Delivering reform in English healthcare: an ideational perspective

A variety of perspectives has been put forward to understand reform across healthcare systems. Recently, some have called for these perspectives to give greater recognition to the role of ideational processes. The purpose of this article is to present an ideational approach to understanding the delivery of healthcare reform. It draws on a case of English healthcare reform – the Next Stage Review led by Lord Darzi – to show how the delivery of its reform proposals was associated with four ideational frames. These frames built on the idea of “progress” in responding to existing problems; the idea of “prevailing policy” in forming part of a bricolage of ideas within institutional contexts; the idea of “prescription” as top-down structural change at odds with local contexts; and the idea of “professional disputes” in challenging the notion of clinical engagement across professional groups. The article discusses the implications of these ideas in furthering our understanding of policy change, conflict and continuity across healthcare settings

Policy Feedback and the Politics of the Affordable Care Act

There is a large body of literature devoted to how “policies create politics” and how feedback effects from existing policy legacies shape potential reforms in a particular area. Although much of this literature focuses on self‐reinforcing feedback effects that increase support for existing policies over time, Kent Weaver and his colleagues have recently drawn our attention to self‐undermining effects that can gradually weaken support for such policies. The following contribution explores both self‐reinforcing and self‐undermining policy feedback in relationship to the Affordable Care Act, the most important health‐care reform enacted in the United States since the mid‐1960s. More specifically, the paper draws on the concept of policy feedback to reflect on the political fate of the ACA since its adoption in 2010. We argue that, due in part to its sheer complexity and fragmentation, the ACA generates both self‐reinforcing and self‐undermining feedback effects that, depending of the aspect of the legislation at hand, can either facilitate or impede conservative retrenchment and restructuring. Simultaneously, through a discussion of partisan effects that shape Republican behavior in Congress, we acknowledge the limits of policy feedback in the explanation of policy stability and change

Enhanced heterogeneously catalyzed Suzuki–Miyaura reaction over SiliaCat Pd(0)

The SiliaCat Pd(0) solid catalyst can be efficiently employed in the Suzuki–Miyaura cross-coupling of an ample variety of haloarenes, including economically viable chloroarenes. The catalyst can be extensively recycled without loss of activity and with low leaching of valued palladium, opening the route to widespread utilization of the method to afford high yields of biaryls devoid of contaminating by-products

A set of moment tensor potentials for zirconium with increasing complexity

Machine learning force fields (MLFFs) are an increasingly popular choice for atomistic simulations due to their high fidelity and improvable nature. Here, we propose a hybrid small-cell approach that combines attributes of both offline and active learning to systematically expand a quantum mechanical (QM) database while constructing MLFFs with increasing model complexity. Our MLFFs employ the moment tensor potential formalism. During this process, we quantitatively assessed structural properties, elastic properties, dimer potential energies, melting temperatures, phase stability, point defect formation energies, point defect migration energies, free surface energies, and generalized stacking fault (GSF) energies of Zr as predicted by our MLFFs. Unsurprisingly, model complexity has a positive correlation with prediction accuracy. We also find that the MLFFs wee able to predict the properties of out-of-sample configurations without directly including these specific configurations in the training dataset. Additionally, we generated 100 MLFFs of high complexity (1513 parameters each) that reached different local optima during training. Their predictions cluster around the benchmark DFT values, but subtle physical features such as the location of local minima on the GSFE surface are washed out by statistical noise

Selection of summer feeding sites and food resources by female migratory caribou (Rangifer tarandus) determined using camera collars

Migratory caribou (Rangifer tarandus) is a socioeconomically and culturally key species for northern communities in the Arctic, and most of its populations are experiencing a sharp decline. Female migratory caribou depend on the availability of summer habitat resources to meet the needs associated with lactation and the accumulation of fat reserves to survive when resources are less abundant. Because of the large scales at which habitat and resource data are usually available, information on how female migratory caribou select habitat and resources at fine scales in the wild is lacking. To document selection of summer feeding sites, we equipped 60 female caribou with camera collars from 2016 to 2018. We collected a total of 65,150 10-sec videos between June 1 st and September 1 st for three years with contrasted spring phenology. We determined the selection at the feeding site scale (3 rd scale of Johnson) and food item scale (4 th scale of Johnson) using resource selection probability functions. Wetlands were highly selected as feeding sites in June and July while they were avoided in August. Shrublands were mostly selected in July and August. At the resources scale, lichen, birch, willow, and mushrooms were the most strongly selected resources. Our results provide precise and novel information on habitat selection at feeding sites and food resources selected by female caribou in the wild. This information will help understand foraging patterns and habitat selection behavior of female migratory caribou and will contribute to the management and conservation of its declining populations

