text:
Study protocol
Identification of factors associated with diagnostic error in primary care
Sergio Minué1Email author,
Clara Bermúdez-Tamayo1, 2, 3, 9,
Alberto Fernández1,
José Jesús Martín-Martín4,
Vivian Benítez1,
Miguel Melguizo5,
Araceli Caro1,
María José Orgaz5,
Miguel Angel Prados6,
José Enrique Díaz7 and
Rafael Montoro8
BMC Family Practice201415:92
© Minué et al.; licensee BioMed Central Ltd. 2014
Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed.
Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified.
This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.
Diagnostic error
Missed, delayed or incorrect diagnoses are considered to be diagnostic errors [1]. Although the incidence of diagnostic error is difficult to establish [2], it is estimated to be between 5% and 20% [3], depending on the medical speciality analysed. Berner and Graber [4] distinguish between "perceptual" specialities (radiology and anatomical pathology), where the diagnosis is made based on the perception of an image, and other clinical fields (family medicine, internal medicine, emergency department). The incidence of diagnostic error in the former is between 2% and 5%, while the incidence in the latter can be up to 15% [5]. In the United States, it is estimated that more than 150,000 patients per year may undergo misdiagnosis-related harm, and 50,000 missed diagnostic opportunities occur each year in primary care (PC) alone [6]. Diagnostic errors lead to more deaths than any other medical error type [7], and this can have major legal repercussions: diagnostic errors are the leading cause of malpractice claims in the United States [8].
However, few studies on the diagnostic process have been published, probably because it is still considered to be more of an individual art than a science. The complexity of the diagnostic process and the lack of established methods for its analysis also play a part. There are even fewer studies on the diagnostic process in the PC setting [9].
Clinical reasoning
In order to provide the right clinical care, a correct diagnosis is essential, although not sufficient on its own. To reach the right diagnosis, physicians must take a complete medical history and perform the right physical examinations and further tests. Not ordering the correct tests is potentially just as dangerous as performing unnecessary tests, which can lead to iatrogenic effects and overdiagnosis [10].
Studies on decision-making under conditions of uncertainty in the fields of psychology and behavioural economics have very slowly started to spread into the medical field. Stanovich and West [11] coined the terms "system 1" and "system 2" to refer to the 2 systems of cognitive function. System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control. System 2 allocates attention to the effortful mental activities that demand it, and its operations are often associated with the subjective experience of agency, choice and concentration. Diagnostic error is typically viewed as a cognitive failing [12], often caused by biases linked to system 1 (non-analytical, intuitive thinking). Some authors [13] believe that these cognitive biases can be a warning sign for possible diagnostic errors.
Heuristics are "the strategies that people use deliberately in order to simplify judgemental tasks that would otherwise be too difficult for the typical human mind to solve" [14]. Kahneman, Slovic and Tversky [15] identified different types of heuristics involved in the decision-making process. However, not all researchers believe that the use of heuristics (and by extension, system 1) in clinical reasoning necessarily leads to a higher risk of error [16].
This study uses only the 3 general heuristics described initially by Kahneman and Tversky, the validity of which has been confirmed by many empirical findings over the last few decades [17]: 1) Availability, i.e. the diagnostic alternatives available during the reflective process at a particular point in medical care; 2) Representativeness, i.e. the case's similarity to a particular known diagnostic category; and 3) Anchoring and adjustment, i.e. how well the information generated during the diagnostic process fits with the initial diagnostic hypothesis.
"Suboptimal cognitive acts" (SCAs) are cognitive errors that deviate from the optimal cognitive process, and which could lead to an adverse event [18]. Based on Reason's model of unsafe acts [19], cognitive errors can occur as a result of 2 types of action: unintentional and intentional.
1) Unintentional actions: these occur when routine activities are inadequately performed because of failings in attention (slips) or memory (lapses). In these cases, the error is caused by a failure in the storage and/or execution stage in the action sequence, regardless of whether the action is appropriate or not. It is therefore largely influenced by working conditions, especially overwork and fatigue.
2) Intentional actions: deliberate actions that may lead to an error because the person lacks the knowledge required to tackle the situation (mistakes), or because the person disregards the appropriate procedure (violations). In these cases, the error is due to a lack of knowledge (in the first case) or compliance (in the second). They are therefore influenced by experience and attitude.
Factors associated with the diagnostic process in PC
PC physicians work under vastly different conditions from their colleagues in emergency or hospital departments. In PC settings, patients usually present with poorly defined, often psychological or social symptoms. Some patients attend in the initial stages of the disease, while others have confirmed diagnoses. PC physicians see patients whose problems have not yet been reduced to a specific category, so there is a very broad range of possible diagnoses [20]. In order to tackle this diverse range of problems appropriately, PC must fulfil 4 essential criteria [21]: accessibility, comprehensiveness of services, coordination of care within the healthcare system, and longitudinality (the capacity to provide continuous (ongoing) care throughout a patient's lifetime). In addition to these specific aspects, the diagnostic process in PC is determined by factors that influence any care context: professional experience, overwork, fatigue and stress [18, 22]. The increase in PC activities often leads to overwork, and this can have a direct influence on the diagnostic process.
Studying the diagnostic process in PC requires an analysis of the complete process a physician follows when faced with symptoms, not diseases, from the moment care starts to the moment a diagnosis is reached. Dyspnoea was selected for this study because it is a frequent PC problem and provides an opportunity for a differential diagnostic procedure.
The aims of this study are to:
Identify and describe the SCAs that occur during care of patients with dyspnoea attending PC centres.
Analyse cognitive aspects of the process by which PC physicians diagnose dyspnoea using heuristics.
Analyse the relationship between situational factors (perceived overwork, fatigue, professional experience) and SCAs during the diagnostic process in patients with dyspnoea in PC settings.
Analyse the relationship between those situational factors and the use of heuristics during the diagnostic process in patients with dyspnoea in PC settings.
We designed a prospective cohort study of new episodes of dyspnoea. The cohort monitoring period begins when the patient first attends because of a new episode and ends when a concrete diagnosis is reached. This period is estimated to be between 2 days and 8 months [18]. The study procedure is shown in Figure 1.
Study procedure. New episodes of dyspnea and identification of suboptimal cognitive acts.
Selection of centres
We selected 4 PC centres in the province of Granada (Spain). The family physicians working at the centres have different levels of experience, the centres have different patient numbers, and the patients come from different socioeconomic backgrounds (lower, middle-lower, middle-upper and upper classes). 2 distinct physician types were selected: residents and experienced family physicians.
Study subjects
The study analyses diagnostic processes in patients registered at the practices of the participating family physicians, attending because of a new episode of dyspnoea. A consecutive sampling method was used, recruiting diagnostic procedures from the accessible population of patients attending because of a new episode of dyspnoea.
We calculated the number of cases required based on the method set out by Zwaan et al. [18]. In that study, in order to obtain a substantial number of SCAs in each of the 5 categories (slips, lapses, mistakes, violations, patient record problems), a confidence interval was calculated assuming an equal distribution of suboptimal cognitive acts in each category (20% of SCAs in each category). An average of 1.5 SCAs was expected per patient record, so 250 records of dyspnoea (375/1.5) were required. Based on this, the number of cases of dyspnoea expected in our study is 384.
