Systematic development and validation of a predictive model for major postoperative complications in the Peri-operative Quality Improvement Project (PQIP) dataset.

Complications are common following major surgery and are associated with increased use of healthcare resources, disability and mortality. Continued reliance on mortality estimates risks harming patients and health systems, but existing tools for predicting complications are unwieldy and inaccurate. We aimed to systematically construct an accurate pre-operative model for predicting major postoperative complications; compare its performance against existing tools; and identify sources of inaccuracy in predictive models more generally. Complete patient records from the UK Peri-operative Quality Improvement Programme dataset were analysed. Major complications were defined as Clavien-Dindo grade ≥ 2 for novel models. In a 75% train:25% test split cohort, we developed a pipeline of increasingly complex models, prioritising pre-operative predictors using Least Absolute Shrinkage and Selection Operators (LASSO). We defined the best model in the training cohort by the lowest Akaike's information criterion, balancing accuracy and simplicity. Of the 24,983 included cases, 6389 (25.6%) patients developed major complications. Potentially modifiable risk factors (pain, reduced mobility and smoking) were retained. The best-performing model was highly complex, specifying individual hospital complication rates and 11 patient covariates. This novel model showed substantially superior performance over generic and specific prediction models and scores. We have developed a novel complications model with good internal accuracy, re-prioritised predictor variables and identified hospital-level variation as an important, but overlooked, source of inaccuracy in existing tools. The complexity of the best-performing model does, however, highlight the need for a step-change in clinical risk prediction to automate the delivery of informative risk estimates in clinical systems.

Behavioral and genetic architecture of fear conditioning and related phenotypes.

Contextual fear conditioning is a form of Pavlovian learning during which an organism learns to fear previously neutral stimuli following their close temporal presentation with an aversive stimulus. In mouse models, freezing behavior is typically used to quantify learned fear. This dependent variable is the sum of multiple processes, including associative/configural learning, fear and anxiety, and general activity. To explore phenotypic constructs underlying contextual fear conditioning and correlated behaviors, as well as factors that may contribute to individual differences in learning and mental health, we tested BXD recombinant inbred strains previously found to show extreme contextual fear conditioning phenotypes and BXD parental strains, C57BL/6J and DBA/2J, in a series of tests including locomotor, anxiety, contextual/cued fear conditioning and non-associative hippocampus-dependent learning behaviors. Hippocampal expression of two previously identified candidate genes for contextual fear conditioning was also quantified. Behavioral and gene expression data were analyzed using exploratory factor analysis (EFA), which suggested five unique constructs representing activity/anxiety/exploration, associative fear learning, anxiety, post-shock freezing, and open field activity phenotypes. Associative fear learning and expression of one candidate gene, Hacd4, clusteredas a construct withinthefactor analysis. Post-shock freezingduring fear conditioning and expression of candidate gene Ptprd emerged as another unique construct, highlighting theindependenceof freezing after footshock from other fear conditioning variables in the current dataset.EFA results additionally suggest shared phenotypic variance in adaptive murine behaviors related to anxiety, general activity, and exploration. These findings inform understanding of fear learning and underlying biological mechanisms that may interact to produce individual differences in fear- and learning-related behaviors in mice.

Obstetric anaesthesia over the next 10 years: Africa and Middle East.

Maternal and neonatal health outcomes vary within Africa and the Middle East. Despite substantial improvements over the past 20 years, there are persisting inequities in access to, and the quality of, obstetric anaesthetic care. These are most noticeable in Sub-Saharan Africa which has only 3% of the world's healthcare workforce but approximately two-thirds of global maternal deaths. Improvements are being made by: improving access; increasing numbers of trained staff; delivering accessible training; gathering data; conducting research and quality improvement activities; using innovative technologies; and forming productive collaborations. Further improvements will be needed to cope with increasing demand, the impacts of climate change and potential future pandemics.

Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model.

Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of < 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.

A learning health systems approach to improving the quality of care for patients in South Asia.

Poor quality of care is a leading cause of excess morbidity and mortality in low- and middle- income countries (LMICs). Improving the quality of healthcare is complex, and requires an interdisciplinary team equipped with the skills to design, implement and analyse setting-relevant improvement interventions. Such capacity is limited in many LMICs. However, training for healthcare workers in quality improvement (QI) methodology without buy-in from multidisciplinary stakeholders and without identifying setting-specific priorities is unlikely to be successful. The Care Quality Improvement Network (CQIN) was established between Network for Improving Critical care Systems and Training (NICST) and University College London Centre for Perioperative Medicine, with the aim of building capacity for research and QI. A two-day international workshop, in collaboration with the College of Surgeons of Sri Lanka, was conducted to address the above deficits. Innovatively, the CQIN adopts a learning health systems (LHS) approach to improving care by leveraging information captured through the NICST electronic multi-centre acute and critical care surveillance platform. Fifty-two delegates from across the CQIN representing clinical, civic and academic healthcare stakeholders from six countries attended the workshop. Mapping of care processes enabled identification of barriers and drivers to the delivery of care and facilitated the selection of feasible QI methods and matrices. Six projects, reflecting key priorities for improving the delivery of acute care in Asia, were collaboratively developed: improving assessment of postoperative pain; optimising sedation in critical care; refining referral of deteriorating patients; reducing surgical site infection after caesarean section; reducing surgical site infection after elective general surgery; and improving provision of timely electrocardiogram recording for patients presenting with signs of acute myocardial infarction. Future project implementation and evaluation will be supported with resources and expertise from the CQIN partners. This LHS approach to building capacity for QI may be of interest to others seeing to improve care in LMICs.

