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We investigate the potential of transparency to influence committee decision-making. We present a model in which career concerned committee members receive private information of different type-dependent accuracy, deliberate, and vote. We study three levels of transparency under which career concerns are predicted to affect behavior differently and test the model’s key predictions in a laboratory experiment. The model’s predictions are largely borne out—transparency negatively affects information aggregation at the deliberation and voting stages, leading to sharply different committee error rates than under secrecy. This occurs despite subjects revealing more information under transparency than theory predicts.

ObjectiveTo determine whether robot-assisted training is cost-effective compared with an enhanced upper limb therapy (EULT) programme or usual care.DesignEconomic evaluation within a randomised controlled trial.SettingFour National Health Service (NHS) centres in the UK: Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Northwick Park Hospital, London Northwest Healthcare NHS Trust; Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde; and North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust.Participants770 participants aged 18 years or older with moderate or severe upper limb functional limitation from first-ever stroke.InterventionsParticipants randomised to one of three programmes provided over a 12-week period: robot-assisted training plus usual care; the EULT programme plus usual care or usual care.Main economic outcome measuresMean healthcare resource use; costs to the NHS and personal social services in 2018 pounds; utility scores based on EQ-5D-5L responses and quality-adjusted life years (QALYs). Cost-effectiveness reported as incremental cost per QALY and cost-effectiveness acceptability curves.ResultsAt 6 months, on average usual care was the least costly option (£3785) followed by EULT (£4451) with robot-assisted training being the most costly (£5387). The mean difference in total costs between the usual care and robot-assisted training groups (£1601) was statistically significant (p<0.001). Mean QALYs were highest for the EULT group (0.23) but no evidence of a difference (p=0.995) was observed between the robot-assisted training (0.21) and usual care groups (0.21). The incremental cost per QALY at 6 months for participants randomised to EULT compared with usual care was £74 100. Cost-effectiveness acceptability curves showed that robot-assisted training was unlikely to be cost-effective and that EULT had a 19% chance of being cost-effective at the £20 000 willingness to pay (WTP) threshold. Usual care was most likely to be cost-effective at all the WTP values considered in the analysis.ConclusionsThe cost-effectiveness analysis suggested that neither robot-assisted training nor EULT, as delivered in this trial, were likely to be cost-effective at any of the cost per QALY thresholds considered.Trial registration numberISRCTN69371850.

Background Loss of arm function is a common and distressing consequence of stroke. We describe the protocol for a pragmatic, multicentre randomised controlled trial to determine whether robot-assisted training improves upper limb function following stroke. Methods/design Study design: a pragmatic, three-arm, multicentre randomised controlled trial, economic analysis and process evaluation. Setting : NHS stroke services. Participants: adults with acute or chronic first-ever stroke (1 week to 5 years post stroke) causing moderate to severe upper limb functional limitation. Randomisation groups: 1. Robot-assisted training using the InMotion robotic gym system for 45 min, three times/week for 12 weeks 2. Enhanced upper limb therapy for 45 min, three times/week for 12 weeks 3. Usual NHS care in accordance with local clinical practice Randomisation: individual participant randomisation stratified by centre, time since stroke, and severity of upper limb impairment. Primary outcome: upper limb function measured by the Action Research Arm Test (ARAT) at 3 months post randomisation. Secondary outcomes: upper limb impairment (Fugl-Meyer Test), activities of daily living (Barthel ADL Index), quality of life (Stroke Impact Scale, EQ-5D-5L), resource use, cost per quality-adjusted life year and adverse events, at 3 and 6 months. Blinding: outcomes are undertaken by blinded assessors. Economic analysis: micro-costing and economic evaluation of interventions compared to usual NHS care. A within-trial analysis, with an economic model will be used to extrapolate longer-term costs and outcomes. Process evaluation: semi-structured interviews with participants and professionals to seek their views and experiences of the rehabilitation that they have received or provided, and factors affecting the implementation of the trial. Sample size: allowing for 10% attrition, 720 participants provide 80% power to detect a 15% difference in successful outcome between each of the treatment pairs. Successful outcome definition: baseline ARAT 0–7 must improve by 3 or more points; baseline ARAT 8–13 improve by 4 or more points; baseline ARAT 14–19 improve by 5 or more points; baseline ARAT 20–39 improve by 6 or more points. Discussion The results from this trial will determine whether robot-assisted training improves upper limb function post stroke. Trial registration ISRCTN, identifier: ISRCTN69371850 . Registered 4 October 2013.

