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Many decisions in everyday life involve a choice between exploring options that are currently unknown and exploiting options that are already known to be rewarding. Previous work has suggested that humans solve such “explore-exploit” dilemmas using a mixture of two strategies: directed exploration, in which information seeking drives exploration by choice, and random exploration, in which behavioral variability drives exploration by chance. One limitation of this previous work was that, like most studies on explore-exploit decision making, it focused exclusively on the domain of gains, where the goal was to maximize reward. In many real-world decisions, however, the goal is to minimize losses and it is well known from Prospect Theory that behavior can be quite different in this domain. In this study, we compared explore-exploit behavior of human subjects under conditions of gain and loss. We found that people use both directed and random exploration regardless of whether they are exploring to maximize gains or minimize losses and that there is quantitative agreement between the exploration parameters across domains. Our results also revealed an overall bias towards the more uncertain option in the domain of losses. While this bias towards uncertainty was qualitatively consistent with the predictions of Prospect Theory, quantitatively we found that the bias was better described by a Bayesian account, in which subjects had a prior that was optimistic for losses and pessimistic for gains. Taken together, our results suggest that explore-exploit decisions are driven by three independent processes: directed and random exploration, and a baseline uncertainty seeking that is driven by a prior.
Serial position scores on verbal memory tests are sensitive to early Alzheimer’s disease (AD)-related neuropathological changes that occur in the entorhinal cortex and hippocampus. The current study examines longitudinal change in serial position scores as markers of subtle cognitive decline in older adults who may be in preclinical or at-risk states for AD.
This study uses longitudinal data from the Religious Orders Study and the Rush Memory and Aging Project. Participants (n = 141) were included if they did not have dementia at enrollment, completed follow-up assessments, and died and were classified as Braak stage I or II. Memory tests were used to calculate serial position (primacy, recency), total recall, and episodic memory composite scores. A neuropathological evaluation quantified AD, vascular, and Lewy body pathologies. Mixed effects models were used to examine change in memory scores. Neuropathologies and covariates (age, sex, education, APOE e4) were examined as moderators.
Primacy scores declined (β = −.032, p < .001), whereas recency scores increased (β = .021, p = .012). No change was observed in standard memory measures. Greater neurofibrillary tangle density and atherosclerosis explained 10.4% of the variance in primacy decline. Neuropathologies were not associated with recency change.
In older adults with hippocampal neuropathologies, primacy score decline may be a sensitive marker of early AD-related changes. Tangle density and atherosclerosis had additive effects on decline. Recency improvement may reflect a compensatory mechanism. Monitoring for changes in serial position scores may be a useful in vivo method of tracking incipient AD.
The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.
Background: Hospitalized patients with COVID-19 often receive antimicrobial therapies due to concerns for bacterial and fungal coinfections. We analyzed patients admitted with COVID-19 to our VA facility to understand antimicrobial use, frequency of coinfections, and outcomes in our population. Methods: This retrospective study included veterans who were 18 years or older and hospitalized with COVID-19 from March 10, 2020, to March 9, 2021 at the Louis Stokes VA Medical Center in Cleveland, Ohio. We identified antimicrobials administered and coinfections with bacterial or fungal pathogens. Patients were deemed to have coinfection if there was supporting microbiological data and a consistent clinical course upon review of clinical records. Urinary tract infections were excluded because of difficulty determining infection. Odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality were derived using multivariate logistic regression models that included age, Charlson comorbidity index (CCI), corticosteroid use, and time of infection. Results: In our cohort of 312 patients, the median age was 70 years and 97% of the patients were male. The mean CCI was 3.7 (SD, 3.0), and 111 patients (35.6%) had a score ≥5. Oxygen was administered to 250 patients (80.1%), and 20 (6.4%) required mechanical ventilation. Antimicrobials were administered to 164 patients (52.6%) (Fig. 1). Of 20 patients (6.4%) with coinfection, 11 (3.5%) had a bloodstream infection (BSI) and 9 (2.9%) had bacterial pneumonia (Fig. 2). The overall 30-day mortality rate was 12.5% (39 of 312). Among patients with coinfection, the 30-day mortality rate was 45% (9 of 20). Diagnoses of BSI (OR, 6.35; 95% CI, 1.41–26.30) and bacterial pneumonia (OR, 9.34; 95% CI, 2.01–46.34) were associated with increased mortality. Of the data available, 12 (63%) of 19 patients with coinfection had elevated procalcitonin levels (ie, >0.50). At the time of COVID-19 diagnosis, the median absolute lymphocyte count in patients who died was 0.7 K/mm3 (95% CI, 0.6–1.12) in comparison to 1 K/mm3 (95% CI, 0.7–1.4) in patients who survived at 30 days. Conclusions: Our analysis of hospitalized COVID-19 patients with advanced age and underlying comorbid conditions demonstrated that coinfections were infrequent but that they were independently associated with increased mortality. This finding highlights the need for better tools to diagnose the presence or absence of bacterial and fungal coinfection in COVID-19 patients. Our findings also emphasize the need for judicious use of antimicrobials while discerning which patients are at risk of critical illness and mortality.