The impact of a culturally appropriate STD/AIDS education intervention on black male adolescents' sexual and condom use behavior.

A culturally appropriate, theoretically based videotape was developed to promote condom use among African American males, ages 15 to 19, attending a municipal sexually transmitted disease (STD) clinic. The videotape's impacts were compared to those achieved by an African American health educator who delivered the same messages during a face-to-face session and by standard care. Data were obtained on participants' (N = 562) condom use knowledge, self-efficacy, and intentions; sexual and condom use behaviors; and perceived risk of infection. At posttest, "videotape" and "health educator" participants demonstrated greater condom use knowledge; "health educator" participants indicated greater self-efficacy and stronger condom use intentions with steady partners. At 6 months, participants in all conditions reported more partners and acts of vaginal intercourse (past month); however, they were more likely to report consistent condom use with steady partners (18% vs. 53%) and casual partners (26% vs. 50%). Perceived risk of infection was lower at the posttest and declined during the study period.

Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments.

OBJECTIVES: Women in impoverished inner-city neighborhoods are at high risk for contracting HIV. A randomized, multisite community-level HIV prevention trial was undertaken with women living in 18 low-income housing developments in 5 US cities. METHODS: Baseline and 12-month follow-up population risk characteristics were assessed by surveying 690 women at both time points. In the 9 intervention condition housing developments, a community-level intervention was undertaken that included HIV risk reduction workshops and community HIV prevention events implemented by women who were popular opinion leaders among their peers. RESULTS: The proportion of women in the intervention developments who had any unprotected intercourse in the past 2 months declined from 50% to 37.6%, and the percentage of women's acts of intercourse protected by condoms increased from 30.2% to 47.2%. Among women exposed to intervention activities, the mean frequency of unprotected acts of intercourse in the past 2 months tended to be lower at follow-up (mean = 4.0) than at baseline (mean = 6.0). These changes were corroborated by changes in other risk indicators. CONCLUSIONS: Community-level interventions that involve and engage women in neighborhood-based HIV prevention activities can bring about reductions in high-risk sexual behaviors.

Subsequent infection among adolescent African-American males attending a sexually transmitted disease clinic.

PURPOSE: To identify predictors of subsequent infection among a sample of 15- to 19-year-old African-American males attending an urban sexually transmitted disease (STD) clinic in the Midwest. METHODS: During a 14-month period, 562 youth participated in a brief STD prevention intervention designed to promote condom use. They completed self-administered questionnaires (baseline, posttest, 30-day and 6-month) on their sexual and condom use behavior in the past month. Infection data (baseline, 5 years before, and 12 months after baseline) were obtained from clinic and state surveillance records. Logistic regression was used to predict infection within 6 and 12 months of the baseline visit. RESULTS: Within 12 months of the baseline, 31.3% were treated for an infection, of whom 1.4% returned within 30 days, an additional 17.1% within 6 months, and the remaining 12.8% within the last 6 months. The 12-month rate was 1.6-1.7 times higher than the rates reported for older STD clinic attendees. Subsequent infection was positively associated with age at first intercourse, number of children fathered, infection prior to and at the index visit, exchange of sex for drugs in the past year, and perceived risk of infection within the year; it was negatively associated with frequency of condom use with one's steady partner. CONCLUSIONS: Sexually transmitted disease clinic staff routinely obtain information from young African-American males that can be used to identify individuals who are most likely to become reinfected. Because repeaters account for a disproportionate number of infections, prevention efforts tailored to their needs would have a corresponding impact on STD rates.

Retrospective searching for poisonous plant vouchers.

Few published reports of plant poisoning, whether experimental or accidental, document vouchers. This can be rectified by retrospective location of vouchers through determination of a collaborating botanist or herbarium of deposit. An absolute voucher is referenced in the toxicology report. For a probable voucher the report does not identify an herbarium specimen, but the report and the specimen label or sheet agree on plant name, collector's name, collection date and place. A possible voucher is perhaps from the exposure lot, but was collected by the collaborating botanist at a somewhat earlier or later date than the exposure date. On the other hand, a supporting specimen was collected by the collaborating botanist but is not from the exposure lot. Vouchers and supporting specimens for some species of Asclepias tested for toxicity by CD Marsh and coworkers were found in the US National Herbarium at the Smithsonian Institution, Washington DC.

Poisonous plant vouchers.

