Canadian Pregnancy Outcomes in Rheumatoid Arthritis and Systemic Lupus Erythematosus

Objective. To describe obstetrical and neonatal outcomes in Canadian women with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). Methods. An administrative database of hospitalizations for neonatal delivery (1998–2009) from Calgary, Alberta was searched to identify women with RA (38 pregnancies) or SLE (95 pregnancies), and women from the general population matched on maternal age and year of delivery (150 and 375 pregnancies, resp.). Conditional logistic regression was used to calculate odds ratios (OR) for maternal and neonatal outcomes, adjusting for parity. Results. Women with SLE had increased odds for preeclampsia or eclampsia (SLE OR 2.16 (95% CI 1.10–4.21; P = 0.024); RA OR 2.33 (95% CI 0.76–7.14; P = 0.138)). Women with SLE had increased odds for cesarean section after adjustment for dysfunctional labour, instrumentation and previous cesarean section (OR 3.47 (95% CI 1.67–7.22; P < 0.001)). Neonates born to women with SLE had increased odds of prematurity (SLE OR 6.17 (95% CI 3.28–11.58; P < 0.001); RA OR 2.66 (95% CI 0.90–7.84; P = 0.076)) and of SGA (SLE OR 2.54 (95% CI 1.42–4.55; P = 0.002); RA OR 2.18 (95% CI 0.84–5.66; P = 0.108)) after adjusting for maternal hypertension. There was no excess risk of congenital defects in neonates. Conclusions. There is increased obstetrical and neonatal morbidity in Canadian women with RA or SLE

Networks and History

Events and event structures compose the constituent elements of history. In order to construct historical accounts of event sequences, historians have to make cases. This article proposes a method for casing historical events. We illustrate the analytic strategy by considering a complex population of interrelated events that make up a narrative of revolution, counter revolution, and revolution in a small village in China. Implications for the methodology of historical social science are discussed

Animation as Kinetic Art

Animation can be simply described as giving motion, or the appearance of motion, to normally static objects and kinetic is defined by Webster as "to move" or "resulting from motion." In an animated film a large number of normally static compositions are filmed frame by frame and the differences between them give the viewer the illusion of motion. In making an animation, unlike filming live action, the artist is in complete charge of the material and the movements portrayed. He chooses the images he wishes and combines them in compositions that are expressively effective. He can move his images according to laws he sets up to establish new relationships. He is not limited to recording the reality of the world around him but can illustrate his own internalized reality or dream world. &nbsp; For me however, film is a more personal medium than either traditional drawing or painting. I think that this is partly because of the unusual visual impact of the film medium. Film has all the potentialities of other media but also adds its own unique qualities. Color in a projected film is much richer than is possible in painting and film has the inherent property of motion. I feel that I have just begun to explore the potential of animated films as a medium for truly kinetic art.</p

Absence of bias against smokers in access to coronary revascularization after cardiac catheterization

Objective. Many consider smoking to be a personal choice for which individuals should be held accountable. We assessed whether there is any evidence of bias against smokers in cardiac care decision-making by determining whether smokers were as likely as non-smokers to undergo revascularization procedures after cardiac catheterization. Design. Prospective cohort study. Subjects and setting. All patients undergoing cardiac catheterization in Alberta, Canada. Main measures. Patients were categorized as current smokers, former smokers, or never smokers, and then compared for their risk-adjusted likelihood of undergoing revascularization procedures (percutaneous coronary intervention or coronary artery bypass grafting) after cardiac catheterization. Results. Among 20406 patients undergoing catheterization, 25.4% were current smokers at the time of catheterization, 36.6% were former smokers, and 38.0% had never smoked. When compared with never smokers (reference group), the hazard ratio for undergoing any revascularization procedure after catheterization was 0.98 (95% CI 0.93-1.03) for current smokers and 0.98 (0.94-1.03) for former smokers. The hazard ratio for undergoing coronary artery bypass grafting was 1.09 (1.00-1.19) for current smokers and 1.00 (0.93-1.08) for former smokers. For percutaneous coronary intervention, the hazard ratios were 0.93 (0.87-0.99) for current smokers and 1.00 (0.94-1.06) for former smokers. Conclusion. Despite potential for discrimination on the basis of smoking status, current and former smokers undergoing cardiac catheterization in Alberta, Canada were as likely to undergo revascularization procedures as catheterization patients who had never smoke

SnTox3 Acts in Effector Triggered Susceptibility to Induce Disease on Wheat Carrying the Snn3 Gene