Background:Pseudomonas aeruginosa is an important pathogen in the hospital setting; it has the ability to cause severe disease and a high mortality rate. Its increasing ability to elude even novel antimicrobial mechanisms of action is a significant cause for concern. More effective treatment options and increasing understanding of this pathogen likely effect P. aeruginosa incidence and severity; however, longer-term studies are lacking. The Veterans’ Health Administration (VHA) population is a socially, demographically, and medically distinct entity, representing a rich source of data for studying contributing factors to P. aeruginosa infection and mortality. We sought to identify the system-wide case count and mortality rate of P. aeruginosa bacteremia and the rate of resistance to antipseudomonal agents over the course of several years. We described trends observed over the study period. Methods: We utilized the nationwide VHA database to identify all inpatients with a positive blood culture for P. aeruginosa treated between January 1, 2009, and December 31, 2020. We identified the annual count of bacteremia cases and associated 30-day mortality rate. Additionally, we determined rates of resistance to antipseudomonal agents. Results: In total, 7,480 cases of P. aeruginosa bacteremia were identified. The total case count of P. aeruginosa bacteremia decreased from 774 in 2009 to 519 in 2014, then remained relatively stable. The 30-day mortality rate decreased from 26.5 in 2009 to 19.3 in 2019, but this rate increased to 23.6 in 2020 (Fig. 1). The fluoroquinolone class had the highest resistance rate at 23%, followed by ceftazidime, cefepime, and the carbapenem class with rates of ~15%–16%. All classes were noted to have decreased resistance over time (Fig. 2). Conclusions: Occurrences, mortality rate, and associated resistance of P. aeruginosa bacteremia across the VHA system generally decreased during the study period. Potential explanations for these observations include improved infection control measures, more effective therapeutic agents, and enhanced antimicrobial stewardship efforts. The increased mortality in 2020 could be related to concomitant COVID-19 or the result of delayed medical care in the pandemic setting. Limitations of this study include inability to identify causative factors for observed trends and potential variability between labs affecting the rates of observed resistance. Additionally, VHA data may not be representative of entire adult population. Future studies could explore the relationship between P. aeruginosa bacteremia and infection prevention and antimicrobial stewardship efforts and could describe associations between P. aeruginosa and COVID-19 and identify risk factors associated with P. aeruginosa bacteremia and mortality.
