Hospital discharge data is not accurate enough to monitor the incidence of postpartum hemorrhage.

Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Therefore, cumulative incidence of postpartum hemorrhage and severe postpartum hemorrhage are commonly monitored within and compared across maternity hospitals or countries for obstetrical safety improvement. These indicators are usually based on hospital discharge data though their accuracy is seldom assessed. We aimed to measure postpartum hemorrhage and severe postpartum hemorrhage using electronic health records and hospital discharge data separately and compare the detection accuracy of these methods to manual chart review, and to examine the temporal trends in cumulative incidence of these potentially avoidable adverse outcomes. We analyzed routinely collected data of 7904 singleton deliveries from a large Swiss university hospital for a three year period (2014-2016). We identified postpartum hemorrhage and severe postpartum hemorrhage in electronic health records by text mining discharge letters and operative reports and calculating drop in hemoglobin from laboratory tests. Diagnostic and procedure codes were used to identify cases in hospital discharge data. A sample of 334 charts was reviewed manually to provide a reference-standard and evaluate the accuracy of the other detection methods. Sensitivities of detection algorithms based on electronic health records and hospital discharge data were 95.2% (95% CI: 92.6% 97.8%) and 38.2% (33.3% to 43.0%), respectively for postpartum hemorrhage, and 87.5% (85.2% to 89.8%) and 36.2% (26.3% to 46.1%) for severe postpartum hemorrhage. Postpartum hemorrhage cumulative incidence based on electronic health records decreased from 15.6% (13.1% to 18.2%) to 8.5% (6.7% to 10.5%) from the beginning of 2014 to the end of 2016, with an average of 12.5% (11.8% to 13.3%). The cumulative incidence of severe postpartum hemorrhage remained at approximately 4% (3.5% to 4.4%). Hospital discharge data-based algorithms provided significantly underestimated incidences. Hospital discharge data is not accurate enough to assess the incidence of postpartum hemorrhage at hospital or national level. Instead, automated algorithms based on structured and textual data from electronic health records should be considered, as they provide accurate and timely estimates for monitoring and improvement in obstetrical safety. Furthermore, they have the potential to better code for postpartum hemorrhage thus improving hospital reimbursement

Competing English, Spanish, and French alabaster trade in Europe over five centuries as evidenced by isotope fingerprinting

A lack of written sources is a serious obstacle in the reconstruction of the medieval trade of art and art materials, and in the identification of artists, workshop locations, and trade routes. We use the isotopes of sulfur, oxygen, and strontium (S, O, Sr) present in gypsum alabaster to unambiguously link ancient European source quarries and areas to alabaster artworks produced over five centuries (12th–17th) held by the Louvre museum in Paris and other European and American collections. Three principal alabaster production areas are identified, in central England, northern Spain, and a major, long-lived but little-documented alabaster trade radiating from the French Alps. The related trade routes are mostly fluvial, although terrestrial transport crossing the major river basin borders is also confirmed by historical sources. Our study also identifies recent artwork restoration using Italian alabaster and provides a robust geochemical framework for provenancing, including recognition of restoration and forgeries

Secretion of Genome-Free Hepatitis B Virus – Single Strand Blocking Model for Virion Morphogenesis of Para-retrovirus

As a para-retrovirus, hepatitis B virus (HBV) is an enveloped virus with a double-stranded (DS) DNA genome that is replicated by reverse transcription of an RNA intermediate, the pregenomic RNA or pgRNA. HBV assembly begins with the formation of an “immature” nucleocapsid (NC) incorporating pgRNA, which is converted via reverse transcription within the maturing NC to the DS DNA genome. Only the mature, DS DNA-containing NCs are enveloped and secreted as virions whereas immature NCs containing RNA or single-stranded (SS) DNA are not enveloped. The current model for selective virion morphogenesis postulates that accumulation of DS DNA within the NC induces a “maturation signal” that, in turn, triggers its envelopment and secretion. However, we have found, by careful quantification of viral DNA and NCs in HBV virions secreted in vitro and in vivo, that the vast majority of HBV virions (over 90%) contained no DNA at all, indicating that NCs with no genome were enveloped and secreted as empty virions (i.e., enveloped NCs with no DNA). Furthermore, viral mutants bearing mutations precluding any DNA synthesis secreted exclusively empty virions. Thus, viral DNA synthesis is not required for HBV virion morphogenesis. On the other hand, NCs containing RNA or SS DNA were excluded from virion formation. The secretion of DS DNA-containing as well as empty virions on one hand, and the lack of secretion of virions containing single-stranded (SS) DNA or RNA on the other, prompted us to propose an alternative, “Single Strand Blocking” model to explain selective HBV morphogenesis whereby SS nucleic acid within the NC negatively regulates NC envelopment, which is relieved upon second strand DNA synthesis

Control limits to identify outlying hospitals based on risk-stratification.