As independent variables, we are going to explore factors related with the patient, the setting and the professional. The dependent variables are those related with the errors. These are described in Table 1.
Variables studied
Independent variables
Dependent variables
Suboptimal cognitive acts
Use of heuristics
Age/Sex
Number of patients on list
Lapses
Number of patients attended
Anchoring and adjustment
CME related to dyspnoea
Socioeconomic background
Hospital referral
Access to electronic medical record during physician-patient encounter
The study period deemed necessary to recruit the number of patients required and carry out the diagnostic process is 1 year. The audit is carried out at the end of each diagnostic process.
The data are collected in the following phases and through the following sources:
PHASE 1. Record of the diagnostic process (provided by the physician)
Data from the physician
Once they have agreed to take part in the project, the PC physicians fill out records detailing variables about themselves (listed in the first column of Table 1). They also fill out the patients' electronic clinical records in the software application used by all healthcare professionals working for the Andalusian Health Service, the region's public health service.
Data from the diagnostic process
For each patient attending with a new episode of dyspnoea, the physicians fill out 2 questionnaires via a tablet computer with an internet connection. The questionnaire is available as a wufoo application (http://www.wufoo.com) saved on the tablet's desktop. Tables 2 and 3 describes the questionnaires used.
Questionnaire evaluation of first diagnosis
When it is filled out
1. Evaluation Of first diagnosis
First diagnostic impression
After reason for consultation described
Possible use of representativeness heuristic ("Of which disease is this specific episode of dyspnoea representative?")
Differential diagnosis (3 possible diagnoses identified in order of likelihood)
After the medical history is taken and physical examination is performed
Possible use of availability heuristic (diagnostic possibilities that come to the physician's mind at the time of diagnosis)
After the differential diagnosis
Last 2 digits of patient's social security number
After diagnosis
Possible use of anchoring and adjustment heuristic in estimation of the likelihood of the diagnosis being correct
Likelihood that the proposed diagnosis is correct (%)
After recording the last 2 digits of the patient's social security number
Subjective workload
During consultation
Identification of specific situational factors during the consultation that could influence the diagnostic process, in terms of both use of heuristics and performance of suboptimal cognitive acts/errors
Perceived subjective mental workload (adapted from NASA-TLX
Evaluation of aspects of mental demand, physical demand, performance, effort and frustration
Adaptation of the Spanish version of the Swedish Occupational Fatigue Inventory (SOFI)
Evaluation of work-related fatigue
Characteristics of the encounter between physician and patient:
Characteristics of the encounter
• Consultation type
• Number of patients attended
• Patient's number in the order of patients attended
• Consultation delay
Relationship with the patient over time:
Longitudinality (capacity to provide care to patients over time)
• Time physician has been providing care for the patient
• Time physician has been providing care for the same patient list
• Number of previous visits by the patient in the last year
• Date of last visit
Questionnaire of final diagnosis and audit
1. Evaluation Of final diagnosis
- Final diagnosis confirmed
When final diagnosis of underlying cause of dyspnoea is made
Possible use of availability heuristic (diagnostic possibilities that come to the physician's mind at the time of diagnosis) when the hypotheses are compared with the final diagnosis
- Time since first visit
- Number of visits
2. AUDIT
Personal and family history
After diagnosis is confirmed
Evaluation of accuracy of diagnosis
Characteristics of dyspnoea
Accompanying symptoms
Further tests
Appropriateness of diagnostic process
Performance of suboptimal cognitive acts
Identification of error type (slip, lapse, mistake, violation)
Evaluation of existence of suboptimal cognitive act
Identification of diagnostic error
Stage in which it occurs
Evaluation of the existence of an error and its consequences
Existence of misdiagnosis-related damage and damage type
Possibility of damage prevention
PHASE 2. Review of the diagnostic process (provided by the evaluators)
Identification of the optimal diagnostic process
The methodology used by Zwaan [23] has been used as a reference for the audit and adapted to the PC setting.
The clinical practice guidelines set out by the Spanish Society of Family and Community Medicine (semFYC) were reviewed. As no clinical guidelines on the management of dyspnoea in PC were found, an exhaustive review of the literature on dyspnoea care in PC was carried out. The dyspnoea care procedure in PC was revised based on the articles found.
These reviewed guidelines were sent to 4 family physicians with more than 20 years of clinical experience, who made all the necessary corrections to create a consensus reference document.
Creation of the audit questionnaire
Based on the consensus document created, a diagnostic process audit questionnaire [23] analysing the following 7 phases of the process was created: 1) medical history; 2) physical examination; 3) laboratory test results; 4) scans; 5) diagnosis; 6) treatment; 7) follow-up.
The questionnaire was revised and piloted by the participants in the audit process, and a second questionnaire was created based on the suggestions made after the pilot.
The final audit questionnaire will be filled out via wufoo when the audit is carried out.
Each of the cases will be assessed by 2 physicians (not including the physician who performs the diagnosis). If the evaluations of the 2 physicians are different, the case will be assessed by a third evaluator. The physician-evaluators have accredited clinical care experience and have been trained in how to use the audit guide. The stages of data collection will be analysed based on two criteria: 1) whether the correct information was collected; and 2) whether the information was interpreted correctly.
Variables associated with the possible use of heuristics, the performance of suboptimal cognitive acts and the possible existence of diagnostic error will be collected.
Review of the diagnostic process with the physician in charge of the patient's care
The diagnostic process audit will be reviewed by the evaluators and the physicians who performed the diagnostic process through an interview in order to analyse any cognitive acts that took place, as well as any possible diagnostic errors.
PHASE 3. Review of centre reports, to obtain information about centre characteristics
A descriptive statistical analysis of diagnostic errors, suboptimal cognitive acts and use of representativeness, availability and anchoring heuristics will be carried out.
A bivariate analysis will be performed to establish if there are any differences in the diagnostic error variables based on the heuristics identified and the independent variables. To do this, a Chi-square or Fisher's exact test will be used for samples with fewer than 5 individuals.
Multivariate models will be used to determine if there are any differences in the diagnostic error variables based on the heuristics identified, adjusting for the other independent variables, using logistic regression models.
Confidentiality and ethical approval
This project has been approved by the Regional Research Ethics Committee of the province of Granada (Spain).
All participating patients agreed to take part in the research project through the corresponding informed consent process.
All participating physicians also signed consent forms in order to take part, expressly agreeing to keep all the information collected confidential. None of the data collected could be used to identify patients. ID numbers only were used.
The database created, using information exclusively from the questionnaires available through wufoo, was not linked in any way to the electronic medical records of the patients studied.
The empirical evidence gathered over the last few decades about cognitive biases and the use of heuristics in decision-making under conditions of uncertainty [17] has not yet been satisfactorily transferred to the medical field. In fact, there are major differences of opinion about the role of heuristics in clinical decision-making and the effectiveness and risks of their use [24, 25].
