of aneurysms in the oblique plane(15), ultrasound continues to be the choice of screening modality. In 2014, around 2000 men died from ruptured AAA, accounting for around 1% of all registered deaths in men aged 65 and over(16). Past records show a reduction in mortality in England from 7.5% in 2009 to 1.6% in 2012(17). This sheds light on the National AAA Screening Programme (NAAASP) offered by the NHS. Early detection via screening of a large aneurysm of above 5.5cm, means that patients are given the choice of repair surgery thereby increasing their survival rate by 69%(8, 18). Surveillance is offered to patients with a small or medium aneurysm of 3-4.4cm and 4.5-5.4cm, respectively(19, 20). This is through an ultrasound scan every twelve or three months for small and medium aneurysms, respectively. Screening aims to reduce the risk of developing a disease in a healthy population who have no signs of illness with respect to the condition being screened. The NAAASP is based on the policies recommended by the UK National Screening Committee in 2005 following the results of the largest randomised controlled trial about AAA, the Multicentre Aneurysm Screening Study (MASS), which showed that screening reduces mortality by 40% after 10 years(21). Implemented in 2009, the programme achieved a nationwide coverage by the end of 2013. The programme aims to reduce AAA mortality by providing a systematic population-based screening programme for the male population during their 65th year and on request, for men over 65(22). This falls under Domain 2 and 4 of the Public Health Outcomes Framework provided by the Department of Health, with the objectives to help people to live healthy lifestyles and, to reduce the number of people living with preventable ill health and people dying prematurely(22), respectively. NAAASP Annual Data 2014/15 shows that a total of 280,520 men were screened and 83.2% had a conclusive screen(23). During the screening year 2013/14, this was 82% out of a total of 287,126 men(24). Depending on the size of the aneurysm, either surveillance or surgery was offered. Overall, the programme aims to achieve the health outcome of reduced mortality. Quality of life is also reported as a health outcome as shown by several retrospective, observational and cohort studies conducted on patients(25-27). Knowledge on the success of screening programmes like NAAASP remains limited. The aim of this review, therefore, is to examine current evidence on whether a screening programme improves health outcomes, namely reduced mortality and improved quality of life, by critically and systematically reviewing literature using the quality assessment tools of the critical appraisal skills programme (CASP). This will be achieved through the following objectives: Develop inclusion and exclusion criteria based on PICOS relating to AAA and ultrasound scanning Carry out a systematic search of databases- Medline, Web of Science, the Cochrane Database, OneSearch and the ISRCTN Registry (BioMed Central). Filter the search using the inclusion and exclusion criteria and carry out data-extraction using the Cochrane Data Collection form Carry out quality assessment using the CASP tool and use the Cochrane tool to assess risk of bias Conduct an analysis, focusing on mortality and quality of life as the health outcomes Methods Although evidence exists on the accuracy of using ultrasonography for detecting abdominal aortic aneurysms(3) and the validity of the scan results is widely accepted due to its high sensitivity and specificity(3), the process of abdominal aortic scanning was decided to be reviewed first(Appendix A). Prior to conducting the search, inclusion and exclusion criteria were set (Table 1)(28). Following this, databases were chosen for the search-topic Abdominal Aortic Aneurysm. These included PubMed/MEDLINE, ISRCTN Registry, Web of Science, Lancaster University/OneSearch and the Cochrane Database. Search strategies were developed for each source and search filters were decided (Table 3-7). Medical Subject Heading (MeSH) terms were used to further refine the results (Table 2). Overall, seventy-four articles were found and after removing duplicates, forty-nine remained. These were subjected to the inclusion and exclusion criteria, thus narrowing down the results to seventeen relevant articles. The reference lists of the retrieved articles were further reviewed for any relevant cited papers. This process was repeated until no relevant articles were found. Four major randomised clinical trials were identified from these. These were reviewed after undergoing data extraction and quality assessment. Data extraction was carried out using Cochranes data extraction tool and this allowed for a full-text screening that removed any ineligible studies. Moreover, the use of a standardised form increased the validity and reliability of this review whilst also reducing any risk of bias(28). Finally, the trials were critically appraised using the CASP tool. This enabled identifying risk of bias within the trials, particularly selection bias, performance bias and reporting bias. Table 1  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Inclusion Criteria Exclusion Criteria Population General population of males aged 65 years or older Patients who are asymptomatic and symptomatic who were involved in AAA screening Patients from all ethnicities Patients of all socioeconomic status Trials that include females, younger children and males younger than 65 years since AAA is age and sex specific Intervention Ultrasound Screening for AAA Any other imaging modalities like CT, MRI or radiography Comparison Non-screened population Aneurysm Aortic Aneurysm Thoracic Aneurysm Outcome (s) Mortality Quality of Life Study Design Randomised Controlled Trials (RCTs) Trials that look at AAA detection using Ultrasonography Articles in the English language Articles from the time period starting from approximately 20 years before the NAAASP programme came into effect, i.e., 1985 to present Full articles All other types of studies such as qualitative studies, observational studies, cohort or case-series studies. Articles in foreign languages Studies conducted outside this time period Articles that are not fully available Table 2  Ã‚  Ã‚   Medical Search Headings (MeSH) Abdominal Aortic Aneurysm Mass Screening Ultrasonography Rupture Table 3 PubMed Search Strategy/Method Results Abdominal Aortic Aneurysm 23,807 Mass Screening 128,434 Ultrasonography 386,798 Rupture 109,121 AAA + MS 599 AAA + MS + US 300 AAA + MS +US + Rupture 102 AAA + MS +US + RCTs 23 AAA + MS +US + Rupture + RCTs 11 Table 4 Web of Science Search Strategy/Method Results Abdominal Aortic Aneurysm 18,625 Mass Screening 43,081 Ultrasonography 80,257 Rupture 119,830 AAA + MS 131 AAA + MS + US 23 AAA + MS +US + Rupture 12 Limit English 11 Table 5 Cochrane Library (RCTs only) Search Strategy/Method Results Abdominal Aortic Aneurysm 702 Mass Screening 3827 Ultrasonography 11,318 Rupture 3097 AAA + MS 46 AAA + MS + US 23 AAA + MS +US + Rupture 10 Table 6 OneSearch Search Strategy/Method Results Abdominal Aortic Aneurysm 27,819 Mass Screening 73,090 Ultrasonography 122,460 Rupture 94738 AAA + MS 604 AAA + MS + US 123 AAA + MS +US + Rupture 