ObjectiveTo investigate delays from symptom onset to rheumatology assessment for patients with a new onset of rheumatoid arthritis (RA) or unclassified arthritis.MethodsNewly presenting adults with ...either RA or unclassified arthritis were recruited from rheumatology clinics. Data on the length of time between symptom onset and first seeing a GP (patient delay), between first seeing a general practitioner (GP) and being referred to a rheumatologist (general practitioner delay) and being seen by a rheumatologist following referral (hospital delay) were captured.Results822 patients participated (563 female, mean age 55 years). The median time between symptom onset and seeing a rheumatologist was 27.2 weeks (IQR 14.1–66 weeks); only 20% of patients were seen within the first 3 months following symptom onset. The median patient delay was 5.4 weeks (IQR 1.4–26.3 weeks). Patients who purchased over-the-counter medications or used ice/heat packs took longer to seek help than those who did not. In addition, those with a palindromic or an insidious symptom onset delayed for longer than those with a non-palindromic or acute onset. The median general practitioner delay was 6.9 weeks (IQR 2.3–20.3 weeks). Patients made a mean of 4 GP visits before being referred. The median hospital delay was 4.7 weeks (IQR 2.9–7.5 weeks).ConclusionThis study identified delays at all levels in the pathway towards assessment by a rheumatologist. However, delays in primary care were particularly long. Patient delay was driven by the nature of symptom onset. Complex multi-faceted interventions to promote rapid help seeking and to facilitate prompt onward referral from primary care should be developed.
Linda Rae Murray, MD, MPH, a champion of social justice and outspoken advocate for the medically underserved for more than 40 years, is not easy to describe. Part E. F. Hutton (when she talks, people ...listen), part streetwise negotiator (she's not shy about dropping a four-letter word into conversation), she might come across as brash and intimidating to some. But those who know her well will attest to her softhearted interior, and her unwavering commitment to speaking out in the name of better health for all.
This dissertation explores the nature and significance of fear in the works of Seneca the Younger. While a variety of emotions have already been examined within the writings of this author, fear ...remains largely neglected despite its prevalence and fundamental nature. This study contributes to work being done on themes shared across Seneca’s entire literary output, on the relevance of Stoicism to Seneca’s tragedies, and on emotions in the ancient world, especially within the writings of this extremely pertinent author.The project begins with the compilation of a theoretical De metu, based loosely on Seneca’s De ira, to show that a detailed understanding of Seneca’s conception of fear can be gleaned through careful analysis of material from across his corpus. Drawing on the over 1,200 references to fear from throughout Seneca’s corpus, this De metu lays out Seneca’s definition of fear and the causes, effects, and potential therapies he envisions for it. A De metu also allows for a closer comparison of anger and fear, two emotions that Seneca views as similar in both nature and in intensity. This fuller understanding of fear can then be applied to Seneca’s tragedies to see how his ideas of fear are transformed by the tragedic medium.The rest of the project deals with fear within the tragedies on both thematic and narrative levels. The first of these chapters argues that the nature of fear as presented in Seneca’s philosophical works has been adapted for thematic use within various elements of the tragedies. At some points the tragedies reflect his philosophical thinking, reinforcing the philosopher’s understanding of the emotion. More often, however, fear’s nature is distorted or embellished for literary effect, derailing the audience’s expectations of how this emotion functions. Seneca is willing to exceed or vary the nature of fear established in his philosophical works in order to create stronger dramatic effects and follow the conventions of this other genre. Some of the broader thematic uses of fear considered include how fear is used to create suspense, spectacle, and characterization; the use of therapy to combat fear; and what the common sources of fear are, with special focus on the fear of death and the afterlife. Evidence for these thematic uses of fear is drawn from all of Seneca’s tragedies, revealing the widespread relevance of this emotion.The final chapter argues that fear plays a significant role in shaping the situations of several main figures of Seneca’s plays; without a full understanding of fear, the nuance of Seneca’s commentary on these characters’ flaws, misfortunes, and ruling styles is incomplete. The presence of fear in Oedipus has already been noted in scholarship, yet a better understanding of Seneca’s ideal therapies for fear and the dangers fear poses shed more light on this play. In Thyestes, special attention must be paid to the emotions of Atreus and Thyestes: each brother experiences both fear and its related passion anger, and alternate between the two over the course of their plotting. Finally, Troades offers further insight into Seneca’s understanding of the relationship of fear and hope. Andromache and Hecuba endure similar circumstances, but while Hecuba experiences merely resignation, the survival of Andromache’s son drives her to hope and thus also to fear. Fear therefore plays a key role in the development of each of these plays.Ultimately, it is possible to determine not only how Seneca defines the nature of fear, but also to what extent and in what ways fear in the tragedies draws upon Seneca’s philosophy. Fear provides Seneca with a vital tool for creating successful and meaningful tragedies.