Furthermore, some recent reviews [26, 27] warn of the lack of studies analysing the relationship between the reasoning process and diagnostic errors, despite the relevance of the link. This lack of empirical research is particularly pronounced in PC, even though it is the setting where most clinical encounters take place and where the clinical decision-making process is performed under the greatest conditions of uncertainty. Some authors [28] believe that the next step in diagnostic error research would be to better understand how hypotheses developed under experimental conditions translate into real-world situations. Despite its methodological limitations, our study could lead to interesting conclusions to better understand the diagnostic process in real-world PC settings, especially with regard to its determining factors, both situational (overwork, fatigue, stress) or experience-related (training, years of experience).
It can be difficult to collect information about the clinical reasoning process at the time it takes place. However, this can be overcome through the use of recently developed and widely used information technologies in the form of hardware (tablets) and software (apps with links to websites that collect data).
The methodology proposed allows the diagnostic process as a whole to be assessed, using both prospective and retrospective sources [18]. One major strength of the method is the involvement of the participating physicians themselves, particularly the physician being assessed in the interview analysing his/her cognitive processes. This approach makes it possible to check, adjust and increase the information available to the evaluators, turning the audit into a process of ongoing improvement of the physician's practice.
The study is affected by volunteer selection bias, the Hawthorne effect, and the selection criteria used (only cases described as dyspnoea by the physician at the time of consultation are included, excluding false negatives). There is also a differential classification bias, in the sense that it is known that diagnostic error will be underestimated for several reasons: the physician already knows which symptom is being studied, is aware that he/she is going to be observed, and over time there may be a learning effect in the care of patients with this symptom.
There are no objective criteria defining the optimal diagnostic process in patients with dyspnoea attended by PC physicians, so there is no gold standard with which the processes performed can be compared. However, in order to have a reference with which to compare the diagnostic processes performed, we followed the procedure used in other similar studies [18]: review of the best scientific evidence available, review and consensus by expert professionals, and design, pilot and application of a questionnaire for the audit.
Given the study period used in the analysis, it is possible that in some cases the diagnostic process may be deemed finished when it is not, and this means that certain errors may not be detected. There are 3 main causes of losses during follow-up: a) leaving the study; b) death by another cause; and c) "administrative losses" caused by early termination of the study due to reasons other than those initially predicted. To reduce this bias, all of the information available about the lost cases will be collected in order to have as much data as possible about the losses, to quantify their causes and thus evaluate the validity of the study.
Widely available, easy-to-use, uncomplicated electronic devices have been used to facilitate recording of the cognitive and diagnostic processes. Each physician uses a tablet with a 3G connection to record the information in the health centres and in patients' homes. By storing the data on a website as soon as it is recorded, it is immediately available for analysis. However, the possibility of under-recording and delays in the recording process cannot be ruled out, and these could limit the validity of the results obtained.
The medical history review process may also be subject to hindsight bias, i.e. analysis of the diagnostic processes may be affected by prior knowledge of the final result.
The medical history audit is currently being carried out.
This paper sets out a methodology for studying the diagnostic process in PC adapted from previous works by Zwaan et al. [18, 23]. It also takes advantage of the possibilities that new technologies offer in terms of immediate recording of the clinical decision-making process, in order to assess the possible use of heuristics (representativeness, availability and anchoring) during the diagnostic process. Reason's taxonomy, which categorises actions into unintentional (slips and lapses) and intentional ones (mistakes and infractions), is used as a reference for identifying possible suboptimal cognitive acts that physicians may have performed during the dyspnoea diagnostic process. Discussing the results obtained in the audit with each physician will facilitate learning about the diagnostic process, increasing knowledge of the key factors determining clinical reasoning.
The methodology also makes it possible to analyse the influence of clinical experience and situational factors (overwork, fatigue, stress) on the diagnostic process.
PC:
SCAs:
semFYC:
Spanish society of family and community medicine.
The authors gratefully acknowledge funding of this research from the Spanish Research Agency. Ministry of Health (Fondo de Investigaciones Sanitarias) FIS PI10/01468 and the European Regional Development Fund (ERDF). The funder of this study had no role in study design, data analysis, data collection, data interpretation, or writing of the report. The views expressed are those of the authors and not necessarily of the funding bodies. We are also grateful to the physicians who have taken part in the study and Professor Laura Zwaan for her willingness to discuss some aspects of the project.
Previous presentations
The approach used in this project was presented as a poster presentation at the Diagnostic Error in Medicine 6th International Conference held in Chicago (2013).
SM directed the study design process, planned the review and adaptation, drafted the manuscript and wrote the final version. CB participated in the study conception and design, revised the draft manuscript and critically revised the manuscript. AF participated in the study conception and design, revised the draft manuscript and critically revised the manuscript. JJM supervised the study protocol and its design, and critically revised the final manuscript. VB performed the bibliographical review and participated in the design of the audit. MM participated in the study conception, reviewed the design and implementation of the audit, and participated in the design of the dyspnoea protocol and the evaluation questionnaire. AC participated in the study design. MJO reviewed the design and implementation of the audit, and participated in the design of the dyspnoea protocol and the evaluation questionnaire. MAP reviewed the design and implementation of the audit, and participated in the design of the dyspnoea protocol and the evaluation questionnaire. JED reviewed the design and implementation of the audit, and participated in the design of the dyspnoea protocol and the evaluation questionnaire. RM reviewed the design of the initial project. All the authors revised the final version of the manuscript. All authors read and approved the final manuscript.
Andalusian School of Public Health, Cuesta del Observatorio 4, Campus Universitario de Cartuja, 18080 Granada, Spain
Institute de recherche en santé publique. Université de Montréal, Montréal, Canada
CIBERESP. CIBER de Epidemiología y Salud Pública, Madrid, Spain
Universidad de Granada, Facultad de Ciencias Económicas y Empresariales, Campus Universitario de la Cartuja, 18011 Granada, Spain
Centro de salud Almanjayar. Servicio Andaluz de Salud, C/Pintor Joaquín Capulino Jaúregui SN., 18013 Granada, Spain
Centro de salud Cartuja. Servicio Andaluz de Salud, C/Pintor Joaquín Capulino Jaúregui SN., 18013 Granada, Spain
Centro de salud Gran Capitán. Servicio Andaluz de Salud, C/Gran Capitán, 10, 18002 Granada, España
Distrito de Atención Primaria de Granada -Metropolitano. Servicio Andaluz de Salud, Calle Doctor Azpitarte, 4, 18012 Granada, Spain
Département d'administration de la Santé, École de santé publique, 7101, Avenue du Parc., H3N 1X9 Montréal, Québec, Canada
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text:
Бікіні — жіночий купальний костюм, що складається з двох частин. Перша покриває груди, друга — пах і частину (або повністю) сідниць. Найчастіше бікіні носять за гарячої погоди, при купанні чи засмаганні.