42 Limit Articles 39 Table 7 ISRCTN Registry/BioMed Central Search Strategy/Method Results Abdominal Aortic Aneurysm 37 Mass Screening 328 Ultrasonography 88 Rupture 176 AAA + MS 3 Results Four dominant randomised controlled trials (RCTs) were identified- the Multicentre Aneurysm Screening Study(4) (MASS) conducted between 1997 to 1999; the Chichester Study(5), 1988 to 1991; the Viborg County Trial(6), 1994 to 1998 and; the Western Australia (WA) Trial(7), 1996. These collectively showed that AAA mortality rate can be significantly reduced in the population following an ultrasound scan of the abdominal aorta (Table 8). The Mass and Chichester trials were carried out in the UK and had a participant number of 67,770 men aged 65 to 74 years and 6040 men aged 65-80 years, respectively. The Viborg Country trial was conducted in the Viborg county of Denmark with a participant number of   12,639 men aged 65-73 years; the WA trial, carried out   in the province of Western Australia included 41,000 men aged 65-79. All these trials used ultrasound screening of the abdomen to detect AAA and measured AAA-mortality as the primary outcome(4-7). The secondary outcomes of all trials were all-cause mortality. However the Mass trial also measured quality of life and cost-effectiveness as the secondary outcomes. Cost-effectiveness was also measured by the Viborg trial as the secondary outcome. Participants were randomly selected and randomisation was computer-generated(4-7). Mass and Chichester trials recruited participants via GP registers based on gender and date of birth. In the Mass trial, some were excluded if the GP considered them to terminally ill, had other health problems or had undergone AAA repair(4). In the Viborg trial, recruitment was through the countys health department and WA participants were selected from the electoral roll(6, 7). The WA trial excluded those men who were too far from the screening location; the Viborg trial had no such exclusions. MASS Trial The intervention group composed of 33839 men and the control group, 1333 men. Attendance was 80% and the median follow-up was ten years(4). 65 men died in the intervention group and 113 died in the control group, due to AAA. Mortality data was taken from death registry provided by the Office of National Statistics (ONS). The study concluded that AAA mortality rate can be significantly reduced by up to half, following ultrasound screening. There was a 42% reduction in the intervention group, hazard ratio (HR) 0.58 95% CI (0.42-0.78)(4). The study also measured mood and health status outcomes such as state anxiety, depression, and health-status measures such as mental and physical health, and self-rated health(4, 13). These were calculated at intervals of six weeks after screening and, 3 and 12 months after detection of aneurysm or surgery. There were no significant changes in anxiety and depression and these remained within the recommendations(4). However, those screened negative and undergoing surveillance scored higher in health-status measures. This trend continued until 3 months after screening(4). However at 12 months, those who had undergone surgery scored higher than those in surveillance. They also self-rated higher, similar to those screened negative(4). Despite these results, the authors refrained from making a conclusive statement on quality of life. In the intervention group, there was an increase in the number of elective surgeries, odds ratio (OR)- 2.45 95% CI (2.02-2.97)(4). Nevertheless, there was no significant difference in the overall 30-day mortality after elective surgery in the intervention and control groups; this remained at 6%. However, unnecessary surgery and the risk of overdiagnosis are seen as factors reducing the overall quality of life(29). So even though this increase in elective surgery in the intervention group and its effects could be used as a measure of quality of life, the authors did not make such a link. Chichester Trial The intervention group composed of 2995 men and the control group, 3045 men. The median follow-up was fifteen years and the attendance rate, 74%, decreased with age. About 33.8% of men in the age range of 76-80 years declined compared to 19.5% in the age group of 65 years(5). 10 men died in the intervention group and 17 died in the control group, due to AAA-related causes. Like the Mass trial, mortality data was taken from the ONS Death Registry. The study found no differences in mortality rates in the two groups up to four years from screening. However, over 15 years, mortality was found to be reduced in the intervention group by 11%. This was not considered as a significant reduction, HR 0.89 95% CI (0.60-1.32) (5). Viborg Trial The intervention group composed of 6339 men and the control group, 6319 men. Attendance was 76% and the maximum follow-up was fourteen years(6). 6 men died in the intervention group, compared to 19 in the control group. Mortality data was taken from the national registry. There was a significant reduction in AAA-related hospital mortality, OR-0.31 95% CI (0.13-0.79)(6). The study recommends screening men aged 65 years to reduce AAA-mortality. However since the study only noted deaths from AAA in a hospital setting in the county of Viborg, this finding cannot be expanded to other countries. Western Australia Trial The intervention and control groups composed of 19352 men each. Attendance rate was 70% and the maximum follow-up was 43-months(7). 18 men died in the intervention group and 25 died in the control group. Mortality data was taken from the national death registry and the hospital registry. The study found that there was no significant reduction in mortality following ultrasound scanning in the intervention group of men aged 65-83 years in Western Australia, OR- 0.72 95% CI (0.39-1.32)(7). However the study noted that in the subgroup of men aged 65-75 years, mortality was found to be reduced(7). Table 8 AAA mortality: raw data Trial Deaths in Screened Deaths in Unscreened Odds Ratio (95% CI) MASS 65/33,839 113/33,961 0.58 (0.42 to 0.78) Chichester 10/3205 17/3228 0.59 (0.27 to 1.29) Viborg 6/6339 19/6319 0.31 (0.13 to 1.79) Western Australia (WA) 18/19352 25/19352 0.72 (0.39 to 1.32) Total* 93/56,396 155/56,541 0.60 (0.46 to 0.78) *Data from the Viborg trial is not included since the study noted deaths only in a hospital setting. Hence, results cannot be compared to the other studies(30) Discussion The pooled data of 125595 participants shows that AAA mortality rate can be significantly reduced in the population following an ultrasound scan of the abdominal aorta. Data from the four RCTs show that the Absolute Risk Reduction (ARR) for the Mass trial, Chichester, Viborg and WA are 0.14%, 0.21%, 0.21% and 0.04%, respectively (See Table 9 for the full data processed by the review author). Although these may appear insignificant, when applied over a population, the ARR is 140.7, 214.6, 206.0 and 36.2 per 100,000 respectively. Hence, the Numbers Needed to Screen (NNS) are 711, 466, 485 and 2765 respectively. On an average, this is an ARR of 149.4 out of every 100,000 people for an NNS of 1107. This NNS is lower than other screening programmes like breast cancer screening which has an NNS of 1339(31).   