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The density of information in digital health records offers new potential opportunities for automated prediction of cost-relevant outcomes.
We investigated the extent to which routinely recorded data held in the electronic health record (EHR) predict priority service outcomes and whether natural language processing tools enhance the predictions. We evaluated three high priority outcomes: in-patient duration, readmission following in-patient care and high service cost after first presentation.
We used data obtained from a clinical database derived from the EHR of a large mental healthcare provider within the UK. We combined structured data with text-derived data relating to diagnosis statements, medication and psychiatric symptomatology. Predictors of the three different clinical outcomes were modelled using logistic regression with performance evaluated against a validation set to derive areas under receiver operating characteristic curves.
In validation samples, the full models (using all available data) achieved areas under receiver operating characteristic curves between 0.59 and 0.85 (in-patient duration 0.63, readmission 0.59, high service use 0.85). Adding natural language processing-derived data to the models increased the variance explained across all clinical scenarios (observed increase in r2 = 12–46%).
EHR data offer the potential to improve routine clinical predictions by utilising previously inaccessible data. Of our scenarios, prediction of high service use after initial presentation achieved the highest performance.
To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.
From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.
The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.
To update current estimates of non–device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.
Academic teaching hospital.
All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.
From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non–device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50–2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04–4.86), immunosuppression (HR, 1.48; 95% CI, 1.15–1.91), trauma admissions (HR, 1.36; 95% CI, 1.02–1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35–2.94) and opioid use (HR, 1.62; 95% CI, 1.10–2.32). Urinary retention (HR, 1.41; 95% CI, 0.96–2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88–5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83–4.93) may also increase risk, but estimates were imprecise.
Greater than 70% of UTIs are now non–device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.
Many studies have identified changes in the brain associated with obsessive–compulsive disorder (OCD), but few have examined the relationship between genetic determinants of OCD and brain variation.
We present the first genome-wide investigation of overlapping genetic risk for OCD and genetic influences on subcortical brain structures.
Using single nucleotide polymorphism effect concordance analysis, we measured genetic overlap between the first genome-wide association study (GWAS) of OCD (1465 participants with OCD, 5557 controls) and recent GWASs of eight subcortical brain volumes (13 171 participants).
We found evidence of significant positive concordance between OCD risk variants and variants associated with greater nucleus accumbens and putamen volumes. When conditioning OCD risk variants on brain volume, variants influencing putamen, amygdala and thalamus volumes were associated with risk for OCD.
These results are consistent with current OCD neurocircuitry models. Further evidence will clarify the relationship between putamen volume and OCD risk, and the roles of the detected variants in this disorder.
Declaration of interest
The authors have declared that no competing interests exist.
OBJECTIVES/SPECIFIC AIMS: The aims of this study are 2-fold: (1) to determine if maternal schistosomiasis affects maternal immunity to tetanus and/or transplacental transfer of antitetanus toxoid (TT) immunoglobulin G (IgG) from mother to infant and (2) determine the influence of maternal schistosomiasis on infant BCG vaccine immunogenicity. METHODS/STUDY POPULATION: The study will utilize blood samples from a historic cohort of 100 mother-infant pairs from Kisumu, Kenya, a schistosomiasis-endemic area. For the first aim, we will evaluate maternal schistosomal circulating anodic antigen, which has improved sensitivity and specificity to detect active schistosomiasis from serum, and antisoluble egg antigen IgG positivity compared with quantitative maternal anti-TT IgG at delivery and anti-TT IgG cord blood to maternal blood ratio (cord:maternal ratio). For the second aim, we will evaluate association between maternal schistosomiasis as detected by circulating anodic antigen and antisoluble egg antigen IgG at delivery and infant BCG-specific Th1-cytokine positive CD4+ cells at 10 weeks following BCG vaccination at birth. RESULTS/ANTICIPATED RESULTS: We hypothesize that active maternal schistosomiasis will be associated with decreased maternal anti-TT IgG and reduced efficiency of transplacental transfer, as measured by infant cord blood to maternal blood ratio of anti-TT IgG. We also expect that maternal schistosomiasis will be associated with decreased infant immunogenicity to BCG vaccine. DISCUSSION/SIGNIFICANCE OF IMPACT: This is a formative study on infant vaccine immunity using laboratory methodology not previously applied. Understanding infant immunity in the setting of maternal schistosomiasis will inform vaccination strategies and tailor vaccine development in schistosome-endemic areas such as Kenya, where neither TB nor neonatal tetanus have been eradicated. Additionally, our results will inform public health policies to consider integration of antischistosomal agents in antenatal care.