Назва
Назву купальник отримав завдяки атолу Бікіні, на якому в 1946 році проводилися випробування ядерної бомби в рамках операції «Перехрестя», і тому назва купальника мала асоціюватися з вибухом. Існує ще одна поширена (але помилкова) версія, відповідно до якої назва «бікіні» виникла через те, що даний тип купальника за формою нагадує архіпелаг Бікіні. На місцевому мікронезійському діалекті «бікіні» означає — «земля кокосів».

Історія

Одяг, що нагадує бікіні, використовувався жінками для занять спортом ще в Стародавньому Римі. Він складався з настегнової пов'язки-сублігакулума і бюстгальтера-строфіума.

Творцем сучасних бікіні вважається паризький модельєр Луї Реар (Louis Reard) — автомобільний інженер-механік, що став дизайнером одягу після отримання спадщини від своєї матері у вигляді салону жіночої білизни. Бікіні були вперше продемонстровані на публіці 5 липня 1946 року стриптизеркою з Казино де Парі Мішлін Бернардіні. Вона виявилася єдиною моделлю, яка погодилася вийти на подіум лише в кількох трикутниках тканини, які прикривали інтимні частини тіла. Решта моделей відмовлялися зі страху осоромитися. Світ моди був шокований: ніхто не повірив, що жінка сповна розуму зможе отаке носити на пляжі. А Мішлін Бернардіні за кілька тижнів після показу отримала від чоловіків з усієї Європи зо 50 тис. шлюбних пропозицій.

