Biochemistry

Far From the Biliary Tree: A Case of Overlapping Autoimmune Liver Disease in a Patient Presenting With Sicca Symptoms – Cureus

Primary biliary cholangitis (PBC) is achronic autoimmune condition with many extrahepatic manifestations that are commonly encountered as a patient's primary presenting complaints. Rarely, PBC co-exists as an overlapping syndrome with other liver-related autoimmune conditions such as autoimmune hepatitis (AIH). Presented is a rare case of PBC with features of AIH diagnosed in a patient who initially presented with hemoptysis and worsened sicca symptoms due to advanced Sjgrens syndrome. The patient had a three-year evolution of abnormal liver biochemistry and was found to be a heterozygous carrier for hereditary hemochromatosis (H63D mutation). Given that patients with PBC-AIH are at an increased risk of complications compared to isolated disease from either disorder, early diagnosis and prompt management can helpspare patients from cirrhosis, liver failure and transplantation, or even death.

Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by the progressive destruction of intrahepatic bile ducts. Various genetic and environmental interactions trigger an autoimmune response against biliary epithelial cells, which leads to cholestasis and fibrosisand can ultimately result in liver cirrhosis and failure [1]. The global incidence rate of PBC differs widely among geographic areas, ranging from 40 to 400 per million individuals with a peak incidence in the fifth decade of life and a 10:1 predominance in females compared to males [2]. Symptoms of PBC related to cholestasis typically develop within two to four years of diagnosis and include fatigue, pruritus, dyslipidemia, fat-soluble malabsorption, and osteoporosis, though up to 61% of cases are asymptomatic [2-3]. PBC also has many associations with extrahepatic autoimmune disease, most notably Sjgrens (up to 73%), thyroid dysfunction (up to 23.6%), cutaneous scleroderma (up to 12.3%), and rheumatoid arthritis (RA) (5.6%) [4-6]. The diagnosis of PBC is made if two of the following three criteria are met: (1) biochemical evidence of cholestasis through the elevation of alkaline phosphatase (ALP) to two times the upper limit of normal, (2) presence of antimitochondrial antibody (AMA) with a titer greater than 1:40, (3) histologic evidence of nonsuppurative destructive cholangitis and interlobular bile duct destruction [7-8].

Rarely, PBC can co-exist as an overlapping syndrome with other liver-related autoimmune conditions such as autoimmune hepatitis (AIH). This phenomenon is present in 1-3% of patients with PBC and 7% of patients with AIH [8]. A PBC-AIH overlap syndrome can be diagnosed using the Paris criteria with 92% sensitivity and 97% specificity [9].

For PBC alone, early initiation of ursodeoxycholic acid (UDCA) to slow disease progression is associated with a long-term survival benefit and minimal side effects such as headaches, motility issues, and weight gain. Along with interval monitoring of liver biochemical tests, recommendations for immunizations for hepatitis A and B are given to individuals without serologic evidence of immunity, in addition to abstention from heavy alcohol use. In general, evidence is limited to making treatment recommendations for patients with PBC as well as features of AIH, though it includes UDCA with or without a component of immunosuppression [8].

A 52-year-old female with a history of Sjgrens and rheumatoid arthritis presented to the clinic with worsening sicca symptoms and persistent cough with hemoptysis over the past two weeks. She also reported fatigue and arthralgias. She had been seeing a rheumatologist and had been started on azathioprinetwo years prior, in addition to pilocarpine for dry eyes. She was also taking levothyroxine for hypothyroidism. The patients vital signs were all within normal limits. Her physical exam was notable for a non-tender liver edge palpated six centimeters below the mid-clavicular costal margin with negative shifting dullness or fluid wave. Other pertinent negatives included the absence of icteric sclera,skin hyperpigmentation, gland or lymph node prominence or tenderness, focalizing lung findings, active synovitis or contractures, palmar excoriations, or cutaneous vasculitis.

On review of her medical chart, she had an extensive rheumatologic workup notable for positive antinuclear antibody (ANA), positive anti-SS-A with negative anti-SS-B,positive salivary gland biopsy, and positive rheumatoid factor (RF). She also had a history of consistently elevated gamma-glutamyl transferase (GGT) and alanine (ALT) and aspartate (AST) transaminases with normal alkaline phosphatase (ALP) and normal total and direct bilirubin levels. Labs were obtained at her clinic visit and notable for elevated AST 237 IU/L, ALT 223 IU/L, GGT 169 IU/L, and normal ALP 101 IU/L with otherwise normal complete blood count and mildly elevated values on the lipid panel (Table 1).

Based on her autoimmune history and elevated transaminases, an expandedrheumatologic workup was performed, notable for a positive anti-mitochondrial antibody (AMA) 128.6 U (normal < 20.0 U), negative anti-smooth muscle antibody (ASMA) 11.0 U (normal < 19 U), and immunoglobulin A (IgA) 287 mg/dL (normal 87-352 mg/dL). The patient was referred to a gastroenterologist and found to have a normal esophagogastroduodenoscopy. Upon genetic analysis, the patient was noted to be a carrier for hereditary hemochromatosis (heterozygous carrier for H63D mutation). The rest of her workup was negative, including hepatitis panel, alpha-1-antitrypsin, double-stranded DNAand anti-Smith/ribonucleoprotein antibodies, SCL-70 (scleroderma) antibody, and centromere antibody.

Imaging with ultrasound demonstrated hepatomegaly with fatty infiltration of the liver (Figure 1). The patient was evaluated by a pulmonologist forher cough and hemoptysis and a CT chest was performed. CT imaging demonstrated prominent mucus and debris along the trachea with subpleural reticulations possibly due to respiratory involvement of her Sjgrens syndrome (images were unable to be obtained for inclusion in this article). It also noted questionable hepatic surface lobulation that could represent early cirrhosis morphology. With a positive AMA and biochemical pattern of cholestasis and hepatocellular injury, the patient was referred forliver biopsy, which revealed extensive inflammatory infiltrate consisting of lymphocytes and plasma cells surrounding portal tract structures, with the presence of interface hepatitis into lobular parenchyma (Figure 2). No evidence of malignancy was noted.

