Identifying key health system components associated with improved outcomes to inform the re-configuration of services for adults with rare autoimmune rheumatic diseases: a mixed-methods study.

BACKGROUND: Adults with rare autoimmune rheumatic diseases face unique challenges and struggles to navigate health-care systems designed to manage common conditions. Evidence to inform an optimal service framework for their care is scarce. Using systemic vasculitis as an exemplar, we aimed to identify and explain the key service components underpinning effective care for rare diseases. METHODS: In this mixed-methods study, data were collected as part of a survey of vasculitis service providers across the UK and Ireland, interviews with patients, and from organisational case studies to identify key service components that enable good care. The association between these components and patient outcomes (eg, serious infections, mortality) and provider outcomes (eg, emergency hospital admissions) were examined in a population-based data linkage study using routine health-care data obtained from patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis from national health datasets in Scotland. We did univariable and multivariable analyses using Bayesian poisson and negative binomial regression to estimate incident rate ratios (IRRs), and Cox proportional hazards models to estimate hazard ratios (HRs). People with lived experiences were involved in the research and writing process. FINDINGS: Good care was characterised by service components that supported timely access to services, integrated care, and expertise. In 1420 patients with ANCA-associated vasculitis identified from national health datasets, service-reported average waiting times for new patients of less than 1 week were associated with fewer serious infections (IRR 0·70 [95% credibility interval 0·55-0·88]) and fewer emergency hospital admissions (0·78 [0·68-0·92]). Nurse-led advice lines were associated with fewer serious infections (0·76 [0·58-0·93]) and fewer emergency hospital admissions (0·85 [0·74-0·96]). Average waiting times for new patients of less than 1 week were also associated with reduced mortality (HR 0·59 [95% credibility interval 0·37-0·93]). Cohorted clinics, nurse-led clinics, and specialist vasculitis multi-disciplinary team meetings were associated with fewer serious infections (IRR 0·75 [0·59-0·96] for cohorted clinics; 0·65 [0·39-0·84] for nurse-led clinics; 0·72 [0·57-0·90] for specialist vasculitis multi-disciplinary team meetings) and emergency hospital admissions (0·81 [0·71-0·91]; 0·75 [0·65-0·94]; 0·86 [0·75-0·96]). Key components were characterised by their ability to overcome professional tensions between specialties. INTERPRETATION: Key service components associated with important health outcomes and underpinning factors were identified to inform initiatives to improve the design, delivery, and effectiveness of health-care models for rare autoimmune rheumatic diseases. FUNDING: Versus Arthritis.

The role of framing, agency and uncertainty in a focus-divide dilemma.

How to prioritise multiple objectives is a common dilemma of daily life. A simple and effective decision rule is to focus resources when the tasks are difficult, and divide when tasks are easy. Nonetheless, in experimental paradigms of this dilemma, participants make highly variable and suboptimal strategic decisions when asked to allocate resources to two competing goals that vary in difficulty. We developed a new version in which participants had to choose where to park a fire truck between houses of varying distances apart. Unlike in the previous versions of the dilemma, participants approached the optimal strategy in this task. Three key differences between the fire truck version and previous versions of the task were investigated: (1) Framing (whether the objectives are familiar or abstract), by comparing a group who placed cartoon trucks between houses to a group performing the same task with abstract shapes; (2) Agency (how much of the task is under the participants' direct control), by comparing groups who controlled the movement of the truck to those who did not; (3) Uncertainty, by adding variability to the driving speed of the truck to make success or failure on a given trial more difficult to predict. Framing and agency did not influence strategic decisions. When adding variability to outcomes, however, decisions shifted away from optimal. The results suggest choices become more variable when the outcome is less certain, consistent with exploration of response alternatives triggered by an inability to predict success.

Six of one, half dozen of the other: Suboptimal prioritizing for equal and unequal alternatives.

It is possible to accomplish multiple goals when available resources are abundant, but when the tasks are difficult and resources are limited, it is better to focus on one task and complete it successfully than to divide your efforts and fail on both. Previous research has shown that people rarely apply this logic when faced with prioritizing dilemmas. The pairs of tasks in previous research had equal utility, which according to some models, can disrupt decision-making. We investigated whether the equivalence of two tasks contributes to suboptimal decisions about how to prioritize them. If so, removing or manipulating the arbitrary nature of the decision between options should facilitate optimal decisions about whether to focus effort on one goal or divide effort over two. Across all three experiments, however, participants did not appropriately adjust their decisions with task difficulty. The only condition in which participants adopted a strategy that approached optimal was when they had voluntarily placed more reward on one task over the other. For the task that was more rewarded, choices were modified more effectively with task difficulty. However, participants were more likely to choose to distribute rewards equally than unequally. The results demonstrate that situations involving choices between options with equal utility are not avoided and are even slightly preferred over unequal options, despite unequal options having larger potential gains and leading to more effective prioritizing strategies.