Background: Interventions for anger represent the largest body of research on the adaptation of cognitive behavioural therapy (CBT) for people with intellectual disabilities. The extent to which the effectiveness of these interventions reflects the behavioural or cognitive components of CBT is uncertain. This arises in part because there are few measures of anger-related cognitions. Method: The Profile of Anger-related Cognitions (PAC) is built around interpersonal scenarios that the participant identifies as personally anger-provoking, and was designed as an extension of the Profile of Anger Coping Skills (PACS). A conversational presentational style is used to approach ratings of anger experienced in those situations and of four relevant cognitive dimensions: attribution of hostile intent, unfairness, victimhood, and helplessness. The PAC, and other measures, including the PACS, was administered to (i) people with ID identified as having problems with anger control (n = 12) and (ii) university students (n = 23); its psychometric properties were investigated and content analyses were conducted of participants’ verbal responses. In a third study, clinicians (n = 6) were surveyed for their impression of using the PAC in the assessment of clients referred for help with anger problems. Results: The PAC had good consistency and test-retest reliability, and the total score on the four cognitive dimensions correlated significantly with anger ratings but not with impersonal measures of anger disposition. The predominant cognitions reported were perceptions of unfairness and helplessness. People with ID and university students were in most respects very similar in both the psychometric analyses and the content analyses of their verbal responses. The PAC had high acceptability both to people with ID and to clinicians. Conclusions: The PAC may be a useful instrument for both clinical and research purposes. Personal relevance and the conversational mode of administration are particular strengths.
Research suggests that the way in which cognitive therapy is delivered is an important factor in determining outcomes. We test the hypotheses in which the development of a shared problem list, use of case formulation, homework tasks and active intervention strategies will act as process variables.
Presence of these components during therapy is taken from therapist notes. The direct and indirect effect of the intervention is estimated by an instrumental variable analysis.
A significant decrease in the symptom score for case formulation (coefficient =–23, 95% CI –44 to –1.7, P = 0.036) and homework (coefficient =–0.26, 95% CI –0.51 to –0.001, P = 0.049) is found. Improvement with the inclusion of active change strategies is of borderline significance (coefficient =–0.23, 95% CI –0.47 to 0.005, P = 0.056).
There is a greater treatment effect if formulation and homework are involved in therapy. However, high correlation between components means that these may be indicators of overall treatment fidelity.
The ApRES (autonomous phase-sensitive radio-echo sounder) instrument is a robust, lightweight and relatively inexpensive radar that has been designed to allow long-term, unattended monitoring of ice-shelf and ice-sheet thinning. We describe the instrument and demonstrate its capabilities and limitations by presenting results from three trial campaigns conducted in different Antarctic settings. Two campaigns were ice sheet-based – Pine Island Glacier and Dome C – and one was conducted on the Ross Ice Shelf. The ice-shelf site demonstrates the ability of the instrument to collect a time series of basal melt rates; the two grounded ice applications show the potential to recover profiles of vertical strain rate and also demonstrate some of the limitations of the present system.
In the May 1997 general election ‘New Labour’ won a landslide victory. The roots of the New Labour project lay in four successive, traumatic election defeats experienced by the party over the period from May 1979 to April 1992. The gradual transformation of Old Labour during these years came to fruition in 1997 and it produced a spectacular electoral success under the leadership of Tony Blair. Two more victories followed in 2001 and 2005, making Blair the only Labour leader in history to win three successive general elections. In May 2010, the New Labour era ended. Although the 2010 general election produced a hung parliament, Labour's much reduced share of seats made it very difficult – virtually impossible – for the party to continue in power as part of a viable coalition government. After five days of intensive interparty negotiations, Gordon Brown resigned as prime minister and Conservative Leader, David Cameron, was invited to form a government. The result was the Conservative–Liberal Democrat Coalition, Britain's first such government in over half a century.
In previous books, Political Choice in Britain (Clarke et al., 2004b) and Performance Politics and the British Voter (Clarke et al., 2009b), we have investigated alternative explanations of voting behaviour that have been proposed to account for the fates of British political parties both in the ‘New Labour’ era and more generally. We have provided a theoretical account of electoral choice which applies not only to Britain but also to other contemporary mature democracies such as Canada, France, Germany and the United States (see e.g. Clarke et al., 2009a; Clarke and Whitten, 2013; Lewis-Beck et al., 2012). According to this account, electoral choice in these countries is best understood as the product of the process of ‘valence’ or ‘performance’ politics. In a world of valence politics – where stakes are frequently high and risk is often better described as uncertainty – voters make choices primarily on the basis of evaluations of rival parties’ perceived abilities to deliver policy outcomes on salient issues involving broad consensus about what government should do.
In Affluence, Austerity and Electoral Change in Britain we have investigated factors affecting electoral choice and change in modern Britain. Beginning with the landslide 1997 general election that brought Tony Blair's New Labour Party to power, analyses show that the valence politics model that emphasizes party performance judgments, party leader images and flexible partisan attachments does much to account for voting decisions and patterns of party support in inter-election periods. Spatial models of party competition that focus on distances between parties and voters on positional issues dividing the electorate are relevant, but their effects are secondary. Sociological models featuring social class or other sociodemographic characteristics have much weaker effects. As discussed in Chapters 2 and 3, the valence politics model dominated throughout the Blair years and its explanatory power continued unabated during Gordon's Brown's premiership.