The patient met the criteria for diagnosis (Table 2) and was started on UDCA at 15 mg/kg. She was alsocontinued on azathioprine at a therapeutic dose of 2 mg/kg for AIH. At the three-month follow-up, the patient had down-trending transaminases and was reporting subjective improvement in symptoms of fatigue and arthralgias.

Primary biliary cholangitis (PBC) is a rare but potentially life-threatening autoimmune cholestatic disease of the liver that, when left undiagnosed and untreated, can culminate in end-stage liver cirrhosis. Similar to the patient presented in this case report, PBC has a peak prevalence for those between their fourth and sixth decades of life with a predominance for women [2-3]. Diagnostic criteria for primary hepatic autoimmune diseases rely on biochemical evidence of either cholestasis or hepatocellular damage, presence of auto-antibodies, and histopathological features on liver biopsy [7-9]. While present in fewer than 10% of patients with either PBC or AIH, the overlapping syndrome (PBC-AIH) is well-represented in the current case [8]. There are several subtypes and classifications of this condition, though, like other autoimmune disorders, it can be thought to exist on a spectrum of primary tissue involvement. It is hypothesized that patients with underlying bile duct destruction (characteristic of PBC) also possess a genetic predisposition to develop a hepatitic pattern of liver injury (more consistent with AIH), and thus can also be referred to as PBC, hepatitic form [10].

The patient presented in this case report met the Paris criteria for PBC-AIH both on histology as well as an elevated ALT and presence of anti-AMA antibody. Though not meeting diagnostic criteria (5 times upper limit of normal (ULN)), she also had an elevated GGT at 3.1 times ULN. Her past medical history of several extrahepatic autoimmune diseases is consistent with other cases of PBC-AIH. PBC is known to have associations with Sjgrens syndrome in more than half of individualsand to a lesser extent, with thyroid dysfunction, RA, and cutaneous scleroderma[4-6]. Though a majority of patients eventually diagnosed with PBC are asymptomatic, this patient had multiple symptoms on presentation. She presented with cough and hemoptysis along with xerostomia and dry eyes, all potentially attributed to her Sjgrens diagnosis. She was found to have hepatomegaly both on clinical exam and ultrasound imaging, as well as three years of worsening liver transaminases that prompted an expanded autoimmune work-up.

This case highlights the importance of primary care physicians to not only be familiar with the criteria for autoimmune liver diseases but also to not devalue minor changes in liver biochemistry. Though she had been previously followed by a rheumatologist, the patient had been lost to follow-up and her medical record revealed several inconsistencies regarding the interpretation of her autoimmune laboratory findings between specialists and generalists that she had seen in the past. She had also been noted to have an extensive history of alcohol consumption throughout her medical record. While her AST and ALT abnormalities have been attributed to this, her AST:ALT ratio was inconsistent with this assertion.

Interestingly, this patient was also found to be a heterozygous carrier for hereditary hemochromatosis (HH). On discussion with her gastroenterologist, it is difficult to discern the patients elevated ferritin as related to excess collection versus an acute phase reactant given her history of autoimmune disease. In general, HFE H63D heterozygous carriers rarely develop clinically significant iron overload syndromes [11] though may be at increased riskfor breast and colorectal cancers [12-13]. As of the time of this publication, there are no reports in the literature regarding increased rates of PBC or AIH in those with the H63D mutation.

Compared to patients with PBC alone, individuals with PBC-AIH have higher rates of portal hypertension, esophageal varices, gastrointestinal bleeding, ascites, and liver failure [14-15]. Studies have demonstrated death or liver transplantation in PBC-AIH at rates twice as high compared to PBC alone at six-year mean follow-up [14] and nearly four times as high compared to AIH alone at the two-year follow-up [16]. At 10 years following diagnosis, 44-48% of patients with PBC-AIH progress to cirrhosis [8,15], and transplant-free survival ranges from 52-92% [8-9,14].

Goals of management for autoimmune liver disease include suppression of the underlying pathogenic process as well as treatment of acute symptoms that result from chronic cholestasis, including pruritus, fatigue, and xerostomia. Evidence is limited regarding specific treatment recommendations for diseases with overlapping characteristics. The 2018 practice guidelines from the American Association for the Study of Liver Diseases (AASLD) guidelines concede that the clinical benefit and harm of adding immunosuppressive medications require further study, and recommend tailoring pharmacotherapy to the predominant histologic pattern (PBC or AIH) [17-18]. The 2017 practice guidelines from the European Association for the Study of Liver Diseases (EASL) recommend that in addition to UDCA, immunosuppression be given, or considered, in patients with severe to moderate interface hepatitis, respectively [19]. A meta-analysis for the comparative treatment of various overlap syndromes demonstrated that combination therapy with UDCA and immunosuppression may be superior to both UDCA alone and to steroids with or without azathioprine with respect to biochemical improvement and transplant-free survival [8]. The authors concede, however, that these studies are limited by the inclusion ofpatients with a wide range of histologic severity. Additionally, it has been reported that the degree of baseline interface activity on biopsy (pathognomonic of AIH) is a more accurate predictor of failure with UDCA monotherapy compared to the addition of immunosuppressive therapies [19].