Loss of arm function is a common problem after stroke. Robot-assisted training might improve arm function and activities of daily living. We compared the clinical effectiveness of robot-assisted training using the MIT-Manus robotic gym with an enhanced upper limb therapy (EULT) programme based on repetitive functional task practice and with usual care. RATULS was a pragmatic, multicentre, randomised controlled trial done at four UK centres. Stroke patients aged at least 18 years with moderate or severe upper limb functional limitation, between 1 week and 5 years after their first stroke, were randomly assigned (1:1:1) to receive robot-assisted training, EULT, or usual care. Robot-assisted training and EULT were provided for 45 min, three times per week for 12 weeks. Randomisation was internet-based using permuted block sequences. Treatment allocation was masked from outcome assessors but not from participants or therapists. The primary outcome was upper limb function success (defined using the Action Research Arm Test [ARAT]) at 3 months. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN69371850. Between April 14, 2014, and April 30, 2018, 770 participants were enrolled and randomly assigned to either robot-assisted training (n=257), EULT (n=259), or usual care (n=254). The primary outcome of ARAT success was achieved by 103 (44%) of 232 patients in the robot-assisted training group, 118 (50%) of 234 in the EULT group, and 85 (42%) of 203 in the usual care group. Compared with usual care, robot-assisted training (adjusted odds ratio [aOR] 1·17 [98·3% CI 0·70–1·96]) and EULT (aOR 1·51 [0·90–2·51]) did not improve upper limb function; the effects of robot-assisted training did not differ from EULT (aOR 0·78 [0·48–1·27]). More participants in the robot-assisted training group (39 [15%] of 257) and EULT group (33 [13%] of 259) had serious adverse events than in the usual care group (20 [8%] of 254), but none were attributable to the intervention. Robot-assisted training and EULT did not improve upper limb function after stroke compared with usual care for patients with moderate or severe upper limb functional limitation. These results do not support the use of robot-assisted training as provided in this trial in routine clinical practice. National Institute for Health Research Health Technology Assessment Programme.

A compromised gut barrier function may be associated with systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction syndrome in patients after major trauma or critical illness, and inadequate oxygenation of the gut mucosa has been incriminated as an underlying mechanism. The focus of this study was the relationship of splanchnic hypoperfusion to regional and systemic immune responses after major surgery. Patients (n = 20) undergoing curative oncologic resection of the esophagus or esophagogastric junction were studied. Gastric mucosal pH level was monitored by gastric tonometry. The expression of class II major histocompatibility complex antigen (human leukocyte antigen-DR) and L-selectin on systemic monocytes was assessed before surgery, during surgery (as well as portal monocytes), and for 1 week after surgery, along with C-reactive protein levels. Intestinal permeability was measured before surgery and on the first and seventh postoperative days by using dual sugar probes. Significant mucosal acidosis (pH <7.1) intraoperatively was evident in 5 patients (25%), and a further 7 patients (35%) had a nadir gastrointestinal mucosal pH level between 7.1 and 7.2. Severe (<7.1) mucosal acidosis was associated significantly ( P < .05) with postoperative septic complications, an increase in postoperative intestinal permeability, C-reactive protein and L-selectin expression, and a decrease ( P < .05) in monocyte human leukocyte antigen-DR expression. Intraoperative splanchnic hypoperfusion is associated significantly with down-regulation of monocyte function, increased intestinal permeability, and an exaggerated acute phase response. This suggests that splanchnic hypoperfusion alters local and systemic immune function, supporting the thesis that the gut has a central role in the immunoinflammatory response to major surgery.

IntroductionThe incidence of atrial fibrillation (AF) increases with age and carries with it a 5 fold increased risk of having a stroke. The most effective prevention is anticoagulation yet elderly people are often viewed of as high risk and are not started on therapy. The first cycle of this audit included 166 current inpatients of the Care of the Elderly Department (COTE) in Gartnavel General hospital (GGH) aged 65 and over. Over one third (36%) of admissions had AF however only 33% of these were on anticoagulation. 11/40 (28%) of those with AF had no decision about anticoagulation recorded. All patients had a CHADSVASC score of 2 or greater so should have been considered for anticoagulation. Novel anticoagulation (NOACs) are now available as first line treatment of non-valvular atrial fibrillation accounting for 50% of those anticoagulated with the remaining 50% on Warfarin.InterventionThe audit findings were presented to the GGH COTE department and included the current guidelines for AF and use of NOACs. A copy of the presentation was also sent to all departmental staff via email. Information is now included in the junior doctor departmental handbook given at induction, and a section in the admission document regarding Atrial Fibrillation must be completed for each patient.ResultsA regular audit of the COTE department in the form of Plan Do Study Act (PDSA) cycles was implemented to monitor the effectiveness. In March 2015 the first cycle after initial intervention, 60% of those with AF were receiving anticoagulation, however during April (junior doctor changeover) this fell to 23%. Further education was implemented and 50% of patients were on anticoagulation in May. There was also increasing compliance with filling in the admissions box regarding AF, rising from 39% at baseline to 71% in May.Abstract 61 Table 1Comparing initial audit and subsequent PDSA cyclesAbstract 61 Figure 1DiscussionAll new admissions to COTE departments should be assessed for atrial fibrillation and considered for anticoagulation including use of NOACs as an alternative to warfarin. Having a section regarding AF in the admissions booklet is a useful prompt for discussion of anticoagulation.