OBJECTIVES/GOALS: Using the covariate-rich Veteran Health Administration data, estimate the association between Proton Pump Inhibitor (PPI) use and severe COVID-19, rigorously adjusting for confounding using propensity score (PS)-weighting. METHODS/STUDY POPULATION: We assembled a national retrospective cohort of United States veterans who tested positive for SARS-CoV-2, with information on 33 covariates including comorbidity diagnoses, lab values, and medications. Current outpatient PPI use was compared to non-use (two or more fills and pills on hand at admission vs no PPI prescription fill in prior year). The primary composite outcome was mechanical ventilation use or death within 60 days; the secondary composite outcome included ICU admission. PS-weighting mimicked a 1:1 matching cohort, allowing inclusion of all patients while achieving good covariate balance. The weighted cohort was analyzed using logistic regression. RESULTS/ANTICIPATED RESULTS: Our analytic cohort included 97,674 veterans with SARS-CoV-2 testing, of whom 14,958 (15.3%) tested positive (6,262 [41.9%] current PPI-users, 8,696 [58.1%] non-users). After weighting, all covariates were well-balanced with standardized mean differences less than a threshold of 0.1. Prior to PS-weighting (no covariate adjustment), we observed higher odds of the primary (9.3% vs 7.5%; OR 1.27, 95% CI 1.13-1.43) and secondary (25.8% vs 21.4%; OR 1.27, 95% CI 1.18-1.37) outcomes among PPI users vs non-users. After PS-weighting, PPI use vs non-use was not associated with the primary (8.2% vs 8.0%; OR 1.03, 95% CI 0.91-1.16) or secondary (23.4% vs 22.9%;OR 1.03, 95% CI 0.95-1.12) outcomes. DISCUSSION/SIGNIFICANCE: The associations between PPI use and severe COVID-19 outcomes that have been previously reported may be due to limitations in the covariates available for adjustment. With respect to COVID-19, our robust PS-weighted analysis provides patients and providers with further evidence for PPI safety.
World-renowned for having made a totally new kind of theatre, director-designer Robert Wilson first astonished international audiences in Paris in 1971 with Le Regard du sourd (Deafman Glance) and then with his twenty-four-hour Ouverture at the first edition of the Festival d’Automne in 1972. He also refers in this Conversation to Einstein on the Beach, premiered at the Avignon Festival in 1976, as another example among more of France offering him a home before he eventually founded the Watermill Center in 1992 on Long Island in the State of New York. Watermill, a laboratory for multidisciplinary creativity, opened its doors to the public in 2006 and is a focal point of the Conversation as a whole. Wilson’s immediately pre-Covid-pandemic production of The Messiah by Mozart was premiered at the Mozartwoche Salzburg in February 2020 and performed subsequently in Paris during a brief Covid ‘lull’ in September of that year. Discussion of this pivotal work leads to reflections on the opera productions that he had staged not so long before it, emphasizing the elements fundamental to his compositions – light, time, space, architecture, and silence. The Conversation, followed by audience questions addressed to Wilson, took place live online and on Facebook on 4 December 2020 as a prelude to the Festival Internacional Santiago a Mil in Chile, which opened on 3 January 2021. This was the Festival’s twenty-eighth year, but in a significantly restricted form due to Covid-19. A sequel to the Santiago interchange, also online but this time located in Paris, occurred on 17 September 2021. It resumes dialogue mainly on the Watermill Center’s broader cultural and social goals in the present and for the future, noting as well Wilson’s then current activities in Paris: a heavy schedule of four productions from the beginning of September to the end of December 2021, and a sound installation planned for 2022.
Maria Shevtsova gratefully thanks the Fundación Teatro a Mil and its General Director Carmen Romero for their initiative in inviting Robert Wilson with her to converse publicly as part of the Festival a Mil, and for permission to edit the transcript for publication in New Theatre Quarterly. Thanks are due to interpreters Margit Schmohl and Jorge Ramirez, and to Maria Luisa Vergara for organizing the audience participation included below, as well as to Alfonso Arenas, former Coordinator of the Education and Communities Area at the Theatre Foundation a Mil. Warmest gratitude is extended to Robert Wilson for his generosity in all sorts of ways, and not least for finding the time to continue the Conversation in Paris. Thanks for their kind support to Nuria Moreno, Production at Teatro Real Madrid, Christof Belka, Executive Director of RW Work Ltd, Clifford Allen, Director of Archives of the Watermill Center, and Leesa Kelly and Noah Khoshbin, curators of the 2021 outdoor exhibition Minneapolis Protest Murals at the Crossroads Summer Festival held at the Watermill Center. The exhibition presented 190 public artworks from the 900 boards of the Minneapolis Protest Murals which were created organically in Minneapolis following the murder of George Floyd on 25 May 2020. Special thanks for their gift of images are given to photographers Lucie Jansch, Javier del Real, Kristian Kruuser and Kaupo Kikkas, Lovik Delger Ostenrik, and Martyna Szczesna. Kunsang Kelden and Maria Shevtsova transcribed this Conversation in two parts. Shevtsova, Editor of New Theatre Quarterly and author of Robert Wilson (Routledge, 2007; updated edition, 2019) edited and annotated the combined transcript for publication.
To assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments and interventions in this setting. Within a quality improvement framework, staff were trained, a clinical protocol developed and clinical interventions made accessible.
Thirty per cent of women were identified as having unmet SRH needs and proceeded to a specialist appointment, representing a 2.5-fold increase in unmet need detection. Forty-two per cent of women were assessed, representing a 3.5-fold increase in uptake. Twenty-one per cent of women initiated SRH interventions, of which 14% had all their SRH needs met. Staff, patients and carers highlighted the acceptability and importance of SRH care, if interventions were appropriately timed and patients’ individual risk profiles were considered. Barriers to access included lack of routine enquiry, illness acuity and impact of the COVID-19 pandemic.
SRH needs for PICU admissions are greater than previously realised. Providing a nurse-led SRH assessment is acceptable, feasible and beneficial for PICU patients.
To test the hypothesis that higher level of purpose in life is associated with lower likelihood of dementia and mild cognitive impairment (MCI) in older Brazilians.
As part of the Pathology, Alzheimer’s and Related Dementias Study (PARDoS), informants of 1,514 older deceased Brazilians underwent a uniform structured interview. The informant interview included demographic data, the Clinical Dementia Rating scale to diagnose dementia and MCI, the National Institute of Mental Health Diagnostic Interview Schedule for depression, and a 6-item measure of purpose in life, a component of well-being.
Purpose scores ranged from 1.5 to 5.0 with higher values indicating higher levels of purpose. On the Clinical Dementia Rating Scale, 940 persons (62.1%) had no cognitive impairment, 121 (8.0%) had MCI, and 453 (29.9%) had dementia. In logistic regression models adjusted for age at death, sex, education, and race, higher purpose was associated with lower likelihood of MCI (odds ratio = .58; 95% confidence interval [CI]: .43, .79) and dementia (odds ratio = .49, 95% CI: .41, .59). Results were comparable after adjusting for depression (identified in 161 [10.6%]). Neither race nor education modified the association of purpose with cognitive diagnoses.
Higher purpose in life is associated with lower likelihood of MCI and dementia in older black and white Brazilians.
To assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments/interventions in this setting. Secondary aims were to explore the barriers to access and the feasibility of providing SRH assessments and interventions in the PICU.
A retrospective analysis of fifteen months’ activity data found that only 25 SRH referrals had been made across 205 PICU admissions. This low referral rate of 12% likely reflected pathway barriers and was unlikely to represent the actual clinical need in female PICU patients. A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on the PICU over a seven-month period. Within a quality improvement framework, a staff training needs assessment was performed, training delivered, a protocol developed, staff attitudes explored, and patient and carer engagement sought.
A quality improvement approach streamlined SRH assessments on the PICU and resulted in 42% of women being assessed and a 3.5-fold increase in uptake. At least 30% of the women in the PICU had unmet SRH needs identified and proceeded to a specialist appointment. This amounts to a minimum 2.5-fold increase in SRH unmet need detection.
The most common SRH needs were complex gynaecological issues (such as period problems, pelvic pain, vaginal discharge), STI advice/testing and contraception advice/options. 21% of women initiated SRH interventions, and 14% completed all the interventions required for their needs. The most common interventions were in the areas of contraception advice/family planning and STI advice/testing.
Staff confidence on assessing SRH topics was identified as a barrier to access with a positive shift noted after bespoke SRH training was implemented and a protocol introduced: on a scale of 0-10 (with 10 being high), 81.3% of staff rated their confidence 8 or above in relation to discussing contraception/sexually transmitted infections (pre-training: 25.0%), and 93.8% in relation to discussing risky behaviours (pre-training: 18.8%). All 11 patient and carer participants felt it was important to have a forum to talk about SRH and 8 (72.7%) agreed it was important in the PICU.