This confirms the benefits of a population-based screening programme such as the NAAASP. The Mass trial, which looked at the effects of ultrasound screening on the quality of life found its measures to be within normal standards. Since the NAAASP is based on the results of this trial, it can be said that ultrasound screening has no adverse effects on the quality of life of the screened population. However, a   limitation acts on the trial- quality of life was measured only up to twelve months after scan; no data is available for the period after that. If quality of life was continued to be measured during follow-ups or even separately via postal questionnaires or GP appointments, a more valid inference could have been drawn. It would also have provided a fuller picture on the long-term effects on quality of life. One other limitation acting on this review is the possibility of selection bias as a result of excluding some articles in foreign languages. Despite this, the findings of this review remain unaffected and can be considered valid since an exhaustive search of the major databases was carried out systematically. Although the inclusion criteria of free-articles was applied after this search, Lancaster Universitys subscription service ensured access to all available articles and a complete retrieval of the selected search was possible. The pooled study population consisted of 125,595 men and the MASS trial alone had a sample of 67800 people. So, conclusions on quality of life and AAA mortality can be considered reliable. However, there are inconsistencies present in the four RCTs due to the different methods used. For example, the Viborg trial noted mortality only in a hospital setting. This makes its results incomparable to the other trials. Also, the source of mortality data varies in the four studies. All the trials looked at the national death registries but the Chichester and WA trials also looked at other sources(5, 7). This may have resulted in possible over-estimation or duplication of data. Similarly, the cause of death was re-checked by a clinician and two random vascular surgeons in the Chichester and WA trials, respectively. Whilst expert opinion regarding the cause of death could lead to precise and accurate mortality data, there could also be false-positives when opinions are formed on complex cases with multiple causes of mortality. This subject of human error was also noted whilst carrying out the preparatory ultrasound screening (Appendix A). Individual measurements of the same abdominal aortic diameter were varied. Although this points to the possibility of human error that may adversely affect the accuracy the diagnosis, the NAAASP identifies staff training as a significant aspect of the programme to overcome this. Staffs are well-trained in the use of ultrasonography for AAA screening and in the overall delivery of the programme(8). Also, the programme itself has several failsafe procedures incorporated within all phases of the programme so that the performance thresholds are constantly maintained(8). The result of this review can be applied to patient care in the UK. The NAAASP is successfully running its seventh year. Since its implementation in 2009, one million men have been screened(32). Accumulating evidence shows it is feasible to reduce AAA-mortality by ultrasound screening, thereby making it possible to achieve the programmes aim. Public Health England could implement similar screening interventions in other disease areas. There is currently a long of list of conditions like atrial fibrillation, thyroid disease and lung cancer where a population-based screening is not offered (but privately available) due to the absence of enough evidence to inform a screening programme'(33). Evidence-based healthcare could be further expanded to diseases like these. It is not just new and untreatable diseases that prove to be a challenge to 21st century medicine; it is the phenomenon of the disease-iceberg that proves most challenging. By detecting and treating early onset of illnesses, people live a longer and healthier life. Table 9 Data processed by the review author using the results from the four RCTs Trial Experimental Event Rate (EER) Control Event Rate (CER) Absolute Risk Reduction Relative Risk Reduction Number(s) Needed to Screen (NNS) Odds Ratio/Relative Risk MASS 0.00192086 0.00332735 0.00140649 0.422705 710.992 1.73222 Chichester 0.00312012 0.00526642 0.00214629 0.407543 465.919 1.68789 Viborg 0.000946522 0.00300680 0.00206028 0.685207 485.370 3.17669 Western Australia 0.000930136 0.00129186 0.000361720 0.280000 2764.57 1.38889 Overall 0.00157807 0.00276806 0.00118999 0.429901 840.344 1.75408 Overall* 0.00164905 0.00274137 0.00109232 0.398457 915.482 1.66239 *Data from the Viborg trial is not included since the study noted deaths only in a hospital setting. Hence, results cannot be compared to the other studies(30) Conclusion Following critical appraisal of the current available evidence provided by four major RCTs, it was found that mortality from AAA can be significantly reduced in males aged 65 years and older, through a population-based screening programme. Ultrasonography continues to be the chosen imaging modality due to its accuracy and ease-of-use.   It was also found that such a screen

Brown’s Installation Service

Brown’s Installation Service is the leader in installation, relocation, and reconfiguration of office furniture. In business since 1972, you can be sure that their thirty five years of experience will help you in setting up or changing an office easily and efficiently. Along with their expertise in the installation of modular furniture, Brown’s also offers moving services as well as inventory management.All of the crews sent from Brown’s Installation Service are highly trained and familiar with all manufactured office furniture systems and casegoods, including such brand names as Haworth, Steelcase, and Herman Miller. Brown’s Installation Service is aware that businesses are always looking for good quality at a low price. Unfortunately, there are furniture companies that quote really low prices and make a lot of promises, but they rarely follow through. Brown’s is not that kind of company.You will be provided with excellent service at a reasonable p rice, and the crews will work as quickly as possible to ensure that your business is not disrupted. To make this possible, Brown’s Installation Service will come to your office at any time of any day, including weekends. The office is open from 8 to 5 Monday through Friday, but you may reach someone by cell phone 24/7. Brown’s prides themselves on always being available to their customers. There is no job too big or too small for Brown’s Installation Service.Everything is handled in house, so one phone call will take care of your entire project. With years of experience, fair pricing, round the clock service, and one call to take care of everything, there is no reason not to call Brown’s Installation Service for your office furniture needs! Don’t be fooled by the competition. Come to Brown’s first, and come away satisfied! Call 803-735-7196 for inquiries, 803-796-5801 for a quote, or email [email  protected] com, and get your office projec t started today!