The nomenclature, definition and classification of discordant atrioventricular connections

Congenitally corrected transposition is a complex cardiac lesion that is often associated with ventricular septal defect, obstruction of the outflow tract of the morphologically left ventricle, and abnormalities of the morphologically tricuspid valve.1,2Nomenclature for this lesion has been variable and confusing.1In this review, we define, and hopefully clarify this terminology. The lesion is a combination of discordant union of the atrial chambers with the ventricles, and the ventricles with the arterial trunks.1,2In rare circumstances, discordant atrioventricular connections can be associated with concordant ventriculo-arterial connections. This malformation has been called "isolated ventricular inversion". The term is less than precise, and the descriptive approach using the phrase "discordant atrioventricular connections with concordant ventriculo-arterial connections" is preferred, as discussed below

Impact of ultraviolet radiation on marine crustacean zooplankton and ichthyoplankton: a synthesis of results from the estuary and Gulf of St. Lawrence, Canada

The objectives of the research program reported upon here were (1) to measure ambient levels of UV radiation and determine whichvariables most strongly affected its attenuation in the waters of the estuary and Gulf of St. Lawrence, Canada; and (2) to investigate the potential direct impacts of W radiation on species of crustacean zooplankton and fish whose early life stages are planktonic. In this geographic region, productivity-determining biophysical interactions occur in the upper 0 to 30 m of the water column. Measurements of the diffuse attenuation coefficients for ultraviolet-B radiation (W-B, 280 to 320 nm) at various locations in this region indicated maximum 10% depths (the depth to which 10% of the surface energy penetrates at a given wavelength) of 3 to 4 m at a wavelength of 310 nm. Organisms residing in this layer-including the eggs and larvae of Calanus finmarchicus and Atlantic cod Gadus morhua-are exposed to biologically damaging levels of W radiation. As a result of these physical and biological characteristics, this system offered a relevant opportunity to assess the impacts of UV on subarctic marine ecosystems. Eggs of C. finmarchicus were incubated under the sun, with and without the W-B and/or UV-A (320 to 400 nm) wavebands. W-exposed eggs exhibited low percent hatchmg compared to those protected from W : W radiation had a strong negative impact on C. finmarchicus eggs. Further, percent hatching in W-B-exposed eggs was not significantly lower than that in eggs exposed to UV-A only: under natural sunlight, UV-A radiation appeared to be more detrimental to C. finmarchicus embryos than was UV-B. In analogous experiments with Atlantic cod eggs, exposure to UV-B produced a significant negative effect. However, UV-A had no negative effect on cod eggs. Additional experiments using a solar simulator (SS) revealed high wavelength-dependent mortality in both C. finmarchicus and cod embryos exposed to UV. The strongest effects occurred under exposures to wavelengths below 312 nm. At the shorter wavelengths (<305 nm) UV-B-induced mortality was strongly dose-dependent, but (for both C. finmarchicus and cod) not significantly influenced by dose-rate. Thus, at least within the limits of the exposures under which the biological weighting functions (BWFs) were generated, reciprocity held. The BWFs derived for UV-B-induced mortality in C. finmarchicus and cod eggs were similar in shape to the action spectrum for UV-B effects on naked DNA. Further, the wavelengthdependence of DNA damage was similar to that for the mortality effect. These observations suggest that W-induced mortality in C. finmarchicus and cod eggs is a direct result of DNA damage. There was no evidence of a detrimental effect of UV-A radiation in these SS-derived results. A mathematical model that includes the BWFs, vertical mixing of eggs, meteorological and hydrographic conditions, and ozone depletion, indicates that W-induced mortality in the C. finmarchicus egg population could be as high as 32.5 %, while the impact on the cod egg population was no more than 1.2%. Variability in cloud cover, water transparency (and the variables that affect it), and vertical distribution and displacement of planktonic organisms within the mixed layer can all have a greater effect on the flux of UV-B radiation to which they are exposed than will ozone layer depletion at these latitudes. Our observations indicate that C, finmarchicus and cod eggs present in the first meter of the water column (likely only a small percentage of the total egg populations) are susceptible to W radiation. However, although exposure to UV can negatively impact crustacean zooplankton and ichthyoplankton populations, these direct effects are likely minimal within the context of all the other environmental factors that produce the very high levels of mortality typically observed in their planktonic early life stages. The impact of indnect effects-which may well be of much greater import-has yet to be evaluated

