The Transportation Revolution and its Consequences: The Railway Freight Rate Controversy of the Late Nineteenth Century

By the turn of the century, a growing coalition of business and political leaders came to share a common goal — the creation of a national regulatory commission to control railway freight rates. The development of a coordinated railway network and advances in locomotive technology made possible a general decline in transportation costs. Business leaders consequently became concerned with the uneven way in which the private rate-making process distributed the benefits of the transportation revolution, particularly declining freight rates. In eastern Canada, they blamed railway rate-making policies for disrupting established patterns of trade. In western Canada, they castigated railway officials for failing to adjust the rate structure in response to the rapid development of new centres of economic activity. At the same time as it made possible the development of large-scale mercantile and industrial enterprise, then, the transportation revolution also created demands for a significant expansion of the state's authority over the largest of all nineteenth-century industries, the railway.Au tourant du siècle, les hommes d'affaires et les chefs politiques en vinrent à partager le même objectif: créer une commission nationale pour réglementer les tarifs du transport des marchandises par chemin de fer. Le développement d'un réseau coordonné de chemins de fer et les progrès technologiques concernant la locomotive permettaient une diminution générale des coûts de transport. En conséquence, les hommes d'affaires se mirent à éprouver des inquiétudes devant le fait que les régimes tarifaires donnaient lieu à une répartition inégale des profits à tirer de la révolution des transports, notamment en ce qui a trait à une réduction des tarifs de fret. Dans l'est du Canada, c'est aux dispositions tarifaires des chemins de fer qu'ils ont attribué l'interruption des réseaux d'échanges commerciaux établis de longue date. Dans l'ouest du pays, ils ont reproché aux responsables du chemin de fer de n'avoir pas su ajuster la tarification au développement rapide des nouveaux centres d'activité économique. Certes, la révolution des transports permettait une expansion du commerce et de l'industrie sur une large échelle, mais en même temps, elle requérait de l'État une autorité d'autant plus ferme sur la plus importante de toutes les industries du XIXe siècle, celle des chemins de fer

Uniform or Sex-Specific Cardiac Troponin Thresholds to Rule-out Myocardial Infarction at Presentation

Background: Myocardial infarction can be ruled out in patients with a single cardiac troponin measurement. Whether use of a uniform rule-out threshold has resulted in sex-differences in care remains unclear.Objectives: To evaluate implementation of a uniform rule-out threshold in females and males with possible myocardial infarction, and to derive and validate sex-specific thresholds. Methods: The implementation of a uniform rule-out threshold (&lt;5 ng/L) with a high-sensitivity cardiac troponin I assay was evaluated in consecutive patients presenting with possible myocardial infarction. The proportion of low-risk patients discharged from Emergency Department (ED) and incidence of myocardial infarction or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and proportion of female and male patients stratified as low-risk compared with uniform threshold.Results: In 16,792 patients (58±17 years, 46% female) care was guided using a uniform threshold. This identified more female than male patients as low-risk (73% versus 62%), but a similar proportion of low-risk patients were discharged from ED (81% for both) with fewer than 5 (&lt;0.1%) patients having a subsequent myocardial infarction or cardiac death at 30 days. Compared to uniform threshold of &lt;5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% versus 65.9%) and reduce the proportion of male (54.8% versus 47.8%) patients identified as low-risk.Conclusions: Implementation of a uniform rule-out threshold for myocardial infarction was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited.Keywords: Cardiac troponin, sex, myocardial infarction<br/

High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study

Objective To evaluate the diagnosis of myocardial infarction using a high sensitivity troponin I assay and sex specific diagnostic thresholds in men and women with suspected acute coronary syndrome. Design Prospective cohort study. Setting Regional cardiac centre, United Kingdom. Participants Consecutive patients with suspected acute coronary syndrome (n=1126, 46% women). Two cardiologists independently adjudicated the diagnosis of myocardial infarction by using a high sensitivity troponin I assay with sex specific diagnostic thresholds (men 34 ng/L, women 16 ng/L) and compared with current practice where a contemporary assay (50 ng/L, single threshold) was used to guide care. Main outcome measure Diagnosis of myocardial infarction. Results The high sensitivity troponin I assay noticeably increased the diagnosis of myocardial infarction in women (from 11% to 22%; P&lt;0.001) but had a minimal effect in men (from 19% to 21%, P=0.002). Women were less likely than men to be referred to a cardiologist or undergo coronary revascularisation (P&lt;0.05 for both). At 12 months, women with undisclosed increases in troponin concentration (17-49 ng/L) and those with myocardial infarction (≥50 ng/L) had the highest rate of death or reinfarction compared with women without (≤16 ng/L) myocardial infarction (25%, 24%, and 4%, respectively; P&lt;0.001). Conclusions Although having little effect in men, a high sensitivity troponin assay with sex specific diagnostic thresholds may double the diagnosis of myocardial infarction in women and identify those at high risk of reinfarction and death. Whether use of sex specific diagnostic thresholds will improve outcomes and tackle inequalities in the treatment of women with suspected acute coronary syndrome requires urgent attention