Our patient had already been started on azathioprine for her other rheumatological conditions two years prior to her initial presentation to our clinic. Therefore, given her extrahepatic autoimmune diseases that prompted early immunosuppression, she had theoretically been spared from several years of additional damage due to her PBC-AIH. Relapse rates of AIH up to 90% have been demonstrated when discontinuing immunosuppression. Despite this, a withdrawal trial of immunosuppressives can be consideredonce remissionhas been established (normalization of aminotransferases) and maintained for 24 months[19-20]. She was also started on UDCA after confirming the diagnosis with a biopsy and therefore is now on combination UDCA with immunosuppressive therapy. Long-term monitoring for patients with PBC includes liver biochemical and function tests every three to six months in addition to annual screening for thyroid dysfunction and bone mineral densitometry. Of note, our patient did have a degree of long-bone osteopenia on a dual-energy X-ray absorptiometry scan. We also recommended screening for colorectal and breast cancer given her increased risk with HH carrier status.

Primary liver autoimmune conditions are often associated with extrahepatic manifestations, either as a result of chronic cholestatic symptoms or as distinct, laboratory-identifiable syndromes.Therefore, in patients with a significant rheumatological disease history or when a primary autoimmune workup is being performed in the context of abnormal liver biochemistry, PBC and AIH must both be considered. The Paris diagnostic criteria can be used with a high degree of both sensitivity and specificity to either distinguish or correlate these conditions.Based on the current evidence, early initiation of UDCA with immunosuppressive therapies has been shown to help delay cirrhosis, liver failure and transplantation, and even death.

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Far From the Biliary Tree: A Case of Overlapping Autoimmune Liver Disease in a Patient Presenting With Sicca Symptoms - Cureus

Embryology

Y Combinator-Backed Lilia Launches A More Convenient And Affordable Egg Freezing Offering Built For The Millennial Women – Forbes

While a womans age at thaw has relatively little impact on a womans chances of success, the age at ... [+] freeze does, according to the U.K.'s Human Fertilisation and Embryology Authority

Lilia, a full-service egg freezing concierge, today announced they are now offering egg freezing directly for their clients at nearly half the price of an average IVF procedure and in half the time, and coordinated to make the experience less isolating. With this new breakthrough offering, women have access to the leading, most progressive doctors in the country dedicated to Lilias mission of giving every woman the freedom to make her own decisions on her own timeline.

According to the Human Fertilisation and Embryology Authority, the U.K.'s independent fertility regulator, the data shows that while a womans age at thaw has relatively little impact on a womans chances of success, the age at freeze does, with evidence showing that if eggs are frozen below the age of 35, the chances of success will be higher than the natural conception rate as the woman gets older.

Alyssa Atkins, founder and CEO of Lilia

As a Y Combinator graduate, and having raised roughly $1.5 million to date, Lilia is revolutionizing how women plan their futures. Founded in 2019 by Alyssa Atkins, who froze her eggs at the age of 29, the idea for Lilia was conceived when she founder realized the whole experience was built for an IVF couple, not young women focused on their futures. The company is currently operating with doctors in New York City, Chicago, and San Francisco, with plans to go national by the end of 2023. As explained by Atkins, Lilia is now a single point of contact for women - no more waiting on hold for doctors offices or fielding a million emails from the clinics different departments.

The convenience of Lilias offerings is reflected in the fact that they coordinate everything for the patient from contracts, to appointments, meds, and virtual consulting and prep work. The whole process, Atkins highlights, takes less than a month. And lets be honest until now, no one has focused specifically on serving the millions of women aged 24 35 for whom egg freezing works best.

Most women have considered freezing their eggs at some point and many have been thinking about it for years. But when they turn to Google, they are bounced out by the complexity of how to start, where to go, or what to do. Egg freezing, when done early, is the best way to relieve reproductive pressure and give women more optionality. Optionality is freedom and freedom is everything for women who dont want to be pressured into having a child before they are ready.

Lilia is changing a stale narrative about what a womans life ought to look like. Society is pretty prescriptive about its expectations of women college, career, marriage, baby in that order and ideally by 30, which leaves most women feeling behind no matter what theyve accomplished or what their personal goals are, explains Atkins.

Its 2022 (in case you havent noticed) and its time we usher in a new normal. One where egg freezing isnt perceived as something you do in your late 30s as a last resort, but something you can do early, in your 20s, because you have the right to reproductive freedom, autonomy, and choice. Its not just something to be done for your future self; it has real and direct impacts on the present you by taking the pressure off, especially in dating. With eggs secured early, women dont have to rush; every first date isnt an evaluation of whether the person in front of you is the future father of your children.

Atkins admits she sees so many women in their late 30s saying they wish someone had told them to freeze their eggs earlier. So, she and her team are working on showing women how common and normal this process is and educating them along the way. People think egg freezing is about the future you, but really its about taking the pressure off of you today because it lets you date differently, make different career moves, and live with more freedom, she adds.

It is more important now than ever that women have the power of choice and freedom. Choice over whether they take certain jobs, and when or whether to have kids at all. They deserve the freedom not to settle, to stop doing the dating math, and not to be rushed in making important decisions about their careers or matters of the heart. Every woman deserves the feeling of freedom and inner peace that comes from knowing all doors to her future are open, continues Atkins.

So who are Lilia's users and target audience? Obviously, someone for whom being a biological mom is incredibly important, and they want to ensure this happens at some point in their lives. Perhaps its a woman who knows she wants to use a surrogate at some point and so egg freezing is a path to this; startup founders, who are super busy and want kids but know they need time to build their companies first; women who arent sure they want kids at all, but want the option later; basically, any woman who wants to take the pressure off and keep their options open.

We believe that in time, egg freezing will be as common as birth control, and it should not only be a luxury for a small group of society. While egg freezing might not have been part of our fairy tale stories growing up, it has become extremely common and is one of the most radical acts of self-care a woman can make. We don't want women to wait until egg freezing becomes an absolute emergency, at which point its either often too late to retrieve enough healthy eggs, or to do so would require many cycles and the corresponding costs that come with it, adds Atkins.