Results identify that SRH needs for PICU admissions are greater than previously realised. Staff highlighted the acceptability and importance of SRH care, if interventions are appropriately timed and the patient's individual risk profile considered. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients.
As part of the Pathology, Alzheimer’s and Related Dementias Study, we conducted uniform structured interviews with knowledgeable informants (72% children) of 1,493 older (age > 65) Brazilian decedents.
The interview included measures of social isolation (number of family and friends in at least monthly contact with decedent), emotional isolation (short form of UCLA Loneliness Scale), and major depression plus the informant portion of the Clinical Dementia Rating Scale to diagnose dementia and its precursor, mild cognitive impairment (MCI).
Decedents had a median social network size of 8.0 (interquartile range = 9.0) and a median loneliness score of 0.0 (interquartile range = 1.0). On the Clinical Dementia Rating Scale, 947 persons had no cognitive impairment, 122 had MCI, and 424 had dementia. In a logistic regression model adjusted for age, education, sex, and race, both smaller network size (odds ratio [OR] = 0.975; 95% confidence interval [CI]: 0.962, 0.989) and higher loneliness (OR = 1.145; 95% CI: 1.060, 1.237) were associated with higher likelihood of dementia. These associations persisted after controlling for depression (present in 10.4%) and did not vary by race. After controlling for depression, neither network size nor loneliness was related to MCI.
Social and emotional isolation are associated with higher likelihood of dementia in older black and white Brazilians.
The use of online platforms for pediatric healthcare research is timely, given the current pandemic. These platforms facilitate trial efficiency integration including electronic consent, randomization, collection of patient/family survey data, delivery of an intervention, and basic data analysis.
We created an online digital platform for a multicenter study that delivered an intervention for sleep disorders to parents of children with autism spectrum disorder (ASD). An advisory parent group provided input. Participants were randomized to receive either a sleep education pamphlet only or the sleep education pamphlet plus three quick-tips sheets and two videos that reinforced the material in the pamphlet (multimedia materials). Three measures – Family Inventory of Sleep Habits (FISH), Children’s Sleep Habits Questionnaire modified for ASD (CSHQ-ASD), and Parenting Sense of Competence (PSOC) – were completed before and after 12 weeks of sleep education.
Enrollment exceeded recruitment goals. Trial efficiency was improved, especially in data entry and automatic notification of participants related to survey completion. Most families commented favorably on the study. While study measures did not improve with treatment in either group (pamphlet or multimedia materials), parents reporting an improvement of ≥3 points in the FISH score showed a significantly improved change in the total CSHQ (P = 0.038).
Our study demonstrates the feasibility of using online research delivery platforms to support studies in ASD, and more broadly, pediatric clinical and translational research. Online platforms may increase participant inclusion in enrollment and increase convenience and safety for participants and study personnel.
We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP).
Four-year retrospective study.
Veterans’ Health Administration (VHA).
VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018.
We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7.
Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and β-lactam/β-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward.
The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.