Нова модель купальника була названа на честь атолу Бікіні, на якому чотирма днями раніше США провели випробування водневої бомби. Рекламний слоган, який супроводжував випуск нової моделі, використовував паралелі між назвою попередньої моделі, і ядерним розпадом: «Бікіні — розділений атом!». На її виготовлення пішло лиш 30 кв. дюймів — 76 см² — тканини.

Луї Реар був не єдиний, хто влітку 1946-го відрізав зайві сантиметри в купальника. За місяць до нього в одному з пляжних магазинів французького курорту Канни модельєр Жак Гайм теж почав був продавати порівняно маленькі купальники. Називав їх «атом» (Atome) — на честь нещодавно розщепленої елементарної частинки. Для реклами замовив літак, який ширяв над пляжами й за допомогою диму писав у повітрі: «Найменший купальник уже в продажу». На такий слоган Реар відреагував так: «Мій менший навіть за найменший купальник». Він же вигадав гасло-визначення справжнього міні-купальника: «Це не бікіні, якщо його не можна пропхати крізь обручку».

Знадобилося більше десяти років, перш ніж бікіні перестали шокувати публіку і увійшли в моду. Адже їх відразу ж після появи заборонили на головних пляжах Європи. В Італії, Португалії й Іспанії жінок у таких купальниках арештовували. Критики стверджували, що бікіні «відкриває в дівчині все, крім дівочого прізвища її матері». 1957 року американський журнал «Сучасна дівчина» писав: «Порядна дівчина ніколи не вдягне таку річ». Леді й далі виходили на пляж у закритих купальниках.

Пізніше бікіні стало прапором сексуальної революції на Заході, що і зробило його популярним. І першою зі знаменитостей його застосувала французька актриса Бріжит Бардо. 1956 року її чоловік Роже Вадим зняв її в білому бікіні у стрічці «І Бог створив жінку». Бріжит під час Каннського кінофестивалю з'являлася в бікіні й на місцевих пляжах. Після фільму жінок годі було стримати: вони шукали такі ж купальники, як у кінозірки. Чоловіки ж тим часом штурмували кінотеатри. Кравці не хотіли втрачати прибутку. Швейні фабрики почали працювати по три зміни й назбирали замовлень на кілька років наперед. «Жінки вибирають бікіні прискіпливіше, ніж чоловіків. Принципи однакові: шукають те, в чому комфортно і що дає можливості для росту», — описувала ажіотаж тих років американська журналістка Ерма Бомбек.

Після Бріжит Бардо рекламу бікіні зробила швейцарська акторка Урсула Андресс. 1962 року вона зіграла дівчину Джеймса Бонда у першому фільмі бондіани «Доктор Но». У білому бікіні Урсула виходить із води перед враженим агентом 007. Андресс стала черговим секс-символом. Свій білий міні-купальник вона через багато років випадково знайшла вдома на запиленому горищі. 2001-го виставила його на аукціон «Крісті» й продала за 35 тис. фунтів стерлінгів (майже $160 тис. на сьогоднішні гроші).

Пік популярності бікіні — кінець 1960-х — 1970-ті. Далі ажіотаж пішов на спад. У 1980-х лише кожен третій проданий у світі купальник був бікіні. 1988 року закрилася компанія Луї Реара.

Сучасні бікіні — офіційна спортивна форма в жіночому пляжному волейболі.

Різновиди
Зараз існує багато різних модифікацій бікіні. Популярність цього купального костюму привела до того, що назви багатьох видів купальників стали утворюватися за зразком «бікіні» — із закінченням «-кіні». Відомі такі типи одягу (й аксесуарів), назви яких утворені за цією моделлю:

Залежно від різновиду плавок, виділяють такі види бікіні:
 Стринг-бікіні
 Бікіні-танга
 Бразильське бікіні
 Міні-бікіні
 Мікро-бікіні

Матеріали

Галерея

Міні-бікіні

Мікро-бікіні

Трикіні

Спортивні бікіні

Примітки

Посилання

 Metropolitan Museum of Art exhibition—The Bikini
 The California Swimsuit
 Two-Piece Be With You: LIFE Celebrates the Bikini

Жіноча білизна
Історія моди
Спортивний одяг
Атол Бікіні
Купальники

redpajama_set_name: RedPajamaWikipedia


text:
Groove Digital Integrated Website Builder
By Matthew P. James on	 September 19, 2021 Website builder
GrooveDigital announced a new update to its platform, which is now called Groove.cm. It is a digital marketing suite, a customer relationship management tool and a fast growing website.
GrooveDigital announced a new update to its platform, which is now called Groove.cm. It is a fast growing digital marketing suite, customer relationship management tool and website builder.
The latest update ensures that entrepreneurs and business owners of all experience levels can access the tools they need to achieve their growth goals. Groove includes a drag-and-drop web design studio, email marketing, webinar tools, and a variety of other options.
More information can be found at: Groove Digital Specials
Following the announcement, business owners can now take advantage of integrated content tools to elevate their brand in one destination. GrooveVideo provides streamlined video editing for engaging marketing content, while GrooveSell makes it easy to sell products online.
With GrooveMember, business owners can create and manage their own communities. The full suite lends itself to building a targeted audience, which can then be used to drive sales on an ongoing basis.
According to the latest data from the US Bureau of Labor Statistics, nearly half of all new businesses fail within five years. This is in part due to the lack of education, difficulty accessing tools, and the expense of running a business in today's landscape.
GrooveDigital, led by Mike Filsaime, is designed to streamline every element of building and running an online business. Business owners can overcome common challenges and obstacles by using the cutting edge tools in the Groove dashboard.
Registration is free, no credit card is required to access the innovative features. Plus, business owners have access to comprehensive training and onboarding to ensure they can scale quickly and use each tool in harmony to achieve their growth goals.
The company is committed to making business management more intuitive. Multiple websites can be created, with landing pages and main magnets designed using conversion-oriented templates.
One recent user said, "This brand new software is hands down the best website and funnel building platform out there and will save me over $ 600 per month by having everything under one roof. I've been building funnels for about 10 years now and use every other platform on the market and it wipes the floor with all of them, even in beta. The future is bright, the future is Groove.
A detailed information sheet covering all functionalities is available at: Start an Online Business Today
Professional Website Builder Duda Raises $ 50 Million Series D
1 & 1 IONOS MyWebsite Website Builder Review
Launch of digital marketing apps for e-commerce business website builder platform
The pros and cons of using a website builder