Lilia is under the medical leadership of Dr. Roohi Jeelani, who does the highest volume of ... [+] egg-freezing retrievals in the country

The time and cost savings are created to let the company deliver an outstanding experience to women for a predictable $9,000 all-in, instead of the nebulous $15,000+ women are usually faced with. Under the medical leadership of Dr. Roohi Jeelani, who does the highest volume of egg-freezing retrievals in the country, Lilia is able to deliver this breakthrough offering while maintaining the highest standards in medicine.

We have carefully selected clinic partners who are equally committed to making egg freezing affordable and accessible to all, and dedicated to together creating a better experience for women.

Atkins and her team spent a lot of time getting the offering right, ensuring they could drive down costs and improve the experience while maintaining a superlative standard of care. Now that theyve done this, theyre working on changing the entire narrative around egg freezing and normalizing this process as a regular part of womanhood.

Were especially interested in how dating and egg freezing relate, because we know when women freeze eggs early theyre able to date differently and that it gives them more power in their love lives. Were working on telling more womens stories about whove frozen their eggs so women see just how common this is. Something I realized when I froze my eggs is I had all these friends whod done it but werent talking about it, concludes Atkins.

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Y Combinator-Backed Lilia Launches A More Convenient And Affordable Egg Freezing Offering Built For The Millennial Women - Forbes

Embryology

Handful of Tories declare themselves as candidates to replace Johnson – Morning Star Online

THEresignation of Boris Johnson as prime minister has seenattention turntowho will replace him.

Only a handful of Tories have so far declared themselves candidates, although a number of others are thought to be set to do so.

Attorney GeneralSuella Braverman and Commons foreign affairs committee chairman Tom Tugendhat have confirmed their intention to stand while Steve Baker has said he is seriously considering standing.

Ms Bravermantook the unusual step this week of calling on Mr Johnson to resign, saying that she would not be stepping down but at the same time throwing her hat into the ring as his potential successor.

Mr Tugendhatlaunched his leadership bid with an article in the Daily Telegraph today, promising tax cuts and new energy and ideas for government.

"I have served before in the military and now in Parliament. Now I hope to answer the call once again as prime minister, said the former soldier, who has been a prominent critic of Mr Johnson and an advocate of a more aggressive foreign policy.

Former chancellorRishi Sunak also unveiled his candidacy today, the most high-profile figure so far to do so.

Foreign Secretary Liz Truss, former health secretarySajid Javid, ChancellorNadhim Zahawi, health and social care select committee chairmanJeremy Hunt and Transport SecretaryGrant Shapps are all expected to enter an increasingly crowded field.

More declarations are expected in the coming days, but some senior Tories have already said that they will not be standing, including former levelling up secretary Michael Gove, Deputy Prime Minister Dominic Raab and disgraced former health secretary Matt Hancock.

Another candidate yet to confirm, but already installed as the bookies favourites, is Defence Secretary Ben Wallace.

Polling of Tory Party members by YouGov also puts Mr Wallace in pole position, where he beats all of the main presumed contenders.

Mr Wallace, who served in the Scots Guards, has had a prominent role in Britains response to the Russian invasion of Ukraine.

However, he has one of the worst voting records on LGBT rights in Parliament.

He has opposed every piece of LGBT legislation put in front of him, including same-sex marriage and the Equality Act.

Mr Wallace also voted in favour of the Human Fertilisation and Embryology Bill, which, had it passed, would have made it harder for lesbian couples to conceive children through IVF.

Hehas also repeatedly opposed raising welfare benefits and has always backed more hard-line immigration and asylum laws.

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Handful of Tories declare themselves as candidates to replace Johnson - Morning Star Online

Anatomy

Grey’s Anatomy season 19: When could we hear about season 20? – CarterMatt

Greys Anatomyseason 19 is coming to ABC a little this year but for the sake of this article, were looking ahead far ahead. To be specific, were talking about season 20 and when some of the first news could officially come out about that.

Just like youre having to be patient to get news on season 19 production, youre also going to need patience to get news on season 20 a LOT of patience, in fact. The earliest that we can see discussions even happening on the future is this fall, and thats because the top priority is getting the new season off the ground. The important thing to remember along the way here is that the writers are typically several scripts ahead of where the cast and crew are in filming. That means that by the end of the fall, it would be useful for them to have a rough idea.

We would assume that by the first couple of months in the new year, folks behind the scenes will start to understand more of which way things are leaning. For us as viewers, ABC could easily drag this out further. Dont be shocked if there is a situation where we dont find out anything definite until the spring. We do think they will tell us prior to the final episodes if this is the final season or not, largely because that is the thing that makes the most overall sense.

Do we think the show is going to be winding down at some point sooner rather than later? Most likely, yes however, season 20 is such a nice number to end things on, and we can think of no other appropriate way to tie everything together. (Of course, if ABC gives the show a season 20 we wouldnt be mad about that, either.)

Related Be sure to get some more news when it comes to Greys Anatomy right now

Share right now in the comments! Once you do just that, come back there are other updates on the way and of course, we dont want you missing any of them. (Photo: ABC.)

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Grey's Anatomy season 19: When could we hear about season 20? - CarterMatt

Anatomy

The anatomy of a rumor: Fact checking abortion claims – The Dickinson Press

DICKINSON Dr. Thomas Arnold is a practicing gynecologist and obstetrician at CHI St. Alexius Health in Dickinson who also volunteers at Connect Medical Clinic. Arnold earned his degree from the Uiversity of North Dakota, School of Medicine, in 1984 and has been a practicing OBGYN for decades.

Arnold explained how an ectopic pregnancy occurs, noting that it is defined as those rare instances when a fertilized egg grows outside the uterus usually in the fallopian tubes. He said that both legally and medically, this is completely different from an abortion.

Ectopic pregnancies most commonly occur in the fallopian tubes, and they can be life threatening to the mother because of rupture and bleeding that can occur. They're not pregnancies that can be sustained in the woman's body. The fallopian tubes cannot accommodate a pregnancy like that, Arnold said. If you have a patient that has an ectopic pregnancy, that can be managed within the environment of the Catholic Health System.