The Lost Symbol Chapter 102-106

CHAPTER 102 Robert Langdon had often heard it said that an animal, when cornered, was capable of miraculous feats of strength. Nonetheless, when he threw his full force into the underside of his crate, nothing budged at all. Around him, the liquid continued rising steadily. With no more than six inches of breathing room left, Langdon had lifted his head into the pocket of air that remained. He was now face-to-face with the Plexiglas window, his eyes only inches away from the underside of the stone pyramid whose baffling engraving hovered above him. I have no idea what this means. Concealed for over a century beneath a hardened mixture of wax and stone dust, the Masonic Pyramid's final inscription was now laid bare. The engraving was a perfectly square grid of symbols from every tradition imaginable–alchemical, astrological, heraldic, angelic, magical, numeric, sigilic, Greek, Latin. As a totality, this was symbolic anarchy–a bowl of alphabet soup whose letters came from dozens of different languages, cultures, and time periods. Total chaos. Symbologist Robert Langdon, in his wildest academic interpretations, could not fathom how this grid of symbols could be deciphered to mean anything at all. Order from this chaos? Impossible. The liquid was now creeping over his Adam's apple, and Langdon could feel his level of terror rising along with it. He continued banging on the tank. The pyramid stared back at him tauntingly. In frantic desperation, Langdon focused every bit of his mental energy on the chessboard of symbols. What could they possibly mean? Unfortunately, the assortment seemed so disparate that he could not even imagine where to begin. They're not even from the same eras in history! Outside the tank, her voice muffled but audible, Katherine could be heard tearfully begging for Langdon's release. Despite his failure to see a solution, the prospect of death seemed to motivate every cell in his body to find one. He felt a strange clarity of mind, unlike anything he had ever experienced. Think! He scanned the grid intensely, searching for some clue–a pattern, a hidden word, a special icon, anything at all–but he saw only a grid of unrelated symbols. Chaos. With each passing second, Langdon had begun to feel an eerie numbness overtaking his body. It was as if his very flesh were preparing to shield his mind from the pain of death. The water was now threatening to pour into his ears, and he lifted his head as far as he could, pushing it against the top of the crate. Frightening images began flashing before his eyes. A boy in New England treading water at the bottom of a dark well. A man in Rome trapped beneath a skeleton in an overturned coffin. Katherine's shouts were growing more frantic. From all Langdon could hear, she was trying to reason with a madman–insisting that Langdon could not be expected to decipher the pyramid without going to visit the Almas Temple. â€Å"That building obviously holds the missing piece to this puzzle! How can Robert decipher the pyramid without all the information?!† Langdon appreciated her efforts, and yet he felt certain that â€Å"Eight Franklin Square† was not pointing to the Almas Temple. The time line is all wrong! According to legend, the Masonic Pyramid was created in the mid-1800s, decades before the Shriners even existed. In fact, Langdon realized, it was probably before the square was even called Franklin Square. The capstone could not possibly have been pointing to an unbuilt building at a nonexistent address. Whatever â€Å"Eight Franklin Square† was pointing to . . . it had to exist in 1850. Unfortunately, Langdon was drawing a total blank. He probed his memory banks for anything that could possibly fit the time line. Eight Franklin Square? Something that was in existence in 1850? Langdon came up with nothing. The liquid was trickling into his ears now. Fighting his terror, he stared up at the grid of symbols on the glass. I don't understand the connection! In a petrified frenzy, his mind began spewing all the far-flung parallels it could generate. Eight Franklin Square . . . squares . . . this grid of symbols is a square . . . the square and the compass are Masonic symbols . . . Masonic altars are square . . . squares have ninety-degree angles. The water kept rising, but Langdon blocked it out. Eight Franklin . . . eight . . . this grid is eight-by-eight . . . Franklin has eight letters . . . â€Å"The Order† has eight letters . . . 8 is the rotated symbol for infinity . . . eight is the number of destruction in numerology . . . Langdon had no idea. Outside the tank, Katherine was still pleading, but Langdon's hearing was now intermittent as the water was sloshing around his head. † . . . impossible without knowing . . . capstone's message clearly . . . the secret hides within–â€Å" Then she was gone. Water poured into Langdon's ears, blotting out the last of Katherine's voice. A sudden womblike silence engulfed him, and Langdon realized he truly was going to die. The secret hides within– Katherine's final words echoed through the hush of his tomb. The secret hides within . . . Strangely, Langdon realized he had heard these exact words many times before. The secret hides . . . within. Even now, it seemed, the Ancient Mysteries were taunting him. â€Å"The secret hides within† was the core tenet of the mysteries, urging man kind to seek God not in the heavens above . . . but rather within himself. The secret hides within. It was the message of all the great mystical teachers. The kingdom of God is within you, said Jesus Christ. Know thyself, said Pythagoras. Know ye not that ye are gods, said Hermes Trismegistus. The list went on and on . . . All the mystical teachings of the ages had attempted to convey this one idea. The secret hides within. Even so, mankind continued looking to the heavens for the face of God. This realization, for Langdon, now became