redpajama_set_name: RedPajamaCommonCrawl


Down the gently sloping hill from the Merriweather VIP Parking, under the majestic and comforting canopy of trees, sits the extraordinary site for the extraordinary Chrysalis. Living up to Howard County's mandate for a "new kind of cultural park, where the landscape becomes a setting for arts, cultural and civic uses," the approved design for Merriweather Park at Symphony Woods is filled with functional art, beautiful designs that delight as they serve.
As the first of these designs to be built, the Chrysalis is a shining example of hardworking art. The 5,000 square foot structure is a very capable Stage. In fact, it is two stages with the Alpha Stage proscenium for larger productions, and the Beta Stage proscenium, with a thrust stage, for smaller events. Both stages work off of the same wood deck floor, and they can be used in combination for festival events, as they share the hillside for lawn seating.
Everyday the Chrysalis is an urban-scale Sculpture, nestled into the woods. The iconic sculpture is "alive" in dynamic, organic form, where no line stands still, but flows in highly calculated serendipity. The Chrysalis is the fusion of beautiful form and pure function that captures our fascination with this intrinsic balance in nature, while celebrating our collective spirt.
The Chrysalis Stage, Pavilion & Sculpture (right) is found on a gentle hill, opposite of the future Butterfly (left) guest services building.


It is widely known that women all over the world try doing their best so as to make sure that they look gorgeous and beautiful at all time.
While some of us like doing our hair, others love using make up, but the truth of the matter is that women can be beautiful without using make up.
Of course, we all have our flaws, but that does not mean we cannot look wonderful without covering them all up with a lot of foundation, powder and all sorts of other things.
There are a lot of things we can do to keep our skin beautiful and healthy and some of these things are staying hydrated. Drinking water or whatever type of fluid we enjoy, such as coffee or tea, is absolutely helpful, especially for women who are very active and who run from place to place all the time.
Let's see what we can do to look beautiful without make up. Keep in mind that natural beauty is the best and we are all beautiful.
As I have already said, drinking water is absolutely important for having a nice skin. Hydration is a very important factor, which influences greatly the way in which we look and feel. If all of us drank at least 8 or 10 glasses of water, we would always look out best, being all hydrated and having a glowing skin throughout the entire day.
Another way in which you can have a beautiful face without wearing any make up is by taking care of your eyebrows. They are very important in defining a woman's face and this is the main reason for which they have to be tidy and groomed at all times.
Washing your face must happen not only in the morning. A woman must wash her face at least twice a day. Having a daily routine involving washing your face and applying facials is a good way of heaving a nice, beautiful face without having to wear make up.
Aside of staying hydrated and keeping our face clean throughout the day, we also have two more things we can do. For one, we can keep the skin moisturized and nourished. There are numerous skin creams which we can use and they all have the same properties – they have the role of keeping our face beautiful, hydrated and glowing for a longer period of time.
Even so, you need to know that a woman can be beautiful without make up especially if she has a flashing smile.
The smile we put forth is a very important trick we can use to draw the attention to our lips.
Regardless of how our skin may look, if we have a beautiful smile, we can say we are fully wearing make-up.
You need to know that make up can lead to serious problems, especially for women who do not have the need of using it.


text:
Q: Salesforce Email sending with attachment adds extra extension .html I am sending email with 3 attachment it's work fine but when attachment files size are large then it adds extra extension with file name i.e test.pdf comes along with (test.pdf.html) in my email and mail goes to SPAM folder.
below is my code.
    if(strAttachFile != null && strAttachFile != '' && fileBody != null) {
        Messaging.Emailfileattachment efa1 = new Messaging.Emailfileattachment();
        efa1.setFileName(objAttachment1.Name);
        efa1.setbody(objAttachment1.Body);
        fileAttachments.add(efa1);
    }
    if(strAttachFile1 != null && strAttachFile1 != ''  && fileBody1 != null) {
        Messaging.Emailfileattachment efa2 = new Messaging.Emailfileattachment();
        efa2.setFileName(objAttachment2.Name);
        efa2.setbody(objAttachment2.Body);
        fileAttachments.add(efa2);
        system.debug('---fileAttachments---'+fileAttachments);
    }
    if(strAttachFile2 != null && strAttachFile2 != '' && fileBody2  != null) {
        Messaging.Emailfileattachment efa3 = new Messaging.Emailfileattachment();
        efa3.setFileName(objAttachment3.Name);
        efa3.setbody(objAttachment3.Body);
        fileAttachments.add(efa3);
    }

    mail.setFileAttachments(fileAttachments);
    system.debug('---mail---'+mail);
    Messaging.sendEmail(new Messaging.SingleEmailMessage[] { mail });

