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Uncertainty, investment and productivity with relational contracts
No full textThis paper shows that, in the presence of relational contracts, an increase in uncertainty with no change in factor prices reduces capital investment and productivity in the long run even if the parties are otherwise risk neutral. Recent literature on the effect of uncertainty on investment has focused on the option value arising from irreversibility of investment and on the impact of financial risk on the cost of capital. For the option value model, however, Bloom et al. (Econometrica, 2018) find that a negative aggregate shock to total factor productivity, not just an increase in its uncertainty, is required to capture the drop in investment and productivity associated with the increase in uncertainty in recessions. With the cap ital cost model, the reduction in investment lasts only as long as the higher capital cost is sustained. The current paper first develops a relational contract model to demonstrate the impact of uncertainty on investment and how the effect depends on whether the investment is general or specific. To illustrate how taking account of relational contracts can help capture the effect of uncertainty on investment empirically, it then uses a specification calibrated with parameters from Bloom et al. (Econometrica, 2018) to show that this model can generate effects on investment of the magnitude of the negative aggregate shock in that paper purely with an increase in uncertainty with no change in factor prices
AI alignment and human reward
No full textAccording to a prominent approach to AI alignment, AI agents should be built to learn and promote human values. However, humans value things in several different ways: we have desires and preferences of various kinds, and if we engage in reinforcement learning, we also have reward functions. One research project to which this approach gives rise is therefore to say which of these various classes of human values should be promoted. This paper takes on part of this project by assessing the proposal that human reward functions should be the target for AI alignment. There is some reason to believe that powerful AI agents which were aligned to values of this form would help us to lead good lives, but there is also considerable uncertainty about this claim, arising from unresolved empirical and conceptual issues in human psychology
Treatment satisfaction, patient preferences, and the impact of suboptimal disease control in a large international rheumatoid arthritis cohort: SENSE study
No full textBackground:
Patients’ needs and perspectives are important determinants of treatment success in rheumatoid arthritis (RA). Assessing patients’ perspectives can help identify unmet needs and enhance the understanding of treatment benefits.
Objectives:
The SENSE study assessed the impact of inadequate response to disease-modifying antirheumatic drugs (DMARDs) on treatment satisfaction, disease outcomes, and patient perspectives related to RA disease management.
Methods:
SENSE was a noninterventional, cross-sectional study conducted in 18 countries across Europe, Asia, and South America. Adult patients with poorly controlled RA of moderate/high disease activity were eligible. Patient satisfaction was assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM v1.4). Treatment adherence, healthcare resource utilization (HRU), quality of life (QoL), work ability, digital health literacy (DHL), patient preference information, and treatment strategy were also assessed.
Results:
1,624 patients were included in the study: most were female (84.2%) and middle-aged, and mean disease duration was 10.5 years. Mean TSQM global satisfaction subscore was 60.9, with only 13.5% of patients reporting good treatment satisfaction (TSQM global ≥80). The strongest predictor of good treatment satisfaction was treatment with advanced therapies. Most patients (87.4%) reported good treatment adherence. In general, patients had impaired QoL and work ability, high HRU, and 67.4% had poor DHL. Leading treatment expectations were “general improvement of arthritis” and “less joint pain”. Most patients preferred oral RA medications (60.7%) and rapid (≤1 week) onset of action (71.1%). “Increased risk for malignancies” and “increased risk for cardiovascular disease” were the least acceptable side effects. Despite suboptimal control, advanced therapies were only used in a minority of patients, and DMARD switches were planned for only half of the patients.
Conclusion:
Suboptimal disease control negatively impacts treatment satisfaction, work ability, QoL, and HRU. Data collected on patient perspectives may inform shared decision-making and optimize treat-to-target strategies for improving patient outcomes in RA
Slow-fast auditory streams for audio recognition
No full textWe propose a two-stream convolutional network for audio recognition, that operates on time-frequency spectrogram inputs. Following similar success in visual recognition, we learn Slow-Fast auditory streams with separable convolutions and multi-level lateral connections. The Slow pathway has high channel capacity while the Fast pathway operates at a fine-grained temporal resolution. We showcase the importance of our two-stream proposal on two diverse datasets: VGG-Sound and EPIC-KITCHENS-100, and achieve state- of-the-art results on both
Mental health crises in the emergency department: simulation training for interprofessional collaboration and teamwork attitudes
No full textIntroduction
Emergency departments can often be the first place to which people present when in mental health emergencies, although these departments and staff are not always adequately supported to meet the needs of these patients. This study aimed to evaluate the impact of simulation-based training for mental health crisis in the emergency department on knowledge, confidence and attitudes towards interprofessional collaboration.