Outcome indicators are routinely used to compare hospitals with respect to quality of care. Indicators might be based on observed proportions of adverse events (binary outcomes) or observed averages of e.g. lengths or costs of hospital stays (continuous outcomes). These observed values are compared with expected ones in an average hospital, which might be estimated from a reference sample and should be appropriately adjusted for the case mix of patients. One possibility to achieve a reliable adjustment is to stratify the patients according to their risks, where each patient belongs to one and only one stratum. Control limits calculated under the null hypothesis of an average hospital, allowing to decide whether a discrepancy between an observed and an expected value might be explained by chance or not, are then plotted around the indicator, such that hospitals falling above those control limits are detected as being statistically worse than an average hospital. Calculation of valid control limits is however not always obvious. In this article, we propose a simple and unified framework to calculate such control limits when adjustment is based on stratification, where we allow to distinguish and disentangle the variability explained by stratification and the variability due to chance, where we take into account the uncertainty about the estimation of the expected values, and where it is possible not only to detect those hospitals which are statistically worse, but also those which are statistically much worse than an average hospital. The method applies both to binary and continuous outcomes and is illustrated on Swiss hospital discharge data

Identifying common patterns of health services use: a longitudinal study of older Swiss adults' care trajectories.

Population ageing puts pressure on health systems initially designed to handle acute and episodic illnesses. Segmenting an ageing population based on its healthcare utilization may enable policymakers to undertake evidence-based resource planning. We aimed to derive a typology of healthcare utilization trajectories in Swiss older adults. Our work used data from the Lc65 + study, a population-based cohort of individuals aged 65 to 70 years at enrolment. The dimensions of healthcare utilization considered were ambulatory care, emergency care, hospitalizations, professional home care and nursing home stay. We applied the Sequence Analysis framework, within which we quantified the variation between each multidimensional pair of sequences, implemented a clustering procedure that grouped together older persons with similar profiles of health services use, and characterized clusters of individuals using selected baseline covariates. Healthcare utilization trajectories were analysed for 2271 community-dwelling older adults over a period of 11 years. Six homogeneous subgroups were identified: constant low utilization (83.3% of participants), increased utilization (4.9%), late health deterioration (4.4%), ambulatory care to nursing home (1.5%), early fatal event (3.8%) and high ambulatory care (2.1%). Associations were found between cluster membership and age, sex, household composition, self-perceived health, grip strength measurement, comorbidities, and functional dependency. The heterogeneous healthcare utilization profiles can be clustered into six common patterns. Different manifestations of functional decline were apparent in two distinct trajectory groups featuring regular home care use. Furthermore, a small proportion of individuals with a unique set of characteristics was related to the highest levels of ambulatory and emergency care use. New research avenues are outlined to investigate time-varying effects of health factors inside the clusters containing most unfavourable outcomes

Coping with the worst of both worlds: Phenotypic adjustments for cold acclimatization benefit northward migration and arrival in the cold in an Arctic-breeding songbird

Cold acclimatization (phenotypic adjustments to cope with cold conditions) is an imperative requirement for birds living at high latitudes during the cold depths of winter. Despite the significant remodelling of key phenotypic traits and energetic costs associated with elevating cold endurance, winter cold acclimatization can also provide further carryover benefits to subsequent stages in species wintering, migrating and breeding in cold environments (e.g. the Arctic). We tested this beneficial carryover hypothesis using outdoor captive Arctic-breeding snow buntings Plectrophenax nivalis, a cold specialist known for its impressive wintering thermogenic capabilities. We compared changes in phenotypic traits supporting cold acclimatization—body composition (body, fat, lean mass, pectoral muscle thickness), oxygen carrying capacity (haematocrit), thermogenic capacity and endurance (Msum, time to Msum), cold tolerance (Ta at Msum) and maintenance energy expenditure (BMR)—between the wintering, migratory and arrival/summer stages. Body mass (+31%), fat mass (+226%) and BMR (+13%) increased relative to the winter phenotype, likely to support the added costs of migration—that is the migratory upregulation hypothesis. In contrast, lean mass, pectoral muscle thickness, haematocrit and thermogenic capacity remained high and stable at winter level across stages in support of the thermal carryover hypothesis. The maintenance of these traits likely offers spare capacity for unpredictable cold environments expected during migration and breeding in the Arctic. Our results thus suggest that birds can extend the long-term advantages of winter phenotypic adjustments through additional benefits to thermogenic capacity during subsequent life-history stages. These benefits likely make it possible for Arctic-breeding birds to maximize success across diverse life-history stages in the face of extreme cold conditions