A: This is due to the way Salesforce sends attachments, probably related to the size of the attachment.
Salesforce automatically converts attachments over 3mb and sends them as links.
The HTML file links to a server hosted by salesforce and store this file for 30 days.(as a solotion The email must not be sent through the Force.com servers.)
That is all.

redpajama_set_name: RedPajamaStackExchange


Zoe Bradley Design Blog – tagged "holiday windows"
Much like Charles Dicken's protagonist in his novel, A Christmas Carol, the big luxury department stores have focused on Christmas past, present and future, when they unveiled their all important windows, to an ever expectant audience this month.
It's the one time of year, that the bricks and mortar of retail can seize their chance of creating something truly magical to engage with the passing public.
Despite the rising significance of digital touchpoints, where consumers are increasingly switched onto their mobile devices to purchase goods, brands continue to pour money and creativity into their elaborate Christmas windows. The stakes have never been higher.
It will certainly take more than a few switched on twinkly lights in the window to entice prospective shoppers over this festive season.
Christmas windows have become a popular attraction in London, with many people flocking to see the festive displays every year. Its a chance for stores to really turn on the theatre and create drama and storytelling. Consumers want to be taken on a journey, whether that's through nostalgia and sentiment or into the future with technology and wonderment. America has long held this tradition of making family outings to view the magic of the Holiday windows.
Windows at Christmas is all part of the bigger brand story. Brands need to show a sense of escapism and capture the spirit of Christmas. At the very least create a narrative. Tell a story. Take those customers into another world. It should encourage a smile, a sense of revelation. A sense of fun and childlike amusement. It is Christmas after all.
We take a look at those that have caught our attention and impressed with their creative dialogue, along with revisiting some of our own windows from Christmas past.
The Knightsbridge based department store created the drama of the Italian Renaissance for their Christmas window offering, even down to the marble effect front facade.
It captures all the drama we have come to expect from this store, along with lots of detail, props and styling. There are 100,000 glittering ice white balls that form into clouds, elaborate suspended chandeliers and over 90 hand made stars decorating the ceiling.
The windows feature a sizeable 1300 kg of paper, scrunched up to make props. Around 500 litres of paint was used for the marble-effect columns.
Janet Wardley, head of visual display at Harvey Nichols for the past 20 years, says "It has been an exciting challenge to transform the store's facade with marbled panels inspired by the Italian Renaissance architecture to bring Italy to our UK and Ireland sites this year.
"The use of lighting effects to create two different night and day displays highlights our iconic, playful and daring brand identity' offers Wardley.
Perhaps the worlds most iconic store, Harrods has teamed up with another very iconic British brand, Burberry for their window campaign, titled A Very British Fairy Tale, this wonderfully visual tale, tells the story of two children on an enchanting adventure through a snow-swept English country house.
The impressive display occupies the store's 29 windows, complete with flying cars, floating bathtubs and secret passageways. What is very impressive in this partnership, is the clever mix of old fashioned story telling with state of the art technology, where the tale can be bought to life by the passing public.
Visitors can interact with a sensory window using a motion sensor, through which they can experiment with the lighting and music. This is when the adults become kids again. Who doesn't love playing with a new gadget at Christmas time?
We couldn't agree more, and if that wasn't enough to engage all those SW1 Christmas shoppers, this genius collaboration have created a short animated film. As a paper artist, I was struck by how detailed and effective the paper characters and scenes looked. It wonderfully captures this fairytale through the imagination of the children.
Situated on one of London's prime retail sites, these windows offer up the cheeky side of Santa Claus. It's definitely party time for Santa in his full sequinned sparkly red suits. Having taken a two year sabbatical from the iconic Selfridges windows, he's back with a party bang and shows his irreverent side, mischiellously mixing with a host of penguins, poodles and polar bears, not to mention some 70's Disco divas.
Santa feature's in five windows along Oxford Street, where each set took over 100 hours to make and include 90 mirrored disco balls. It should be noted that no Polar Bears or Penguins were harmed in the making of these windows.
The store has also added a fun interactive feature for the estimated 100,000 passing public. A revolutionary speaker system which vibrates the window glass to produce unique soundtracks for the display behind. It really is the season to be jolly.
You could argue Liberty is retail's spiritual home of Christmas and perhaps looking to Christmas past, its fitting that the world famous Tudor building collaborated in an exclusive partnership with The Royal Ballet this season. Showcasing the enchanting story & well known ballet, The Nutcracker.
Carved wood ballerinas and toy soldiers stand proudly amongst the turning cogs of clocks and piles of presents in the Liberty windows.
Each of its windows is themed around a different scene from Drosselmeyer the magician's magical kingdom to the Nutcracker's battle with the Mouse King.
Across the pond in New York City, the story of Christmas is big business and is the most important time of year for the big named department stores.
The luxury retailer's overall theme this year is "Land of 1000 Delights," which includes magical landscapes of colourful sweets and festive fashion. There is larger than life lollipops swirls, skyscraper size sticks of stripy rock, that will have the kids eyes and tongues pressed against the Fifth Avenue windows.
Saks Fifth Avenue also features six windows along Fifth Avenue titled, "The Nutcracker Sweet," where you'll find Clara and the Mouse King frolicking amongst a luscious playground filled with treats. The multicoloured ten-story tall light show, which the department store is most known for during the holidays, is not to be missed. It play's daily from 5 to11pm every ten minutes until 2nd January.
Nancy Hansell, senior strategist at branding firm Siegel+Gale, comments the importance of this time of year for department stores like this. "Window displays, and holiday windows in particular, are really effective in helping brands elevate themselves beyond a transactional experience and remind people of the wonders of shopping," she says.
If we are referencing the Dicken's Christmas Carol, then world famous store Bloomingdales have looked to the Christmas future with their collaboration. Teaming up with a group of young dynamic artist's in aid of The Child Mind Institute. These creative visual artists have produced one-of-a-kind chandeliers that are works of their artistic expression based on a word about "light", the stores holiday campaign theme.
These works of art will be auctioned off for charity as "Bloomingdale's Lights Up A Young Mind". In the spirit of giving, Abby Modell, Allison Eden, Susanne Bartsch, Inma Barrero, Sean Augustine March, Erika deVries, Jonan Meyer, George Kroenert and Esmeralda Kosmatopoulos gave much of their time and their passion to support these children and the Child Mind Institute.
Bloomingdale's operating VP of Visual Merchandising says "Holiday windows are a big part of Bloomingdale's heritage and an annual tradition for so many of our customers," he says. "Our goal is to create a unique holiday experience that is like no other store in the world."
We were certainly transported with the magical theme of 'Destination Extraordinary' with luxury department store Bergdorf Goodman. We can completely relate to this other world at Zoe Bradley, taking the viewer on a journey of discovery and getting lost in another world.
David Hoey, Senior Director of Visual Presentation, characterises the department store's displays as "delirious remakes of the classic dioramas seen in natural history museums."
He cites the work of Henri Rousseau and 12th-century Chinese water-colour mountainscapes as inspiration for the lush, larger-than-life windows, each of which depicts a unique destination.
A special highlight is the wonderful work of New York based paper artist Daniel Sean Murphy,creating the 10 foot pair of praying mantis.