Public commons photo

He explained the distinction between an elective abortion and the termination of a non-viable pregnancy and how the two are widely recognized throughout the medical community.

Colleagues of mine, physicians and medical personnel in general, consider an abortion to be the termination of a live pregnancy. I just read an article about someone who had a fetal demise about seven months into the pregnancy and she was told that if if they intervene that it was an abortion. Well, I don't think most medical professionals will look at management of a fetal demise, where you have a baby that's non-viable, as an abortion, he said.

Among those who have spread misinformation on this topic, one of the most seemingly credible sources was Daily Beast Columnist Wajahat Ali. He incorrectly conflated abortion with ectopic pregnancies and further spread a commonly misunderstood legal liability concern to his nearly 300,000 followers on social media both assertions being incorrect.

Do I abort this ectopic pregnancy to literally save my life or do I go to jail? Question women in America now have to ask, Ali stated in a viral tweet. Also, doctors who have taken an Oath to save lives now have to risk jail as well. It's a mess.

Reuters reports that only abortionists, those who perform clandestine abortions, or pharmacists who illegally distribute abortion inducing pills to end life in the womb can suffer prosecution under these state laws. Thirteen states, including North Dakota, have trigger laws that subsequently banned abortion after Roe v. Wade was overturned. The states trigger law took effect on June 28, as the 2007 statute behind it included a 30-day waiting period after Roe being struck down.

Five other states had statutory abortion bans prior to 1973 that now go back into effect.

Of all 18 states, each has an exception to allow procedures to terminate pregnancies in the event the mothers life is in danger. No state penalizes women who seek abortions, and anti-abortion activist groups overwhelmingly oppose prosecuting said women.

Prominent New York Congresswoman Alexandria Ocasio-Cortez also made misleading claims about reproductive health care in a viral Instagram video to her millions of followers.

A bunch of men who are very ignorant about medicine, biology, rape culture and the misogyny that they were raised in, including legal liability and how it factors in with the medical field people who are ignorant to all of that are the ones that are writing these laws, Ocasio-Cortez argued in an Instagram video. "Some of them were even written in the 1800s So dont tell me that people in the 1800s knew what an ectopic pregnancy was."

Despite the seemingly primitive medical technology of the era, not only were medical professionals impressively able to identify ectopic pregnancies, but by the final decades of that century they were even treating them.

In 1883 British surgeon Robert Lawson Tait performed the first successful procedure terminating an ectopic pregnancy, a condition which then had a 60% mortality rate. Tait lost only two of the 42 women he performed this surgery on.

Miscarriages have also been a hot topic of misinformation in light of some states moving to bans on abortion in the wake of the Supreme Court ruling. In a June 24 Facebook post , Lillian Jones, a Democratic NPL nominated candidate for state house in District 41, shared her opposition to the Dobbs v. Jackson decision.

I lost an unexpected child to miscarriage and endured a procedure that saved my life. A womans Constitutional right to choose just got struck down, along with a familys right to make decisions regarding health and household composition, Jones said in the post, implying that such procedures may no longer be available to women who need them.

CHI St. Alexius, an ardently "pro-life institution of the Catholic church," has been providing surgery and medication to treat miscarriages nearly since its inception, and Arnold said they will continue to do so. As previously explained by Arnold, no abortion ban in any state hinders doctors from treating miscarriages.

Arnold categorized a miscarriage as a medical condition that is more common than most people realize, and most often occurs before the woman realizes shes pregnant.

Miscarriages are most often due to a genetic abnormality, where the pregnancy progresses inside the uterus to a certain gestational stage. Then for reasons we don't always find out, the pregnancy becomes non-viable, he said. The body perceives this at some point. It will usually respond by trying to eliminate the pregnancy by contracting, bleeding and passing over the tissue naturally. That's not a perfect system however, and in some cases, the bleeding and cramping can be severe enough where women will come into the clinic or the emergency room for a surgical evacuation of the uterus.

He reiterated that his and most definitions of abortion only include viable pregnancies.

Most people will say the difference between a miscarriage and a termination or an abortion would be that one is a non-viable pregnancy and the other is a viable pregnancy, Arnold said.

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The anatomy of a rumor: Fact checking abortion claims - The Dickinson Press

Anatomy

Anatomy of a modern data stack and 4 key benefits it creates – Construction Dive

Construction firms that know how to harness their data are increasingly at a competitive advantage in today's complex world and the latest research emphasizes just how much of an advantage.

In fact, faulty construction data may have caused $1.8 trillion in losses worldwide and been responsible for 14% of avoidable rework, or $88 billion, according to Autodesk and FMI.

That same report found that 75% of contractors said there's an increased need for rapid decision-making in the field exactly where good data is crucial. But only 55% of contractors had implemented a formal data strategy for project data, and only 12% always incorporated project data into their decision-making.

The solution to these problems is the modern data stack. But just what is it, and why should contractors care?

"The modern data stack is a scalable, low barrier to entry, group of technologies that firms can adopt to drive value from their data," said Matt Monihan, CEO of ResponseVault, a data-engineering firm specializing in the construction industry. "That's important because, with the modern data stack, you can surface data without every single app having a direct integration with another one."

Monihan said the goal is true data integration, which many construction firms mistakenly believe they have achieved because of questionable claims from software-makers about integration. But, while integrations may technically be available, they don't always provide true data insights firms need to make smarter decisions and predict outcomes. "The granularity of the integration is key and varies between vendors," Monihan said.

In this article, we'll explore the anatomy of the modern data stack and answer questions about four key benefits it creates.

Point solutions are where your data originates. Whether it's coming from the field, the office or the owner, your data is being collected in a structured form, like Procore change events, or from free-form data sources like Spreadsheets. The data generated from these point solutions run your business, and the solutions are made to collect the data properly.