We assessed the relationship between antigen and reverse transcription PCR (RT-PCR) test positivity and successful virus isolation. We found that antigen test results were more predictive of virus ...recovery than RT-PCR results. However, virus was isolated from some antigen-negative and RT-PCR‒positive paired specimens, providing support for the Centers for Disease Control and Prevention antigen testing algorithm.
Physical activity (PA) typically declines throughout pregnancy. Low levels of PA are associated with excessive weight gain and subsequently increase risk of pre-eclampsia, gestational diabetes ...mellitus, hypertension disorders, delivery by caesarean section and stillbirth. Systematic reviews on PA during pregnancy have not explored the efficacy of behaviour change techniques or related theory in altering PA behaviour. This systematic review evaluated the content of PA interventions to reduce the decline of PA in pregnant women with a specific emphasis on the behaviour change techniques employed to elicit this change.
Literature searches were conducted in eight databases. Strict inclusion and exclusion criteria were employed. Two reviewers independently evaluated each intervention using the behaviour change techniques (BCT) taxonomy to identify the specific behaviour change techniques employed. Two reviewers independently assessed the risk of bias using the guidelines from the Cochrane Collaboration. Overall quality was determined using the GRADE approach.
A total of 1140 potentially eligible papers were identified from which 14 studies were selected for inclusion. Interventions included counselling (n = 6), structured exercise (n = 6) and education (n = 2). Common behaviour change techniques employed in these studies were goal setting and planning, feedback, repetition and substitution, shaping knowledge and comparison of behaviours. Regular face-to-face meetings were also commonly employed. PA change over time in intervention groups ranged from increases of 28% to decreases of 25%. In 8 out of 10 studies, which provided adequate data, participants in the intervention group were more physically active post intervention than controls.
Physical activity interventions incorporating behaviour change techniques help reduce the decline in PA throughout pregnancy. Range of behaviour change techniques can be implemented to reduce this decline including goals and planning, shaping knowledge and comparison of outcomes. A lack of high quality interventions hampers conclusions of intervention effectiveness.
•Nurse leaders play an important role in the acquisition, implementation and optimization of health information technology.•Currently senior nurse leaders may not be properly equipped to effectively ...participate in health informatics initiatives.•A novel set of informatics competencies specific to nurse leaders in Canada have been identified.•These initial competencies are being used as a starting point for similar studies in at least one other country.
Nurse leaders in senior leadership positions in various parts of the world can play an important role in the acquisition, implementation and use of health information technologies. To date, international research related to nurse leader informatics competencies has been carried out in specific healthcare delivery contexts with very specific health information technology environments. In this body of literature, the definition of a ‘nurse leader’ has not been clearly defined. As a result, it is challenging for senior nurse leaders in leadership and management positions in other countries to apply this research to their unique contexts.
The objective of this study was to obtain consensus on the informatics competencies of priority to senior Canadian nurse leaders. The goal of completing this work was to adapt and validate a set of nurse leader informatics competencies to be endorsed and supported nationally.
This study used a modified Delphi technique with a panel of nurse leaders with significant informatics knowledge from across Canada. Three rounds of information gathering were completed electronically. In Round 1, participants were provided a series of 26 potential competency statements obtained from a review of the literature; they were asked to comment on the clarity and wording of each statement. Two statements were eliminated after Round 1 due to redundancy. In Rounds 2 and 3, participants rated the remaining competency statements on a 7-point Likert scale for relative priority to nurse leaders.
A total of 25, 24 and 23 participants completed the survey in Rounds 1, 2 and 3 respectively. Consensus was achieved at the end of Round 3 with the inclusion of 24 competency statements. All of the statements had a mean of 5 or greater on a 7-point Likert scale (1=low priority and 7=high priority).