The necrotrophic fungus Stagonospora nodorum produces multiple proteinaceous host-selective toxins (HSTs) which act in effector triggered susceptibility. Here, we report the molecular cloning and functional characterization of the SnTox3-encoding gene, designated SnTox3, as well as the initial characterization of the SnTox3 protein. SnTox3 is a 693 bp intron-free gene with little obvious homology to other known genes. The predicted immature SnTox3 protein is 25.8 kDa in size. A 20 amino acid signal sequence as well as a possible pro sequence are predicted. Six cysteine residues are predicted to form disulfide bonds and are shown to be important for SnTox3 activity. Using heterologous expression in Pichia pastoris and transformation into an avirulent S. nodorum isolate, we show that SnTox3 encodes the SnTox3 protein and that SnTox3 interacts with the wheat susceptibility gene Snn3. In addition, the avirulent S. nodorum isolate transformed with SnTox3 was virulent on host lines expressing the Snn3 gene. SnTox3-disrupted mutants were deficient in the production of SnTox3 and avirulent on the Snn3 differential wheat line BG220. An analysis of genetic diversity revealed that SnTox3 is present in 60.1% of a worldwide collection of 923 isolates and occurs as eleven nucleotide haplotypes resulting in four amino acid haplotypes. The cloning of SnTox3 provides a fundamental tool for the investigation of the S. nodorum-wheat interaction, as well as vital information for the general characterization of necrotroph-plant interactions.This work was supported by USDA-ARS CRIS projects 5442-22000-043-00D and 5442-22000-030-00D

Diagnostic error in the emergency department: learning from national patient safety incident report analysis.

BACKGROUND: Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence. METHODS: A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes. RESULTS: There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols. CONCLUSIONS: Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements

Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain

Objective To derive a clinical decision guide (CDG) to identify patients best suited for cervical diagnostic facet joint blocks. Design Prospective cohort study. Setting Pain management center. Participants Consecutive patients with neck pain (N=125) referred to an interventional pain management center were approached to participate. Interventions Subjects underwent a standardized testing protocol, performed by a physiotherapist, prior to receiving diagnostic facet joint blocks. All subjects received the reference standard diagnostic facet joint block protocol, namely controlled medial branch blocks (MBBs). The physicians performing the MBBs were blinded to the local anesthetic used and findings of the clinical tests. Main Outcome Measures Multivariate regression analyses were performed in the derivation of the CDGs. Sensitivity, specificity, positive and negative likelihood ratios, and 95% confidence intervals (CIs) were calculated for the index tests and CDGs. Results A CDG involving the findings of the manual spinal examination (MSE), palpation for segmental tenderness (PST), and extension-rotation (ER) test demonstrated a specificity of 84% (95% CI, 77-90) and a positive likelihood ratio of 4.94 (95% CI, 2.8-8.2). Sensitivity of the PST and MSE were 94% (95% CI, 90-98) and 92% (95% CI, 88-97), respectively. Negative findings on the PST were associated with a negative likelihood ratio of.08 (95% CI,.03-.24). Conclusions MSE, PST, and ER may be useful tests in identifying patients suitable for diagnostic facet joint blocks. Further research is needed to validate the CDGs prior to their routine use in clinical practice

Accuracy of city postal code coordinates as a proxy for location of residence

BACKGROUND: Health studies sometimes rely on postal code location as a proxy for the location of residence. This study compares the postal code location to that of the street address using a database from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH(©)). Cardiac catheterization cases in an urban Canadian City were used for calendar year 1999. We determined location in meters for both the address (using the City of Calgary Street Network File in ArcView 3.2) and postal code location (using Statistic Canada's Postal Code Conversion File). RESULTS: The distance between the two estimates of location for each case were measured and it was found that 87.9% of the postal code locations were within 200 meters of the true address location (straight line distances) and 96.5% were within 500 meters of the address location (straight line distances). CONCLUSIONS: We conclude that postal code locations are a reasonably accurate proxy for address location. However, there may be research questions for which a more accurate description of location is required

Linking Clinical and Administrative Data to Inform Performance Measures Regarding Access to Specialist Care for Patients with Rheumatoid Arthritis

Introduction Rheumatoid arthritis (RA) is the most prevalent type of chronic adult inflammatory arthritis and requires timely diagnosis and subsequent access to specialist care and treatment from a rheumatologist. We developed a set of key performance indicators (KPIs) to evaluate access, effectiveness, acceptability, appropriateness and efficiency of care. Objectives and Approach The overall objective was to measure performance of a central intake system for referral to rheumatology against the KPIs. We report on one accessibility KPIs: the percentage of patients with new onset RA with at least one visit to a rheumatologist in the first 365 days since diagnosis.  We identified a cohort of RA patients using a validated case definition: >16 years, at least 1 RA related hospitalization (ICD-10-CA:M05.x-M06.x) or two RA related physician visits ≥ eight weeks apart within two years (ICD-9: 714.x).  The incident case date was date of hospitalization or second physician visit (whichever came first). Results This KPI assessed the proportion of patients seen by a rheumatologist within one year of first RA visit by patients in the RA cohort. 13,914 cases of RA were diagnosed between April 1 2010 and March 31 2016. The percentage of patients with new onset RA with at least one visit to a rheumatologist in the first 365 days since diagnosis increased between fiscal years 2011 and 2015. Of the 2851 incident RA cases in fiscal year 2011, 1490 (53%) met the performance measure compared to 1710 of 2710 (63%) who met the definition in fiscal year 2015. Other KPIs, including wait times, are being evaluated using both clinical and administrative data. Conclusion/Implications By linking multiple administrative datasets, we are able to measure system performance against a defined KPI and identify opportunities for system improvement. This is the first initiative in Alberta for patients with RA where data from different multi-custodial data repositories have been extracted, linked and analyzed for this purpose