Every published report of plant poisoning, whether experimental or accidental, should document plant identification. The essential elements are: complete botanical Latin name including species, specific epithet and author(s); name of the collaborating botanist who identified the plant; and herbarium and collection number of a voucher specimen from the exposure lot. Additional information to aid identification might include plant photographs, drawings, and descriptions.

Model-based evaluation of HIV prevention interventions.

The ultimate goal of HIV prevention interventions is to reduce the spread of HIV; however, the effectiveness of these programs is seldom assessed directly. Although direct measurement of an intervention's impact via HIV seroincidence monitoring is usually unfeasible, mathematical models can be used to estimate the number of infections averted by the intervention. This article describes three model-based summary measures of sexually transmitted HIV risk and discusses their relevance to HIV program evaluation in general economic efficiency analyses in particular. The calculation of these measures is demonstrated with an illustrative application to previously published data from an HIV prevention intervention for gay men.

Patterns, predictors, and situational contexts of HIV risk behaviors among homeless men and women.

The study discussed in this article investigated psychosocial, relationship, and situational factors associated with HIV risk in a sample of 152 inner-city homeless men and women. Although men at risk of AIDS often had multiple sexual partners, women reported fewer different partners but more frequent unprotected intercourse with them. Different factors were associated with HIV risk level among men and women. In men, high-risk patterns were associated with negative attitudes toward condom use, low levels of intentions to use condoms, high perceived risk of AIDS, and low perceived self-efficacy for avoiding risk. Women at high risk of HIV infection had greater life dissatisfaction; were less optimistic and held more fatalistic views about the future; held more negative condom attitudes; perceived themselves to be at risk; and frequently used alcohol, marijuana, and crack cocaine. HIV prevention efforts tailored to the different risk circumstances of men and women are urgently needed in social services programs for homeless people.

Lessons learned from a mentoring program for teenage mothers.

PURPOSE: This study evaluated a mentoring program designed to decrease the risk of repeat pregnancy among unmarried primiparous teens, ages 12-19. METHODS: Adolescents (n = 110) completed a battery that assessed sexual/contraceptive behavior; psychological adjustment; and attitudes towards school. Teens were then randomly assigned to a mentor or control group, and reassessed at 6, 12, 18, and 24 months. Mentored teens received social support and assistance dealing with community agencies from mentors who were trained community volunteers. RESULTS AND CONCLUSIONS: At baseline, mentor and control teens had similar sexual histories, school achievement profiles (percentage enrolled, cumulative grade point average), and anticipated being the same age when they had a second child. At 24 months (n = 81), most mentor and control teens were making progress in school. Fifty percent had graduated or had advanced two grades; 10 of the 16 graduating teens were seeking additional education. However, the mentoring program did not significantly impact repeat pregnancy rates. At 33 months, 66.0% of the mentored teens and 68.8% of the control teens had experienced a repeat pregnancy. Thirty-six percent of teens had one repeat pregnancy; 24% had two or more pregnancies. Sixty-two percent of the pregnancies with known resolution (89) resulted in live births; 26% were aborted. In providing this mentoring program, several important lessons were learned.

Predictors of condom use and human immunodeficiency virus test seeking among women living in inner-city public housing developments.

BACKGROUND AND OBJECTIVES: To examine prevalence and predictors of condom use and human immunodeficiency virus (HIV) test seeking among women living in inner-city housing developments. STUDY DESIGN: Between April and June 1994, 671 women living in low-income housing developments in five cities in the United States completed an anonymous self-report questionnaire eliciting information on acquired immune deficiency syndrome (AIDS) risk behavior and characteristics indicative of risk. RESULTS: Most participants were women of color who were economically disadvantaged. Fifteen percent reported multiple sex partners, and 30% of women with one sex partner believed he had sex with someone else in the past year. Predictors of condom use included increased rates of safe-sex negotiation, stronger risk reduction intentions, absence of condom barrier beliefs, and multiple sex partners. Women tested for HIV in the past year were younger, perceived themselves to be at risk for HIV infection, reported more conversations with other women about AIDS concerns, and had condoms readily available. CONCLUSIONS: HIV public health prevention interventions are urgently needed for women who live in low-income urban housing developments.

HIV risk behaviors among women living in low-income, inner-city housing developments.

OBJECTIVES: This study describes the prevalence and predictors of human immunodeficiency virus (HIV) risk behaviors among women living in low-income, inner-city housing developments. METHODS: Anonymous questionnaires were administered to 671 women living in 10 inner-city, low-income housing developments in five US cities to determine their levels of HIV risk behavior and predictors of HIV risk practices. RESULTS: Approximately one third of women were at high risk for HIV because of the risk behavior of their sexual partners. HIV risk was highest among women who accurately perceived themselves to be at increased HIV risk, held strong beliefs about barriers to condom use, and reported weak behavioral intentions to reduce risk. Women at higher risk were also younger and reported higher rates of alcohol and substance use. CONCLUSIONS: HIV prevention efforts are needed for inner-city women. Interventions should focus on overcoming women's barriers to condom use, strengthening their intentions to change behaviors, and managing the risk related to their use of substances.