The nomenclature, definition and classification of cardiac structures in the setting of heterotaxy

AbstractIn 2000, The International Nomenclature Committee for Pediatric and Congenital Heart Disease was established. This committee eventually evolved into the International Society for Nomenclature of Paediatric and Congenital Heart Disease. The working component of this international nomenclature society has been The International Working Group for Mapping and Coding of Nomenclatures for Paediatric and Congenital Heart Disease, also known as the Nomenclature Working Group. The Nomenclature Working Group created the International Paediatric and Congenital Cardiac Code, which is available for free download from the internet at [http://www.IPCCC.NET].In previous publications from the Nomenclature Working Group, unity has been produced by cross-mapping separate systems for coding, as for example in the treatment of the functionally univentricular heart, hypoplastic left heart syndrome, or congenitally corrected transposition. In this manuscript, we review the nomenclature, definition, and classification of heterotaxy, also known as the heterotaxy syndrome, placing special emphasis on the philosophical approach taken by both the Bostonian school of segmental notation developed from the teachings of Van Praagh, and the European school of sequential segmental analysis. The Nomenclature Working Group offers the following definition for the term "heterotaxy": "Heterotaxy is synonymous with 'visceral heterotaxy' and 'heterotaxy syndrome'. Heterotaxy is defined as an abnormality where the internal thoraco-abdominal organs demonstrate abnormal arrangement across the left-right axis of the body. By convention, heterotaxy does not include patients with either the expected usual or normal arrangement of the internal organs along the left-right axis, also known as 'situs solitus', nor patients with complete mirror-imaged arrangement of the internal organs along the left-right axis also known as 'situs inversus'." "Situs ambiguus is defined as an abnormality in which there are components of situs solitus and situs inversus in the same person. Situs ambiguus, therefore, can be considered to be present when the thoracic and abdominal organs are positioned in such a way with respect to each other as to be not clearly lateralised and thus have neither the usual, or normal, nor the mirror-imaged arrangements."The heterotaxy syndrome as thus defined is typically associated with complex cardiovascular malformations. Proper description of the heart in patients with this syndrome requires complete description of both the cardiac relations and the junctional connections of the cardiac segments, with documentation of the arrangement of the atrial appendages, the ventricular topology, the nature of the unions of the segments across the atrioventricular and the ventriculoarterial junctions, the infundibular morphologies, and the relationships of the arterial trunks in space. The position of the heart in the chest, and the orientation of the cardiac apex, must also be described separately. Particular attention is required for the venoatrial connections, since these are so often abnormal. The malformations within the heart are then analysed and described separately as for any patient with suspected congenital cardiac disease. The relationship and arrangement of the remaining thoraco-abdominal organs, including the spleen, the lungs, and the intestines, also must be described separately, because, although common patterns of association have been identified, there are frequent exceptions to these common patterns. One of the clinically important implications of heterotaxy syndrome is that splenic abnormalities are common. Investigation of any patient with the cardiac findings associated with heterotaxy, therefore, should include analysis of splenic morphology. The less than perfect association between the state of the spleen and the form of heart disease implies that splenic morphology should be investigated in all forms of heterotaxy, regardless of the type of cardiac disease. The splenic morphology should not be used to stratify the form of disease within the heart, and the form of cardiac disease should not be used to stratify the state of the spleen. Intestinal malrotation is another frequently associated lesion that must be considered. Some advocate that all patients with heterotaxy, especially those with isomerism of the right atrial appendages or asplenia syndrome, should have a barium study to evaluate for intestinal malrotation, given the associated potential morbidity. The cardiac anatomy and associated cardiac malformations, as well as the relationship and arrangement of the remaining thoraco-abdominal organs, must be described separately. It is only by utilizing this stepwise and logical progression of analysis that it becomes possible to describe correctly, and to classify properly, patients with heterotaxy