Once you've collected your jobsite data in point solutions, the next step is to securely and reliably export that data into a storage container, often referred to as a data warehouse, data lake or even a data lakehouse. As technology evolves, the differences between those industry terms have blurred, but what's important is that a piece of middleware is required to move the data between the point solution and its staging area in the warehouse.

The data we're extracting from our point solutions needs to live somewhere, and that is where our storage method is chosen. The cost of entry to this component has reduced, both with the introduction of Amazon Redshift as a lower-cost analytical database and with the rise of accessible, open-source databases introducing features that enable many use cases that weren't previously possible in years past. So, once you've selected and set up your storage and data is flowing, next is doing something with the data: Analysis.

Now is the time to model the data across your data sources, identify fields that combine disparate data sets, and clean the data into unified models. This step requires a dedicated data analyst who can communicate with people in the field who are generating the source data and reconcile any discrepancies with stakeholders looking for reports and dashboards. Your analyst will need to work with many Business Intelligence (BI) tools available in the market today. No one BI tool covers everything you may need. What's important is that you pick one and stick with it.

This step is where you'll need a layer that continually tests and lets you know that the entire stack is functioning correctly. It's where you'll receive alerts about outages, expired authentication tokens, broken models and more.

The goal is to have a robust and comprehensive set of tools to not only proactively monitor the stack's health but also provide a straightforward process for investigating problems that may arise.

Now that you understand the anatomy of a modern tech stack, it's essential to understand its benefits.

1. How does the stack reduce manual data entry and inconsistent data? Manual data entry and conflicting data are collectively costing contractors billions. These twin problems often cause multiple apps and tech tools companies use to gather data. Although processes are digitized, the apps and tools don't integrate; thus, data becomes siloed in the various solutions. To get a report, someone must manually go into the different tools or apps and export the data. 42% of companies use four to six apps for their construction jobs, and 27% report that none of those apps integrate. As a result, data is transferred manually nearly 50% of the time, according to JBKnowledge. Because it integrates data across apps and systems, modern data stacks provide digital access across the enterprise and a single source of truth.

2. How do disparate data sources get connected? Although many construction IT professionals know about major database suppliers, such as Oracle, they may not be aware of the many better off-the-shelf data tools available to integrate data. These connectors save considerable IT time and cost and ensure the data is secure and reliable with a trusted single source of truth. In that scenario, BIM changes can be made in a 3D render using real-time job site data. Then, if an architect or owner wants to make a change, a cost analysis can be done in real-time based on how the project is going.

3. Where does the data go? The modern data stack relies on a data warehouse that's typically cloud-based. This cloud data warehouse can store and quickly access large quantities of data without breaking the bank. It ensures that all company data flows appropriately to this data warehouse so that firms can gain actionable insight into real-time data. That's key because poor project data and miscommunication cause 52% of rework. This means $31.3 billion in rework was caused by bad project data and miscommunication in the U.S. alone in 2018, according to FMI/Autodesk report.

4. How do we ensure that the various integrations are working properly and that data is correct? Unlike black-boxed integrations, the modern data stack provides a clear picture of data, so it's easy to see, manage and manipulate. For example, the stack includes orchestration tooling, data management frameworks and data-quality monitoring tooling for high observability other tools, such as data governance, surface organizational problems.

The result is the ability to create meaningful data dashboards that get insights that matter, such as subs' quality of work, safety scores and schedules. "With the modern data stack, you have a window into exactly what's happening," Monihan said. "It's not a black box. It's a transparent system for diagnosing, understanding and customizing how integration works."

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Anatomy of a modern data stack and 4 key benefits it creates - Construction Dive

Anatomy

Anatomy of an Origin miracle: The manoeuvres behind Hunts magic moment – Sydney Morning Herald

Cherry-Evans finished with 642 kicking metres from 19 punts, on occasion even launching a long-range effort on the second tackle to turn the Blues back three around and nullify their all-important running game.

Queensland didnt mind if NSW had ball in hand as long as it was at their own end, with panicked mistakes from Jarome Luai, Stephen Crichton and Siosifa Talakai giving the Maroons the best of both worlds.

So when the Blues did finally work their way back up-field while trailing 16-12 the added defensive efforts took their toll, Queensland duly having their measure as the stakes increased by the second.

Heres how those frantic final moments and the catalyst of a miracle Origin play panned out.

74.03: After NSW finally start a set somewhere other than their own goal line, Damien Cook and James Tedesco are sniping around the ruck to have Queensland back-pedalling.

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Clearys last-tackle bomb is missed by all as it comes down 12 metres from the try line, Jake Trbojevic of all people following up with a grubber. Tom Dearden covers it with no NSW chasers in pursuit.

76.04: After a grinding Queensland set the Blues are again in decent field position and load up with a right-side shift.

Theres time, space and an overlap out wide, but Isaah Yeo plays short to prop Jacob Saifiti and Dearden is able to bring him down. Clearys bomb back across field is taken by Gagai with the chasers five metres away from being able to challenge him.

77.01: With the Maroons again battling for yardage, Cherry-Evans kicks long and low for the touchline. Daniel Tupou cuts it off but is belted off his feet and into a slow play-the-ball by Tino Faasuamaleaui.

77.45: The Penrith connection swings into gear to create another overlap down the right through Cleary and Yeo. But a critical read from Corey Oates sees the veteran winger flying in on Stephen Crichton who is turned back inside toward Queenslands cover defence.

78.02: The miracle moment. Cleary takes the ball 32 metres out on the last with 10 metres between him and the defence.

NSW has five players lined up outside on the left to Queenslands four defenders because Gagai is already sat back deep in anticipation of another bomb.