The study participants agreed upon 24 informatics competency statements of priority to Canadian nurse leaders. These competencies will be presented to senior national nursing leaders and nursing informatics organizations for endorsement. Inspired by work completed in the United States, the authors plan to develop a self-assessment instrument for use by Canadian nurse leaders using the identified competency statements. Future anticipated work includes identifying and creating resources for nurse leaders to develop these important informatics competencies.
This paper investigates the effects of expanding public health insurance eligibility for older children. Using data from the National Health Interview Surveys from 1986 to 2005, we first show that ...although income continues to be an important predictor of children's health status, the importance of income for predicting health has fallen for children 9–17 in recent years. We then investigate the extent to which the dramatic expansions in public health insurance coverage for these children in the past decade are responsible for the decline in the importance of income. We find that while eligibility for public health insurance unambiguously improves current utilization of preventive care, it has little effect on current health status. However, we find some evidence that Medicaid eligibility in early childhood has positive effects on future health. This may indicate that adequate medical care early on puts children on a better health trajectory, resulting in better health as they grow.
The evaluation of quality of care in juvenile idiopathic arthritis (JIA) is critical for advancing patient outcomes but is not currently part of routine care across all centers in Canada. The study ...objective is to review the current landscape of JIA quality measures and use expert panel consensus to define key performance indicators (KPIs) that are important and feasible to collect for routine monitoring in JIA care in Canada.
Thirty-seven candidate KPIs identified from a systematic review were reviewed for inclusion by a working group including 3 pediatric rheumatologists. A shortlist of 14 KPIs was then assessed using a 3-round modified Delphi panel based on the RAND/UCLA Appropriateness Method. Ten panelists across Canada participated based on their expertise in JIA, quality measurement, or lived experience as a parent of a child with JIA. During rounds 1 and 3, panelists rated each KPI on a 1-9 Likert scale on themes of importance, feasibility, and priority. In round 2, panelists participated in a moderated in-person discussion that resulted in minor modifications to some KPIs. KPIs with median scores of ≥ 7 on all 3 questions without disagreement were included in the framework.
Ten KPIs met the criteria for inclusion after round 3. Five KPIs addressed patient assessments: pain, joint count, functional status, global assessment of disease activity, and the clinical Juvenile Arthritis Disease Activity Score (cJADAS). Three KPIs examined access to care: wait times for consultation, access to pediatric rheumatologists within 1 year of diagnosis, and frequency of clinical follow-up. Safety was addressed through KPIs on tuberculous screening and laboratory monitoring. KPIs examining functional status using the Childhood Health Assessment Questionnaire (CHAQ), quality of life, uveitis, and patient satisfaction were excluded due to concerns about feasibility of measurement.
The proposed KPIs build upon existing KPIs and address important processes of care that should be measured to improve the quality of JIA care. The feasibility of capturing these measures will be tested in various data sources including the Understanding Childhood Arthritis Network (UCAN) studies. Subsequent work should focus on development of meaningful outcome KPIs to drive JIA quality improvement in Canada and beyond.
Abstract
Repeating the BinaxNOW antigen test for severe acute respiratory syndrome coronavirus 2 using 2 groups of readers within 30 minutes resulted in high concordance (98.9%) in 2110 encounters. ...Same-day repeat antigen testing did not significantly improve test sensitivity (77.2% to 81.4%) while specificity remained high (99.6%).
Summary The time is right to shift the focus of the global maternal health community to the challenges of effective implementation of services within districts. 20 years after the launch of the Safe ...Motherhood Initiative, the community has reached a broad consensus about priority interventions, incorporated these interventions into national policy documents, and organised globally in coalition with the newborn and child health communities. With changes in policy processes to emphasise country ownership, funding harmonisation, and results-based financing, the capacity of countries to implement services urgently needs to be strengthened. In this article, four global maternal health initiatives draw on their complementary experiences to identify a set of the central lessons on which to build a new, collaborative effort to implement equitable, sustainable maternal health services at scale. This implementation effort should focus on specific steps for strengthening the capacity of the district health system to convert inputs into functioning services that are accessible to and used by all segments of the population.
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