Background: The survival of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) is largely determined by the timely administration of effective antibiotic therapy. Guidelines for the treatment HAP and VAP recommend empiric treatment with broad-spectrum antibiotics and tailoring of antibiotic therapy once results of microbiological testing are available. Objective: We examined the influence of bacterial identification and antibiotic susceptibility testing on antibiotic therapy for patients with HAP or VAP. Methods: We used the US Veterans’ Health Administration (VHA) database to identify a retrospective cohort of patients diagnosed with HAP or VAP between fiscal year 2015 and 2018. We further analyzed patients who were started on empiric antibiotic therapy, for whom microbiological test results from a respiratory sample were available within 7 days and who were alive within 48 hours of sample collection. We used the antibiotic spectrum index (ASI) to compare antibiotics prescribed the day before and the day after availability of bacterial identification and antibiotic susceptibility testing results. Results: We identified 4,669 cases of HAP and VAP in 4,555 VHA patients. The median time from respiratory sample receipt in the laboratory to final result of bacterial identification and antibiotic susceptibility testing was 2.22 days (IQR, 1.31–3.38 days). The most common pathogen was Staphylococcus aureus (n = 994), with methicillin resistance in 58% of those isolates tested. The next most common pathogen was Pseudomonas spp (n = 946 isolates). The susceptibility of antipseudomonal antibiotics, when tested, was as follows: 64% to carbapenems, 74% to cephalosporins, 75% to β-lactam/β-lactamase inhibitors, 69% to fluoroquinolones, and 95% to amikacin. Lactose-fermenting gram-negative bacteria (296 Escherichia coli and 360 Klebsiella pneumoniae) were also common. Among the 3,094 cases who received empiric antibiotic therapy, 607 (20%) had antibiotics stopped the day after antibiotic susceptibility results became available, 920 (30%) had a decrease in ASI, 1,075 (35%) had no change in ASI, and 492 (16%) had an increase in ASI (Fig. 1). Among the 1,098 patients who were not started on empiric antibiotic therapy, only 154 (14%) were started on antibiotic therapy the day after antibiotic susceptibility results became available. Conclusions: Changes in antibiotic therapy occurred in at least two-thirds of cases the day after bacterial identification and antibiotic susceptibility results became available. These results highlight how respiratory cultures can inform the treatment and improve antibiotic stewardship for patients with HAP/VAP.
Funding: This study was supported by Accelerate Diagnostics.
Home care for older people in England is commissioned through local authorities working predominantly with independent providers of care. Commissioners operate in a market model, planning and procuring home care services for local populations. Their role involves ‘managing’ and ‘shaping’ the market to ensure an adequate supply of care providers. Another imperative, emerging from the principles of personalisation, is the drive to achieve user outcomes rather than ‘time and task’ objectives. Little formal research has investigated the way commissioners reconcile these different requirements and organise commissioning. This study investigated commissioning approaches using qualitative telephone interviews with ten commissioners from different local authorities in England. The characteristics of commissioning were analysed thematically. Findings indicated (a) commissioning involved complex systems and processes, uniquely shaped for the local context, but frequently changed, suggesting a constant need for reframing commissioning arrangements; (b) partnerships with providers were mainly transactional, with occasional examples of collaborative models, that were considered to facilitate flexible services more appropriate for commissioning for personalised outcomes; and (c) only a small number of commissioners had attempted to reconcile the competing and incompatible goals of tightly prescribed contracting and working collaboratively with providers. A better understanding of flexible contracting arrangements and the hallmarks of a trusting collaboration is required to move beyond the procedural elements of contracting and commissioning.
Congenital heart disease (CHD) describes the abnormalities of the heart or great vessels that are present at birth and that significantly impair the function of the cardiovascular system. It is the most common birth defect, affecting up to 2% of live-born children: according to the British Heart Foundation (BHF Statistics 2018), CHD is detected in 1 out of 180 babies (excluding bicuspid aortic valve), which translates into at least 4000 affected infants in the UK per year. CHD is diagnosed in over 8% of premature births and is a leading cause of infant mortality (up to 10% of cases). Cardiac abnormalities account for more than 9% of all stillbirths after 20 weeks and up to 4% of spontaneous miscarriages before 20 weeks of pregnancy. It is estimated that in the European Union, 3000 children with heart defects die annually as ‘terminations of pregnancy for fetal anomaly’, late fetal death or early neonatal death. Some malformations, such as aortic valve anomalies, often do not manifest at birth, and as more diagnoses are being made later in life, the number of CHD cases only increases [1–3].
Amongst the virtues extolled within analytic metaphysics are universality and parsimony. We value an account of what there is that includes everything, and we want a metaphysics that not only excludes what there isn't, but that also avoids the vice of double-counting. This vice leads to redundancies in one's ontology, such as asserting or entailing that there are, for example, minds over and above matter (if one is a materialist in the philosophy of mind), or groups of people over and above the individual people in those groups (if one is an individualist in the social sciences). An ontological view must be sufficiently pluralistic to achieve universality or completeness, yet sparse enough to respect parsimony or non-redundancy.