Cleary goes to the line as Hunt pushes across to pressure him. Luai is on Clearys outside, Tedesco on his right, both ready to pursue the chip kick that comes once Cleary steps back sharply inside for the all-or-nothing play.

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Hunt clutches the ball as it comes off Clearys right boot. Hes going for the charge-down but critically, never takes his eyes off the Steeden.

When Cleary delivers a deft rather than hefty touch, Hunt is airborne but latches on with both hands.

He lands, pivots, and takes off with only Yeo anywhere near him. Just 75 metres 80 he was already correcting observers in the sheds afterwards between him and a slice of Origin history.

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Anatomy of an Origin miracle: The manoeuvres behind Hunts magic moment - Sydney Morning Herald

Anatomy

Grey’s Anatomy star Kevin McKidd to continue filming The Elect in Glasgow tomorrow – here’s where – Glasgow Times

A Glasgow pub will be taken over by camera crews as filming continues for a new ITV drama starring Greys Anatomy heartthrob Kevin McKidd.

The Elect, a four-part Western adaptation of Japanese crime novel Six/Four, has been filming in and around the city.

As well as in the St Vincent Street area back in May, Trainspotting star McKidd was also spotted filming in the citys Drury Laneon Monday evening.

READ MORE:Grey's Anatomy star Kevin McKidd spotted by excited fan in Glasgow city centre

Now, on short notice, the crew will be shooting at The State Bar on Holland Street, which is mere seconds away from several popular Sauchiehall Street destinations.

Nearby residents received a letter through their door on Tuesday apologising for any inconvenience caused with interior filming expected to take place on Wednesday at some point between 8am and 4pm.

English actor Richard Coyle, who appeared in the Netflix series Chilling Adventures of Sabrina, is also starring in the drama alongside Saskia Ashdown and Brian McCardie.

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Grey's Anatomy star Kevin McKidd to continue filming The Elect in Glasgow tomorrow - here's where - Glasgow Times

Anatomy

A ‘Grey’s Anatomy’ Writer Has Allegedly Swindled Shonda Rhimes in the Style of Shondaland’s ‘Inventing Anna’ – Showbiz Cheat Sheet

Shonda Rhimes is no stranger to tales that contain fact stranger than fiction. One of the writer and producers most recent projects, Inventing Anna, followed the story of a pathological liar. Now, it seems like one of Rhimes own Greys Anatomy writers is guilty of the same thing. So, who is Elisabeth Finch?

Finch started writing for Greys Anatomy after a since-deleted personal essay of hers published by Elle. In the piece, she discussed living and working with chondrosarcoma, a rare and usually fatal form of bone cancer. In her essay, Finch talked about how she continued working against the orders of her doctor.

When I defied Dr. Cryptics orders to take an indefinite leave of absence from work he thought chemo deserved my sole attention he doubted my commitment to getting well, she wrote in her article, according to Vanity Fair. At the time, Finch was working on The Vampire Diaries.

I watched the producers cuts under a fog of Demerol, punched up dialogue about vampire-werewolf hybrids with a shunt in my spine, Finch continued. Yes, I was down 17 pounds, bald, vomiting relentlessly, but I was still living alone. Still stubborn as hell.

The Elle essay caught the eye of a development executive at Shondaland, Rhimes production company. Finch ended up getting hired to work on Greys Anatomy. Since joining the show in 2014, Finch was credited as a producer on 172 episodes, and a writer for 13.

Most notably, Finch was credited as a writer on a 2018 episode of the medical drama, called Anybody Have a Map? In the episode, a patient undergoes an operation to treat her aggressive chondrosarcoma.

The people who worked at Shondaland were extremely supportive of Finch. They granted her time off for her chemotherapy and clinical trials. They also found her story inspirational; Finch was the only person who survived in one of her clinical trials yet she still came to work as often as she could.

After years of working at Shondaland, everyone thought they knew Finchs story. That all changed in 2022 when Rhimes received a mysterious email. The message was from Jennifer Beyer, Finchs estranged wife.

Beyer was writing to tell Rhimes that Finch was lying. Even though no one wanted to believe it, as they looked into Finchs story, things started to fall apart.

Finch first claimed she had been diagnosed with cancer while she was working on The Vampire Diaries. According to Vanity Fair, she would visit her family in New Jersey, bald from alleged chemo treatments and sporting a bandage where the chemo port would be.

However, Beyer claimed Finch still had her eyebrows and eyelashes. Notably, chemo patients typically lose these features while being treated. Also, she didnt have a scar where the port would have been.

According to Beyer, when she became suspicious and confronted Finch, the writer admitted, She had at one time had cancer, but that she got chemo, and recovered.

Her estranged wife also claimed that Finch lied about her brother committing suicide (hes alive), a friend dying in the mass shooting at the Tree of Life synagogue, and receiving a kidney from True Blood star Anna Paquin (the actress has denied this claim).

Since her story has been called into question, Finch has gone on a personal leave of absence from Greys Anatomy. Theres no word yet on when, or if, shell come back, or what kind of consequences she might face.

In a statement about her leave, Finch said, according to Deadline, I will always remain one of Greys Anatomys biggest fans. I loved the show from day one and had the honor to write for it since season 11. The proudest moment of my career was watching survivors of rape receive the episode Silent All These Years.

Greys Anatomy is one big-hearted, brilliant family, she continued. As hard as it is to take some time away right now, I know it is more important that I focus on my own family and my health. Im immensely grateful to Disney, ABC, and Shondaland for allowing me to do so and for supporting me through this very difficult time.

Finchs story of sickness, death, and organ donation has not been confirmed or denied. But fans cant help but point out the crazy similarity between her story and Rhimes own Inventing Anna series.