Chapters 4 and 5 demonstrate that valence politics considerations also did much to shape the choices voters made in the 2010 general election – the contest that ended the New Labour era and set the stage for a Conservative–Liberal Democrat Coalition Government. The impact of leader images was dramatically illustrated by the first-ever leaders’ debate when voters’ highly favourable reactions to Nick Clegg's performance boosted the Liberal Democrats’ standing in the polls and reconfigured the election campaign. Analyses show that both the Air War – the national campaign in the media – and the Ground War – local campaigns across the country – were important for understanding voting behaviour in 2010.
This appendix describes key variables in several models analyzed in various chapters. For additional information, please contact Harold Clarke: firstname.lastname@example.org. BES data, questionnaires and technical information are available for free download at: http://bes2009–10.org.
Voting in the 2010 General Election: Respondents were asked: (a) ‘Talking to people about the General Election on May 6th, we have found that a lot people didn't manage to vote. How about you – did you manage to vote in the General Election?’ If a respondent indicated voting, they were asked: (b) ‘Which party did you vote for in the General Election?’ In the binomial logit analyses of Labour voting, Labour voters are scored 1 and voters for all other parties are scored 0. In the multinomial logit analyses of opposition party voting Conservative voters are scored 1, Liberal Democrat voters are scored 2, voters for all other parties except Labour are scored 3, and Labour voters are scored 4.
Partisanship: Partisan attachments are measured using the first question
in the standard BES party identification sequence: ‘Generally
speaking, do you think of yourself as Labour, Conservative, Liberal
Democrat or what?’ Party identification variables are a series of 0–
1 dummies with ‘no’ and ‘don’t know’ responses designated as the
Public reactions to policy delivery are central to the valence model of electoral choice. Governments that succeed in delivering cherished public goods such as economic prosperity, low crime rates, effective health care and efficient public services can anticipate electoral success. In contrast, governments that fail to deliver satisfactory quantities of these goods can expect negative reactions from disgruntled electorates. Mechanisms linking policy performance with party support are generally left implicit in the valence model, since the assumption is that good performance automatically generates positive reactions from performance-oriented voters. However, it is an interesting question why people should behave in this way. The aim of this chapter is to examine this linkage, advancing the argument that successful policy delivery increases happiness or subjective well-being and failed policies have the opposite effect.
At the outset, it bears emphasis that the importance of subjective well-being is not restricted to the valence model of voting; rather, it also highly relevant for Downsian spatial models of party competition. Like their valence rivals, spatial models assume that voters are motivated by a desire to maximize utility. However, in spatial models well-being will be enhanced by the government implementing policies on position issues that divide electorates. Position issues animate both elite and mass political behaviour, and governments aim to deliver policies that some voters favour and others oppose. If the division of preferences on a particular policy is very close, large minorities of voters will not experience an increase, and may well experience a decrease in subjective well-being. In a ‘spatial world’ of fixed voter preferences and strategic politicians, there is no guarantee that government policy implementation will yield aggregate increases in life satisfaction. Minorities with intense preferences may be sorely disappointed with government policies and suffer sizable decreases in their sense of well-being.
Tony Blair propelled New Labour to power in May 1997, campaigning with the slogan ‘New Labour – New Britain’. From the time he became party leader in July 1994, he took full advantage of the difficulties encountered by John Major's weak and divided Conservative government. Blair had two core objectives, both of which reflected reactions to his party's lack of success in four successive elections held since 1979. He aimed to position what he called ‘New Labour’ as a responsible, slightly-left-of-centre party that would strive to achieve Labour's traditional goal of protecting the vulnerable and enhancing the life chances of the disadvantaged. At the same time, however, New Labour would not threaten the interests of Britain's increasingly prosperous middle class. Mr Blair and his colleagues believed that they could achieve these ends by demonstrating that their party was capable of managing the economy effectively – indeed, more effectively than their Conservative rivals. The resulting prosperity would provide the revenue needed for greatly enhanced social policy investment. New Labour thereby would deliver a highly attractive confluence of compassion and competence to government policy. During much of its long sojourn in the political wilderness Labour had been widely regarded as too great a risk to be trusted with the reigns of power. The party might care deeply about increasing public welfare, but it was incompetent to do much, if anything, about it. Blair aimed to change that longstanding perception and keep it changed.
Basking in the glow of his 1997 landslide victory, Blair's government got off to a terrific start. Labour experienced an extended honeymoon, enjoying enormous opinion polls leads over the demoralized Conservatives. By sticking firmly to the Conservatives’ spending plans for the first two years, as it had promised to do during the 1997 election campaign, New Labour demonstrated fiscal responsibility and consolidated a reputation for managerial acumen that it had begun to acquire almost by default in the wake of the 1992 Exchange Rate Mechanism crisis. By handing control of interest rates to the Bank of England's Monetary Policy Committee, Blair displayed his determination to run monetary policy in the service of controlling inflation, rather than as a handmaiden of party interests and the exigencies of the electoral calendar. Political business cycles would give way to sound economic stewardship in the national interest.