The use of aluminium alloys in armour plating of land and sea based combat vehicles can reduce the overall weight of the vehicles and improve manoeuvrability. Aluminium alloys from the 7xxx series (Al-Zn-Mg-Cu) and the 5xxx series (Al-Mg) are most commonly used. Of these, the 5xxx series present an attractive combination of properties including weldability and corrosion resistance. These alloys, however, are lower in strength than their 7xxx series counterparts, and can suffer from issues of sensitisation causing inter-granular corrosion and stress corrosion cracking.Additions of elements such as Zirconium (Zr) and Scandium (Sc) to the alloys can precipitate the L12 dispersoid phase during heat treatment. This phase helps to strengthen the alloys and can improve recrystallisation resistance. It is important to develop a suitable distribution of dispersoid particles within the microstructure of the alloys such that their effect on the material properties is desirable. The effect on material properties from dispersoids can vary widely depending on the treatment undergone by the alloys and the resulting distribution of particles. In this work three aluminium-magnesium (â^¼4wt% Mg) alloys were studied which contained varying concentrations of L12-forming additions.It was found that on casting a severely heterogeneous dendritic microstructure was formed in the alloys, with T-phase (Al-Mg-Zn-Cu) at grain boundaries, Zr concentrated in dendrite cores, and Sc concentrated in dendrite edges. This heterogeneity of L12-forming Zr and Sc could not be alleviated by homogenisation treatments and resulted in a complex distribution of dispersoids. Zr-enriched dendrite cores formed many small L12 dispersoids, with larger dispersoids found in the Sc-enriched dendrite edges after treatment. Electron probe micro-analysis revealed that additions of Erbium (Er) and Yttrium (Y), which were intended as L12-forming additions, instead formed a grain boundary eutectic phase on casting. The Er and Y content was not distributed back into the matrix during homogenisation and was therefore unavailable for secondary L12 dispersoid precipitation. It was also shown that recrystallisation resistance can be maintained to high temperatures with minor additions of L12-forming elements. The experimental work was used to inform a microstructure-property model capable of predicting the effect of changing process conditions on the dispersoid distributions. Coupled to a strengthening model, the strength and work hardening behaviour was calculated. The model demonstrated the synergistic effect that dispersoids have on enhancing work hardening, as well as their direct strengthening effect, and can be used as a predictive tool for alloy and process design.

It is commonly thought that in an election with two parties there can be no strategic voting - voters simply vote for their preferred candidate. In this paper, I show that strategic voting comes to the fore in legislative elections with multiple policy dimensions. In sharp contrast to single-district elections, the intensity of a voter’s preference on each dimension is irrelevant for her voting decision. Instead, she votes solely based on the dimension which is most likely to be pivotal in the legislature. Anticipating this behaviour, candidates put forward a different set of policies than they would in a single-district election. For large elections I show that the implemented policy bundle: (a) is uniquely pinned down by voter preferences, (b) is preferred by a majority of districts on each dimension, (c) is a Condorcet winner, if one exists. These properties are not guaranteed in a single-district election. Furthermore, I show that (i) parliamentary systems generate superior policies to presidential systems and (ii) voter polarisation affects outcomes in single-district elections but not legislative elections.

Models of single district plurality elections show that with three parties anything can happen - extreme policies can win regardless of voter preferences. I show that when single district elections are used to fill a legislature we get back to a world where the median voter matters. An extreme policy will generally only come about if it is preferred to a more moderate policy by the median voter in a majority of districts. The mere existence of a centrist party can lead to moderate outcomes even if the party itself wins few seats. Furthermore, I show that while standard single district elections always have misaligned voting i.e. some voters do not vote for their preferred choice, equilibria of the legislative election exist with no misaligned voting in any district. Finally, I show that when parties are impatient, a fixed rule on how legislative bargaining occurs will lead to more coalition governments, while uncertainty will favour single party governments.