an ultimate irony. Right now, with his eyes facing the heavens like all the blind men who preceded him, Robert Langdon suddenly saw the light. It hit him like a bolt from above. The secret hides within The Order Eight Franklin Square In a flash he understood. The message on the capstone was suddenly crystal clear. Its meaning had been staring him in the face all night. The text on the capstone, like the Masonic Pyramid itself, was a symbolon–a code in pieces–a message written in parts. The capstone's meaning was camouflaged in so simple a manner that Langdon could scarcely believe he and Katherine had not spotted it. More astonishing still, Langdon now realized that the message on the capstone did indeed reveal exactly how to decipher the grid of symbols on the base of the pyramid. It was so very simple. Exactly as Peter Solomon had promised, the golden capstone was a potent talisman with the power to bring order from chaos. Langdon began pounding on the lid and shouting, â€Å"I know! I know!† Above him, the stone pyramid lifted off and hovered away. In its place, the tattooed face reappeared, its chilling visage staring down through the small window. â€Å"I solved it!† Langdon shouted. â€Å"Let me out!† When the tattooed man spoke, Langdon's submerged ears heard nothing. His eyes, however, saw the lips speak two words. â€Å"Tell me.† â€Å"I will!† Langdon screamed, the water almost to his eyes. â€Å"Let me out! I'll explain everything!† It's so simple. The man's lips moved again. â€Å"Tell me now . . . or die.† With the water rising through the final inch of air space, Langdon tipped his head back to keep his mouth above the waterline. As he did so, warm liquid poured into his eyes, blurring his vision. Arching his back, he pressed his mouth against the Plexiglas window. Then, with his last few seconds of air, Robert Langdon shared the secret of how to decipher the Masonic Pyramid. As he finished speaking, the liquid rose around his lips. Instinctively, Langdon drew a final breath and clamped his mouth shut. A moment later, the fluid covered him entirely, reaching the top of his tomb and spreading out across the Plexiglas. He did it, Mal'akh realized. Langdon figured out how to solve the pyramid. The answer was so simple. So obvious. Beneath the window, the submerged face of Robert Langdon stared up at him with desperate and beseeching eyes. Mal'akh shook his head at him and slowly mouthed the words: â€Å"Thank you, Professor. Enjoy the afterlife.† CHAPTER 103 As a serious swimmer, Robert Langdon had often wondered what it would feel like to drown. He now knew he was going to learn firsthand. Although he could hold his breath longer than most people, he could already feel his body reacting to the absence of air. Carbon dioxide was accumulating in his blood, bringing with it the instinctual urge to inhale. Do not breathe! The reflex to inhale was increasing in intensity with each passing moment. Langdon knew very soon he would reach what was called the breath-hold breakpoint–that critical moment at which a person could no longer voluntarily hold his breath. Open the lid! Langdon's instinct was to pound and struggle, but he knew better than to waste valuable oxygen. All he could do was stare up through the blur of water above him and hope. The world outside was now only a hazy patch of light above the Plexiglas window. His core muscles had begun burning, and he knew hypoxia was setting in. Suddenly a beautiful and ghostly face appeared, gazing down at him. It was Katherine, her soft features looking almost ethereal through the veil of liquid. Their eyes met through the Plexiglas window, and for an instant, Langdon thought he was saved. Katherine! Then he heard her muted cries of horror and realized she was being held there by their captor. The tattooed monster was forcing her to bear witness to what was about to happen. Katherine, I'm sorry . . . In this strange, dark place, trapped underwater, Langdon strained to comprehend that these would be his final moments of life. Soon he would cease to exist . . . everything he was . . . or had ever been . . . or would ever be . . . was ending. When his brain died, all of the memories held in his gray matter, along with all of the knowledge he had acquired, would simply evaporate in a flood of chemical reactions. In this moment, Robert Langdon realized his true insignificance in the universe. It was as lonely and humbling a feeling as he had ever experienced. Almost thankfully, he could feel the breath-hold breakpoint arriving. The moment was upon him. Langdon's lungs forced out their spent contents, collapsing in eager preparation to inhale. Still he held out an instant longer. His final second. Then, like a man no longer able to hold his hand to a burning stove, he gave himself over to fate. Reflex overruled reason. His lips parted. His lungs expanded. And the liquid came pouring in. The pain that filled his chest was greater than Langdon had ever imagined. The liquid burned as it poured into his lungs. Instantly, the pain shot upward into his skull, and he felt like his head was being crushed in a vise. There was great thundering in his ears, and through it all, Katherine Solomon was screaming. There was a blinding flash of light. And then blackness. Robert Langdon was gone. CHAPTER 104 It's over. Katherine Solomon had stopped screaming. The drowning she had just witnessed had left her catatonic, virtually paralyzed with shock and despair. Beneath the Plexiglas window, Langdon's dead eyes stared past her into empty space. His frozen expression was one of pain and regret. The last tiny air bubbles trickled out of his lifeless mouth, and then, as if consenting to give up his ghost, the Harvard professor slowly began sinking to the bottom of the tank . . . where he disappeared into the shadows. He's gone. Katherine felt numb. The tattooed man reached down, and with pitiless finality, he slid the small viewing window closed, sealing Langdon's corpse inside. Then he smiled at her. â€Å"Shall we?