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European Strategic Autonomy: The Test Case of Iran
In: European Review of International Studies
Sascha Lohmann
Sascha LohmannThe Americas Research Division of the German Institute for International and Security Affairs( swp), Berlin, Germany, sascha.lohmann@swp-berlin.org
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The ideal of the European Union (EU) as a global peace and security actor is increasingly clashing with the reality of a multipolar world defined by militarised conflict, and a loosening of the formerly close trans-Atlantic relationship with the United States. European policy-makers have identified strategic autonomy as a possible remedy in the face of a growing number of internal and external security threats. This paper adds to the conceptualisation of strategic autonomy by contextualising its current usage and political genealogy. Empirically, European strategic autonomy is examined concerning the efforts to preserve the Iranian nuclear deal after the Trump administration had ceased US participation in May 2018. In particular, the paper assesses the European response to counter the re-imposed unilateral United States (US) sanctions against European individuals and entities by updating the so-called blocking regulation, and setting up a special purpose vehicle (spv) for facilitating trade with Iran. The results show that the European struggle toward achieving strategic autonomy has largely failed, but that it holds valuable lessons to approximate this ideal in the future.
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https://doi.org/10.1163/21967415-08030009
European strategic autonomy; transatlantic relations; economic sanctions; extraterritorial jurisdiction
European Review of International Studies
E-ISSN:
International Relations, International Relations
Abdoli, Amir. 'Iran, Sanctions, and the covid-19 Crisis'. Journal of Medical Economics, vol. 23, no. 12 (2020), available at: https://doi.org/10.1080/13696998.2020.1856855.
Abdoli, Amir. 'Iran, Sanctions, and the covid-19 Crisis'. Journal of Medical Economics, vol. 23, no. 12 (2020), available at: https://doi.org/10.1080/13696998.2020.1856855.)| false
afp, 'Iran Supreme Leader Calls European Trade Mechanism "Bitter Joke"', 21 February 2019, available at: www.bourseandbazaar.com/news-1/2019/3/21/iran-supreme-leader-calls-european-trade-mechanism-bitter-joke.
afp, 'Iran Supreme Leader Calls European Trade Mechanism "Bitter Joke"', 21 February 2019, available at: www.bourseandbazaar.com/news-1/2019/3/21/iran-supreme-leader-calls-european-trade-mechanism-bitter-joke.)| false
Alcaro, Riccardo. Europe and Iran's Nuclear Crisis: Lead Groups and EU Foreign Policy-Making (Cham: Palgrave Macmillan, 2018).
Alcaro, Riccardo. Europe and Iran's Nuclear Crisis: Lead Groups and EU Foreign Policy-Making (Cham: Palgrave Macmillan, 2018).)| false
Alcaro, Riccardo. 'Europe's Defence of the Iran Nuclear Deal: Less than a Success, More than a Failure', The International Spectator, vol. 56, no. 1 (2021), pp. 55–72.
Alcaro, Riccardo. 'Europe's Defence of the Iran Nuclear Deal: Less than a Success, More than a Failure', The International Spectator, vol. 56, no. 1 (2021), pp. 55–72.)| false
Bathmanghelidj, Esfandyar, and Axel Hellmann. Europe, Iran and Economic Sovereignty: A New Banking. Architecture in Response to US Sanctions, Global Security Report (Brussels: The European Leadership Network/Bourse&Bazar, June 2018).
Bathmanghelidj, Esfandyar, and AxelHellmann. Europe, Iran and Economic Sovereignty: A New Banking. Architecture in Response to US Sanctions, Global Security Report (Brussels: The European Leadership Network/Bourse&Bazar, June 2018).)| false
Bendiek, Annegret, Minna Ålander and Paul Bochtler. cfsp: The Capability-Expectation Gap Revisited. A Data-Based Analysis, swpComment 58 (Berlin: German Institute for International and Security Affairs, December 2020).
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