Methods
Healthcare professionals (n = 85) from a range of professions participated in a multicentred simulation-based training activity. Questionnaires evaluating participant knowledge, confidence and interprofessional attitudes were administered pre- and post-activity, and analyses were conducted. Thematic analysis was conducted on free-form participation simulation training evaluation forms.
Results
Participants reported that the simulation training improved their communication skills, clinical practice, encouraged reflective practice and promoted interprofessional collaboration between emergency department and mental health professionals. Significant improvements were seen in participant knowledge and confidence in providing care to individuals presenting to emergency departments in mental health crises. Attitudes towards interprofessional collaboration in a variety of domains improved because of taking the simulation training.
Discussion
The pedagogical qualities of the in-situ simulation-based training presented fostered interprofessional collaboration and allowed participants to achieve challenging outcomes. It is suggested that further research should investigate the impact of simulation-based training on mental health related patient care outcomes in the emergency department
‘Personal Health Surveillance’: the use of mHealth in healthcare responsibilisation
No full textThere is an ongoing increase in the use of mobile health (mHealth) technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses ‘medical monitoring’, and the second ‘personal health surveillance’. After outlining two problems which the use of mHealth might seem to enable us to overcome—fairness of burdens and reliance on self-reporting—I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim
Global mental health should engage with the ethics of involuntary admission
No full textGlobal mental health, as a field, has focused on both increasing access to mental health services and promoting human rights. Amidst many successes in engaging with and addressing various human rights violations affecting individuals living with psychosocial disabilities, one human rights challenge remains under-discussed: involuntary inpatient admission for psychiatric care. Global mental health ought to engage proactively with the debate on the ethics of involuntary admission and work to develop a clear position, for three reasons. Firstly, the field promotes models of mental healthcare that are likely to include involuntary admission. Secondly, the field aligns much of its human rights framework with the UN Convention on the Rights of Persons with Disabilities, which opposes the discriminatory use of involuntary admission on the basis of psychosocial disability or impairment. Finally, global mental health, as a field, is uniquely positioned to offer novel contributions to this long-standing debate in clinical ethics by collecting data and conducting analyses across settings. Global mental health should take up involuntary admission as a priority area of engagement, applying its own orientation toward research and advocacy in order to explore the dimensions of when, if ever, involuntary admission may be permissible. Such work stands to offer meaningful contributions to the challenge of involuntary admission
Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis
No full textBackground
Diagnosis of transient ischaemic attacks (TIAs) can be difficult. There is consensus on classic symptoms (eg, motor weakness, dysphasia, hemianopia, monocular visual loss) but no consensus on several monosymptomatic events with sudden-onset, non-progressive, focal negative symptoms (eg, isolated diplopia, dysarthria, vertigo, ataxia, sensory loss, and bilateral visual disturbance), with much variation in investigation and treatment.
Methods
We prospectively ascertained and investigated all strokes and sudden onset transient neurological symptoms in a population of 92 728 people (no age restrictions) from Oxfordshire, UK, who sought medical attention at nine primary care practices or at the John Radcliffe Hospital, Oxford, UK (Oxford Vascular Study). Patients classified at baseline with minor ischaemic stroke (National Institutes of Health Stroke Score <5), classic TIA, or non-consensus TIA were treated according to secondary prevention guidelines. Risks of stroke (7-day, 90-day, and 10-year risks) and risks of all major vascular events (from the time of first event, and from the time of seeking medical attention) were established by face-to-face follow-up visits and were compared with the risk expected from age and sex-specific stroke incidence in the underlying study population.