† Before Katherine could respond, he hoisted her grief-stricken body onto his shoulder, turned out the light, and carried her out of the room. With a few powerful strides, he transported her to the end of the hall, into a large space that seemed to be bathed in a reddish-purple light. The room smelled like incense. He carried her to a square table in the center of the room and dropped her hard on her back, knocking the wind out of her. The surface felt rough and cold. Is this stone? Katherine had hardly gotten her bearings before the man had removed the wire from her wrists and ankles. Instinctively, she attempted to fight him off, but her cramped arms and legs barely responded. He now began strapping her to the table with heavy leather bands, cinching one strap across her knees and then buckling a second across her hips, pinning her arms at her sides. Then he placed a final strap across her sternum, just above her breasts. It had all taken only moments, and Katherine was again immobilized. Her wrists and ankles throbbed now as the circulation returned to her limbs. â€Å"Open your mouth,† the man whispered, licking his own tattooed lips. Katherine clenched her teeth in revulsion. The man again reached out with his index finger and ran it slowly around her lips, making her skin crawl. She clenched her teeth tighter. The tattooed man chuckled and, using his other hand, found a pressure point on her neck and squeezed. Katherine's jaw instantly dropped open. She could feel his finger entering her mouth and running along her tongue. She gagged and tried to bite it, but the finger was already gone. Still grinning, he raised his moist fingertip before her eyes. Then he closed his eyes and, once again, rubbed her saliva into the bare circle of flesh on his head. The man sighed and slowly opened his eyes. Then, with an eerie calm, he turned and left the room. In the sudden silence, Katherine could feel her heart pounding. Directly over her, an unusual series of lights seemed to be modulating from purple red to a deep crimson, illuminating the room's low ceiling. When she saw the ceiling, all she could do was stare. Every inch was covered with drawings. The mind-boggling collage above her appeared to depict the celestial sky. Stars, planets, and constellations mingled with astrological symbols, charts, and formulas. There were arrows predicting elliptical orbits, geometric symbols indicating angles of ascension, and zodiacal creatures peering down at her. It looked like a mad scientist had gotten loose in the Sistine Chapel. Turning her head, Katherine looked away, but the wall to her left was no better. A series of candles on medieval floor stands shed a flickering glow on a wall that was completely hidden beneath pages of text, photos, and drawings. Some of the pages looked like papyrus or vellum torn from ancient books; others were obviously from newer texts; mixed in were photographs, drawings, maps, and schematics; all of them appeared to have been glued to the wall with meticulous care. A spiderweb of strings had been thumbtacked across them, interconnecting them in limitless chaotic possibilities. Katherine again looked away, turning her head in the other direction. Unfortunately, this provided the most terrifying view of all. Adjacent to the stone slab on which she was strapped, there stood a small side counter that instantly reminded her of an instrument table from a hospital operating room. On the counter was arranged a series of objects–among them a syringe, a vial of dark liquid . . . and a large knife with a bone handle and a blade hewn of iron burnished to an unusually high shine. My God . . . what is he planning to do to me? CHAPTER 105 When CIA systems security specialist Rick Parrish finally loped into Nola Kaye's office, he was carrying a single sheet of paper. â€Å"What took you so long?!† Nola demanded. I told you to come down immediately! â€Å"Sorry,† he said, pushing up his bottle-bottom glasses on his long nose. â€Å"I was trying to gather more information for you, but–â€Å" â€Å"Just show me what you've got.† Parrish handed her the printout. â€Å"It's a redaction, but you get the gist.† Nola scanned the page in amazement. â€Å"I'm still trying to figure out how a hacker got access,† Parrish said, â€Å"but it looks like a delegator spider hijacked one of our search–â€Å" â€Å"Forget that!† Nola blurted, glancing up from the page. â€Å"What the hell is the CIA doing with a classified file about pyramids, ancient portals, and engraved symbolons?† â€Å"That's what took me so long. I was trying to see what document was being targeted, so I traced the file path.† Parrish paused, clearing his throat. â€Å"This document turns out to be on a partition personally assigned to . . . the CIA director himself.† Nola wheeled, staring in disbelief. Sato's boss has a file about the Masonic Pyramid? She knew that the current director, along with many other top CIA executives, was a high-ranking Mason, but Nola could not imagine any of them keeping Masonic secrets on a CIA computer. Then again, considering what she had witnessed in the last twenty-four hours, anything was possible. Agent Simkins was lying on his stomach, ensconced in the bushes of Franklin Square. His eyes were trained on the columned entry of the Almas Temple. Nothing. No lights had come on inside, and no one had approached the door. He turned his head and checked on Bellamy. The man was pacing alone in the middle of the park, looking cold. Really cold. Simkins could see him shaking and shivering. His phone vibrated. It was Sato. â€Å"How overdue is our target?† she demanded. Simkins checked his chronograph. â€Å"Target said twenty minutes. It's been almost forty. Something's wrong.† â€Å"He's not coming,† Sato said. â€Å"It's over.† Simkins knew she was right. â€Å"Any word from Hartmann?