RELATED: Greys Anatomy: Sandra Oh Says Fame Literally Made Her Sick

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A 'Grey's Anatomy' Writer Has Allegedly Swindled Shonda Rhimes in the Style of Shondaland's 'Inventing Anna' - Showbiz Cheat Sheet

Anatomy

Anatomy of Unatu standoff with government | Monitor – Monitor

When the Uganda National Teachers Union (Unatu) and other public service unions signed Collective Bargaining Agreement (CBA) with the government on June 22, 2018, the public servants under the umbrella body thought the worst was behind them.

The CBA highlighted plans for salary enhancement across all categories of civil servants for Financial Years 2018/2019 and 2019/2020.

It, however, didnt take long to run into trouble.

In 2019, Unatu leadership mobilised teachers across the country to withdraw labour over delayed salary enhancement.

Consequently, President Museveni summoned teachers representatives and persuaded them to suspend the strike.

The salary enhancement discussions were put on the back-burner when schools shut their doors to two Covid-19 variants across nearly two years. The schools finally re-opened this January when pandemic curbs were relaxed.

On May 23, Unatus standing committee sat and unanimously ratified the resolution resolved to down their tools on June 15, if there was no satisfactory feedback on the issues pertaining to teachers salary increment across the board for Financial Year 2022/2023.

Mr Filbert Baguma, Unatus secretary general, added thus: Every financial year, teachers have to remind government about the commitments earlier made. Do teachers really matter to this nation? Are the commitments made by government mere boardroom gimmicks meant to silence teachers and foil any plans for industrial action?

Mr Baguma also revealed that due to alleged constant disappointments, anxiety was mounting among teachers.

Only satisfactory feedback from the government on their demands, he added, would stop the intended industrial action in its tracks.

In its absence, as promised, nearly 120,000 Arts teachers in government-aided primary and secondary schools downed their tools on June 15.

It would straddle more than a fortnight before the Arts teachers grudgingly accepted this past week to take up the chalk.

The call for industrial action came after Science teachers under their unionthe Uganda Profession Teachers Union (UPSTU)suspended their strike indefinitely.

The strike had been declared at the start of the second term. The Science teachers relented after the government assured them that the Budget for the 2022/2023 financial year catered to their salary enhancement.

On May 23, Unatu issued a notification to government expressing intention to resume their industrial action if government insisted on implementing discriminatory salary enhancements instead of honouring commitments made in the 2018 CBA.

Mr Baguma said during the signing of the CBA, it was also agreed that negotiations for 2020/2021 and 2022/2023 aimed at removing disparities in scales would proceed as agreed.

He further noted that while some categories of civil servants in the CBAparticularly those in phase onereceived their increment in full, teachers, who were supposed to benefit from phase two, received only 25 percent of the expected increment.

The Unatu secretary general, however, hastened to add that the union leadership was still open for further negotiations.

The option of a strike was not taken off the table, although, especially if their issues were not addressed.

A week into the Arts teachers strike, Ms Ketty Lamarothe Permanent Secretary in the Ministry of Education and Sportsrevealed that Unatus concerns were being discussed, internally.

Teachers should desist from anything that disrupts teaching and learning. Schools were grossly affected by the Covid-19 lockdown, and we are now trying to accelerate learning to recover the lost time, she noted, adding, [The Arts teachers] salaries will be enhanced, but in a phased manner because government does not have enough money to pay everyone at the same time.

Ms Catherine Bitarakwate, the Public Service ministry Permanent Secretary, also reiterated Ms Lamaros appeal.

Unatu though, was unwavering in its demand that the government pay Shs4.8m to graduate secondary school Science teachers and Shs4.5m for their Arts counterparts, among other categories. It wasnt long before the First Lady Janet Museveniwho also doubles as Education and Sports ministerinvited Unatus top brass for a meeting originally scheduled for June 17 but pushed to June 18 at State House, Entebbe.

The meeting, which was held behind closed doors, was addressed by President Museveni. Mr Usher Wilson Owere, the chairman general of National Organisation of Trade Union (Notu), described the meeting as stormy. Mr Museveni is reported to have advised the Arts teachers to return to work, promising that their enhancement would be done in a phased manner.

The Unatu top brass, which is said to have taken offence with the Presidents tone, defied his directive to return to class.

Not even a June 22 letter from Ms Bitarakwate that described the current industrial action by the members of Unatu as illegal swayed the teachers. The letterwhich in no uncertain terms said the striking teachers had decided to close the schools and that no teacher has the legal right or justification to close a public school without the concurrence of the governmentwas roundly criticised by the public.

Keen to mend fences, Ms Bitarakwate and Vice President Jessica Alupo wrote to Unatu on June 27 seeking an audience.

The Unatu top brass met with Ms Alupo on June 28, but the discussions helddescribed as cordial by Mr Bagumayielded no results.

On June 30, Unatu received two letters from the government directing teachers to return to class as negotiations continue.

The letters from Public Service Minister Wilson Muruli Mukasa and Ms Bitarakwate repeated explanations that scientists were cleared for salary enhancements because they are needed in crucial areas of the economy such as agriculture, industry, and ICT.

The letters precipitated a July 3 meeting involving members of Unatus national executive council.

While Unatu resolved to continue with the strike, there was a change in tune when the teachers met President Museveni on July 3. The teachers resolved to return to class effective July 6, with Mr Museveni later tweeting please dont divert us from our journey of attracting and retaining scientists by paying them comparatively and competitively. Dont interfere with governments strategy.

Soon, Mr Baguma found himself on the defensive for the first time after a disbelieving public questioned the sudden change of heart.

There is a rumour flying over social media that the leaders have been bribed. The leaders have a responsibility to take leadership if you dont take over your membership, then you can take them to a wrong direction, he said.

A section of Art teachers, who have since resumed teaching, said they are working with an extremely low morale.

Speaking on the floor of Parliament this past week, Opposition Chief Whip John Baptist Nambeshe (Manjiya County) said the selective enhancement of salaries has opened a Pandoras box.

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Anatomy of Unatu standoff with government | Monitor - Monitor