Findings
Between April 1, 2002, and March 31, 2018, 2878 patients were identified with minor ischaemic stroke (n=1287), classic TIA (n=1021), or non-consensus TIA (n=570). Follow-up was to Oct 1, 2018 (median 5·2 [IQR 2·6–9·2] years). 577 first recurrent strokes after the index event occurred during 17 009 person-years of follow-up. 90-day stroke risk from time of the index event after a non-consensus TIA was similar to that after classic TIA (10·6% [95% CI 7·8–12·9] vs 11·6% [95% CI 9·6–13·6]; hazard ratio 0·87, 95% CI 0·64–1·19; p=0·43), and higher than after amaurosis fugax (4·3% [95% CI 0·6–8·0]; p=0·042). However, patients with non-consensus TIA were less likely to seek medical attention on the day of the event than were those with classic TIA (336 of 570 [59%] vs 768 of 1021 [75%]; odds ratio [OR] 0·47, 95% CI 0·38–0·59; p<0·0001) and were more likely to have recurrent strokes before seeking attention (45 of 570 [8%] vs 47 of 1021 [5%]; OR 1·77, 95% CI 1·16–2·71; p=0·007). After excluding such recurrent strokes, 7-day stroke risk after seeking attention for non-consensus TIA (2·9% [95% CI 1·5–4·3]) was still considerably higher than the expected background risk (relative risk [RR] 203, 95% CI 113–334), particularly if the patient sought attention on the day of the index event (5·0% [2·1–7·9]; RR 300, 137–569). 10-year risk of all major vascular events was similar for non-consensus and classic TIAs (27·1% [95% CI 22·8–31·4] vs 30·9% [27·2–33·7]; p=0·12). Baseline prevalence of atrial fibrillation, patent foramen ovale, and arterial stenoses were also similar for non-consensus TIA and classic TIA, although stenoses in the posterior circulation were more frequent with non-consensus TIA (OR 2·21, 95% CI 1·59–3·08; p<0·0001).
Interpretation
Patients with non-consensus TIA are at high early and long-term risk of stroke and have cardiovascular pathological findings on investigation similar to those of classic TIA. Designation of non-consensus TIAs as definite cerebrovascular events will increase overall TIA diagnoses by about 50%.
Funding
Wellcome Trust, National Institute for Health Research Oxford Biomedical Research Centre, Wolfson Foundation, Masonic Charitable Foundation, and British Heart Foundation
Assessing cardiovascular risk by using the fat attenuation index in coronary CT angiography
No full textPerivascular adipose tissue mapping by means of the coronary CT angiography (CCTA)–derived fat attenuation index is a recently developed method to noninvasively detect coronary inflammation and atherosclerotic changes at CCTA, with incremental prognostic value over and above traditional risk factors.
Coronary CT angiography (CCTA) has evolved into a first-line diagnostic test for the investigation of chest pain. Despite advances toward standardizing the reporting of CCTA through the Coronary Artery Disease Reporting and Data System (or CAD-RADS) tool, the prognostic value of CCTA in the earliest stages of atherosclerosis remains limited. Translational work on the bidirectional interplay between the coronary arteries and the perivascular adipose tissue (PVAT) has highlighted PVAT as an in vivo molecular sensor of coronary inflammation. Coronary inflammation is dynamically associated with phenotypic changes in its adjacent PVAT, which can now be detected as perivascular attenuation gradients at CCTA. These gradients are captured and quantified through the fat attenuation index (FAI), a CCTA-based biomarker of coronary inflammation. FAI carries significant prognostic value in both primary and secondary prevention (patients with and without established coronary artery disease) and offers a significant improvement in cardiac risk discrimination beyond traditional risk factors, such as coronary calcium, high-risk plaque features, or the extent of coronary atherosclerosis. Thanks to its dynamic nature, FAI may be used as a marker of disease activity, with observational studies further suggesting that it tracks the response to anti-inflammatory interventions. Finally, radiotranscriptomic studies have revealed complementary radiomic patterns of PVAT, which detect more permanent adverse fibrotic and vascular PVAT remodeling, further expanding the value of PVAT phenotyping as an important readout in modern CCTA analysis
The role of specialist nurses in delivering effective care in a tertiary sarcoma referral service
No full textMusculoskeletal sarcomas are rare cancers with an incidence of less than 1% of all cancers. Management of these tumors requires multidisciplinary care comprising of numerous specialists. Critical decisions following collaborative discussion among treating specialists followed by timely communication and starting prompt treatment are vital in delivering care in such rare sarcomas. While musculoskeletal surgeons, radiologists, and clinical oncologists are well known, the role of specialist nurses has been less described. They form a vital pillar in any tertiary sarcoma service by assisting in collaborative care, having consultations in nurse-led clinics, offering psychological support, imparting details of treatment to patient and helping in palliative care. This narrative review focuses on the role of trained specialist nurses in a tertiary sarcoma service and gives insight into their vital role in delivering timely, coordinated, effective care