† â€Å"No, he never checked in from Kalorama Heights. I can't reach him.† Simkins stiffened. If this was true, then something was definitely wrong. â€Å"I just called field support,† Sato said, â€Å"and they can't find him either.† Holy shit. â€Å"Do they have a GPS location on the Escalade?† â€Å"Yeah. A residential address in Kalorama Heights,† Sato said. â€Å"Gather your men. We're pulling out.† Sato clicked off her phone and gazed out at the majestic skyline of her nation's capital. An icy wind whipped through her light jacket, and she wrapped her arms around herself to stay warm. Director Inoue Sato was not a woman who often felt cold . . . or fear. At the moment, however, she was feeling both. CHAPTER 106 Mal'akh wore only his silk loincloth as he dashed up the ramp, through the steel door, and out through the painting into his living room. I need to prepare quickly. He glanced over at the dead CIA agent in the foyer. This home is no longer safe. Carrying the stone pyramid in one hand, Mal'akh strode directly to his first-floor study and sat down at his laptop computer. As he logged in, he pictured Langdon downstairs and wondered how many days or even weeks would pass before the submerged corpse was discovered in the secret basement. It made no difference. Mal'akh would be long gone by then. Langdon has served his role . . . brilliantly. Not only had Langdon reunited the pieces of the Masonic Pyramid, he had figured out how to solve the arcane grid of symbols on the base. At first glance, the symbols seemed indecipherable . . . and yet the answer was simple . . . staring them in the face. Mal'akh's laptop sprang to life, the screen displaying the same e-mail he had received earlier–a photograph of a glowing capstone, partially blocked by Warren Bellamy's finger. The secret hides within The Order. Franklin Square. Eight . . . Franklin Square, Katherine had told Mal'akh. She had also admitted that CIA agents were staking out Franklin Square, hoping to capture Mal'akh and also figure out what order was being referenced by the capstone. The Masons? The Shriners? The Rosicrucians? None of these, Mal'akh now knew. Langdon saw the truth. Ten minutes earlier, with liquid rising around his face, the Harvard professor had figured out the key to solving the pyramid. â€Å"The Order Eight Franklin Square!† he had shouted, terror in his eyes. â€Å"The secret hides within The Order Eight Franklin Square!† At first, Mal'akh failed to understand his meaning. â€Å"It's not an address!† Langdon yelled, his mouth pressed to the Plexiglas window. â€Å"The Order Eight Franklin Square! It's a magic square!† Then he said something about Albrecht Durer . . . and how the pyramid's first code was a clue to breaking this final one. Mal'akh was familiar with magic squares–kameas, as the early mystics called them. The ancient text De Occulta Philosophia described in detail the mystical power of magic squares and the methods for designing powerful sigils based on magical grids of numbers. Now Langdon was telling him that a magic square held the key to deciphering the base of the pyramid? â€Å"You need an eight-by-eight magic square!† the professor had been yelling, his lips the only part of his body above the liquid. â€Å"Magic squares are categorized in orders! A three-by-three square is an `order three'! A four-by-four square is an `order four'! You need an `order eight'!† The liquid had been about to engulf Langdon entirely, and the professor drew one last desperate breath and shouted out something about a famous Mason . . . an American forefather . . . a scientist, mystic, mathematician, inventor . . . as well as the creator of the mystical kamea that bore his name to this day. Franklin. In a flash, Mal'akh knew Langdon was right. Now, breathless with anticipation, Mal'akh sat upstairs at his laptop. He ran a quick Web search, received dozens of hits, chose one, and began reading. THE ORDER EIGHT FRANKLIN SQUARE One of history's best-known magic squares is the order-eight square published in 1769 by American scientist Benjamin Franklin, and which became famous for its inclusion of never- before-seen â€Å"bent diagonal summations.† Franklin's obsession with this mystical art form most likely stemmed from his personal associations with the prominent alchemists and mystics of his day, as well as his own belief in astrology, which were the underpinnings for the predictions made in his Poor Richard's Almanack. Mal'akh studied Franklin's famous creation–a unique arrangement of the numbers 1 through 64–in which every row, column, and diagonal added up to the same magical constant. The secret hides within The Order Eight Franklin Square. Mal'akh smiled. Trembling with excitement, he grabbed the stone pyramid and flipped it over, examining the base. These sixty-four symbols needed to be reorganized and arranged in a different order, their sequence defined by the numbers in Franklin's magic square. Although Mal'akh could not imagine how this chaotic grid of symbols would suddenly make sense in a different order, he had faith in the ancient promise. Ordo ab chao. Heart racing, he took out a sheet of paper and quickly drew an empty eight-by-eight grid. Then he began inserting the symbols, one by one, in their newly defined positions. Almost immediately, to his astonishment, the grid began making sense. Order from chaos! He completed the entire decryption and stared in disbelief at the solution before him. A stark image had taken shape. The jumbled grid had been transformed . . . reorganized . . . and although Mal'akh could not grasp the meaning of the entire message, he understood enough . . . enough to know exactly where he was now headed. The pyramid points the way. The grid pointed to one of the world's great mystical locations. Incredibly, it was the same location at which Mal'akh had always fantasized he would complete his journey. Destiny.