A Distinct Plasma Microbiome But Not Gut Microbiome in Patients With Systemic Lupus Erythematosus Compared to Healthy Individuals.

OBJECTIVE: Blood microbiome has been analyzed in cancer patients using machine learning. We aimed to study whether the plasma microbiome represents the microbial community in the gut among patients with systemic lupus erythematosus (SLE) and healthy controls (HCs). METHODS: Paired plasma and stool samples from female patients with SLE and female HCs were assessed for microbiome composition by microbial 16S ribosomal RNA sequencing. RESULTS: Decreased microbial alpha diversity in stool compared to plasma and distinct plasma and gut beta diversity were found in both HCs and patients with SLE. No difference in gut microbial diversity was found; however, plasma alpha diversity was decreased in patients with SLE compared to HCs. The predominant bacteria differed between plasma and stool in both groups. Although the predominant plasma and stool genus bacteria were similar in patients with SLE and HCs, some were clearly different. CONCLUSION: Compared to the gut, the plasma microbiome contained distinct community and greater heterogeneity, indicating that the predominant circulating microbiome may originate from sites (eg, oral or skin) other than the gastrointestinal tract. The decreased plasma but not gut alpha diversity in patients with SLE compared to HCs implies an altered plasma microbiome in SLE, which may be important for systemic immune perturbations and SLE disease pathogenesis.

Stable individual differences in strategies within, but not between, visual search tasks.

A striking range of individual differences has recently been reported in three different visual search tasks. These differences in performance can be attributed to strategy, that is, the efficiency with which participants control their search to complete the task quickly and accurately. Here, we ask whether an individual's strategy and performance in one search task is correlated with how they perform in the other two. We tested 64 observers and found that even though the test-retest reliability of the tasks was high, an observer's performance and strategy in one task was not predictive of their behaviour in the other two. These results suggest search strategies are stable over time, but context-specific. To understand visual search, we therefore need to account not only for differences between individuals but also how individuals interact with the search task and context.

OpenABM-Covid19 - an agent-based model for non-pharmaceutical interventions against COVID-19 including contact tracing

SARS-CoV-2 has spread across the world, causing high mortality and unprecedented restrictions on social and economic activity. Policymakers are assessing how best to navigate through the ongoing epidemic, with models being used to predict the spread of infection and assess the impact of public health measures. Here, we present OpenABM-Covid19: an agent-based simulation of the epidemic including detailed age-stratification and realistic social networks. By default the model is parameterised to UK demographics and calibrated to the UK epidemic, however, it can easily be re-parameterised for other countries. OpenABM-Covid19 can evaluate non-pharmaceutical interventions, including both manual and digital contact tracing. It can simulate a population of 1 million people in seconds per day allowing parameter sweeps and formal statistical model-based inference. The code is open-source and has been developed by teams both inside and outside academia, with an emphasis on formal testing, documentation, modularity and transparency. A key feature of OpenABM-Covid19 is its Python interface, which has allowed scientists and policymakers to simulate dynamic packages of interventions and help compare options to suppress the COVID-19 epidemic.

Inefficient Eye Movements: Gamification Improves Task Execution, But Not Fixation Strategy.

Decisions about where to fixate are highly variable and often inefficient. In the current study, we investigated whether such decisions would improve with increased motivation. Participants had to detect a discrimination target, which would appear in one of two boxes, but only after they chose a location to fixate. The distance between boxes determines which location to fixate to maximise the probability of being able to see the target: participants should fixate between the two boxes when they are close together, and on one of the two boxes when they are far apart. We "gamified" this task, giving participants easy-to-track rewards that were contingent on discrimination accuracy. Their decisions and performance were compared to previous results that were gathered in the absence of this additional motivation. We used a Bayesian beta regression model to estimate the size of the effect and associated variance. The results demonstrate that discrimination accuracy does indeed improve in the presence of performance-related rewards. However, there was no difference in eye movement strategy between the two groups, suggesting this improvement in accuracy was not due to the participants making more optimal eye movement decisions. Instead, the motivation encouraged participants to expend more effort on other aspects of the task, such as paying more attention to the boxes and making fewer response errors.

The chemistry of low molecular weight black tea polyphenols.

This review summarises the chemistry of low molecular weight polyphenols isolated and characterised from black tea, discussing both structures identified and mechanisms of their likely formation.