Capitalism and Freedom by Milton Friedman - 1252 Words

Inspired by lectures given in 1956 and compiled for publication in 1962, Milton Friedman’s Capitalism and Freedom addresses important modern economic issues ranging from the distribution of income to the role of government in education (Friedman vii). According to The Times Literary Supplement, Capitalism and Freedom was â€Å"one of the most influential books published since the war† (TLS). In the seventh chapter of Capitalism and Freedom, Friedman addresses the role capitalism and economic freedom plays in the reduction of discrimination against individuals belonging to particular religious, social, and racial minority groups (Friedman 108). Friedman’s argument concerning the power of capitalism and economic power is supported particularly in the increased mobility of African Americans following World War I and II despite the â€Å"temporary interruption† displayed by collectivist trends following 1945 (Friedman 11). African Americans, with newfound econ omic power, were able to curtail coercive political power held by whites. However, Friedman fails to properly address the chain of events which allowed for the establishment political freedom in the African American community. Despite economic freedom granted following emancipation, African Americans were unable to translate economic freedom to political freedom because laws in place to protect civil liberties were not enforced. World War I provided unprecedented economic opportunities for African Americans. Labor shortages provideShow MoreRelatedMilton Friedman s Capitalism And Freedom Essay1727 Words   |  7 PagesMilton Friedman, in Capitalism and Freedom, investigates the link between economic and political freedom. While many supporters of democratic socialism consider that â€Å"politics and economics are separate and largely unconnected,† Friedman contests that the two are inextricably linked. To prove this assertion, he mentions that â€Å"the citizen of the Unit ed States who is compelled by law to devote †¦ ten percent of his income to the purchase of a particular kind of retirement contact †¦ is being deprivedRead MoreAnalysis Of Capitalism And Freedom By Milton Friedman1741 Words   |  7 Pageslaissez-faire capitalism, Milton Friedman. His arguably most famous text Capitalism and Freedom puts rests the argument for free market capitalism upon three pillars of thought that Friedman believes to be self evident: privately operated markets are naturally occurring, significantly more efficient than a centrally planned economy because of the limited information available to individual actors, and morally justified as an expression of the rights to self-determination and political freedom. As definedRead MoreFree Market Economy: Capitalism and Freedom by Milton Friedman948 Words   |  4 Pagesfree trade to occur and thus no way for free markets to exist. In this way free markets are shown to be essential to freedom and vice ver sa. In his book Capitalism and Freedom Milton Friedman says, â€Å"Historical evidence speaks with a single voice on the relation between political freedom and a free market† (pg. 9). Friedman is right in many ways, there cannot be political freedom without a free market, and so as principle number five states â€Å"there is no better way to organize economic activity†,Read MoreCapitalism and Freedom Book Review1347 Words   |  6 PagesWarren Bryan 3/5/12 Book Review: Capitalism Freedom Author: Milton Friedman Milton Friedman’s Capitalism amp; Freedom is one of the most important books regarding economics of the 20th century. His thoughts laid the groundwork for the emerging modern conservative movement, which was an evolution of the 19th century beliefs surrounding liberalism. Friedman’s major themes of his most famous work consist of the roles of competitive capitalism, as well as the role that government shouldRead MoreMarx View on Capitalism1635 Words   |  7 Pageswritten in 1947, so important to us that we are reading it in University in 2009? History speaks to the present, and this text takes us into the past to help us understand the flaws of our socio economic system of capitalism and questions the social responsibility of businesses under capitalism. Social responsibility of a business is the willingness of a business to accept responsibility for its actions and their impact on a range of stakeholders. In All My Sons, Arthur Miller narrates a story of JoeRead Mo reMilton Friedmans Ideas Essay1646 Words   |  7 PagesINTRODUCTION Milton Friedman’s ideas where thought to be radical, but he was the most authoritative figure in the economics field in the 20th century, (Placeholder2) and was known most for his thoughts on free enterprise, classical liberalism and limited government. (Placeholder3) His views shaped modern capitalism. (Placeholder2) He was against government intervention and favored free markets (Placeholder6). If you put the federal government in charge of the Sahara Desert, in 5 years theredRead MoreThe Relation Between Economic Freedom And Political Freedom1216 Words   |  5 Pagesrelation between Economic Freedom and Political Freedom and also the Role of Government in a Free Society written by Milton Friedman. Many of us believe that politics and economics are separated and that individual’s freedom is a political problem and material welfare is an economic problem, but according to Friedman Political freedom and economics freedom are related. He believes that you cannot have one without the other, because taking an individual political freedom is actually depriving thatRead MoreCapitalism And Freedom By Milton Friedmans Pride And Prejudice1527 Words   |  7 PagesBrigid Ueland Contemporary Economic Thought ECON – 3000A Dr. Coronado September 14th, 2017 Capitalism and Freedom by Milton Friedman: The Economist’s Pride and Prejudice The opening line of Milton Friedman’s Capitalism and Freedom reads as an opening line in a Jane Austen novel: â€Å"It is widely believed that politics and economics and separate and largely unconnected; that individual freedom is a political problem and material welfare an economic problem†¦Ã¢â‚¬  sounds similar in structure and toneRead MoreMilton Friedman and His Contribution For The Economic Field Essay1218 Words   |  5 Pagesproductive uses. The minimal government advocacy of an ‘’unregulated free market’’ is founded on an ‘’assumption about individuals being rational, self-interested and methodical in the pursuit of their goals. Adam Smith was not an advocate of pure capitalism. Adam Smith allowed for many exceptions to a strictly free-market economy. The classical liberals advocated policies to increase liberty and prosperity. They sought to empower the commercial class politically. They abolish royal charters, monopol iesRead MoreThe And The Industrial Man984 Words   |  4 Pagesnecessary to having a thriving society and economy. Clark Kerr wrote the document Industrialism and the Industrial Man which highlights and explains the perspective of having a centralized government in power. Contrastingly, Capitalism and Freedom, written by Milton Friedman is in support of a limited government and placing a check on concentrated power. Both documents reflect the two different styles of government and provide context to their functions and the application of their duties. In Industrialism