“But can chatbots understand sex?” Attitudes towards artificial intelligence chatbots amongst sexual and reproductive health professionals: An exploratory mixed-methods study

Background Artificial Intelligence (AI)-enabled chatbots can offer anonymous education about sexual and reproductive health (SRH). Understanding chatbot acceptability and feasibility allows the identification of barriers to the design and implementation. Methods In 2020, we conducted an online survey and qualitative interviews with SRH professionals recruited online to explore the views on AI, automation and chatbots. Qualitative data were analysed thematically. Results Amongst 150 respondents (48% specialist doctor/consultant), only 22% perceived chatbots as effective and 24% saw them as ineffective for SRH advice [Mean = 2.91, SD = 0.98, range: 1–5]. Overall, there were mixed attitudes towards SRH chatbots [Mean = 4.03, SD = 0.87, range: 1–7]. Chatbots were most acceptable for appointment booking, general sexual health advice and signposting, but not acceptable for safeguarding, virtual diagnosis, and emotional support. Three themes were identified: “Moving towards a ‘digital’ age’“, “AI improving access and service efficacy”, and “Hesitancy towards AI”. Conclusions Half of SRH professionals were hesitant about the use of chatbots in SRH services, attributed to concerns about patient safety, and lack of familiarity with this technology. Future studies should explore the role of AI chatbots as supplementary tools for SRH promotion. Chatbot designers need to address the concerns of health professionals to increase acceptability and engagement with AI-enabled services

The Impact of First UK-Wide Lockdown (March–June 2020) on Sexual Behaviors in Men and Gender Diverse People Who Have Sex with Men During the COVID-19 Pandemic: A Cross-Sectional Survey

The global COVID-19 pandemic resulted in strict social distancing measures restricting close physical contact. Men (cis and trans) and other gender diverse people who have sex with men (MGDSM) are at higher risk of sexually transmitted infections (STIs) and may have experienced changes in sexual behavior during government restrictions on social and sexual contact. We aimed to examine self-reported sexual behavior of MGDSM during the first UK-wide lockdown to identify the characteristics of the individuals who might most require sexual health promotion and clinical support. In April–May 2020, we conducted an online survey of MGDSM, promoted on social media and Grindr. Our exploratory approach used descriptive analysis to identify self-reported changes in sexual behavior and performed regression analyses to identify correlates of casual sex during the lockdown. A total of 1429 respondents completed the survey: mean age 36 years, 84% White, 97% male or trans male, 98% assigned male sex at birth, 2% female or non-binary, 65% degree educated or higher. During the lockdown, 76% reported not having any casual sex partners. While the majority reported reduced casual sex, 3% reported an increase in casual sex with one person and 2% with three or more people (group sex). About 12% of the sample engaged in casual sex with only one person and 5% with four or more sexual partners during the lockdown. Reporting casual sex during lockdown was associated with: lower level of education OR = 2.37 [95% CI 1.40–4.01]; identifying as a member of an ethnic minority OR = 2.27[1.40–3.53]; daily usage of sexual networking apps OR = 2.24[1.54–3.25]; being less anxious about contracting SARS-CoV-2 through sex OR = 1.66[1.12–2.44]; using PrEP before lockdown OR = 1.75[1.20–2.56]; continuing to use PrEP OR = 2.79[1.76–4.57]; and testing for STIs during lockdown OR = 2.65[1.76–3.99]. A quarter of respondents remained sexually active with casual partners, indicating a need to provide STI screening services and health promotion targeted to groups most likely to have need over this period. Future research is required to better understand how to support sexual and gender minorities to manage sexual risk in the context of pandemic public health initiatives

Effect of a Perioperative, Cardiac Output-Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery A Randomized Clinical Trial and Systematic Review

Importance: small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm.Objective: to evaluate the clinical effectiveness of a perioperative, cardiac output–guided hemodynamic therapy algorithm.Design, setting, and participants: OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom. An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to February 2014.Interventions: patients were randomly assigned to a cardiac output–guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366).Main outcomes and measures: the primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care–free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay.Results: baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, ?0.3% to 13.9%]; P?=?.07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]).Conclusions and relevance: in a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output–guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rate

Basic science232. Certolizumab pegol prevents pro-inflammatory alterations in endothelial cell function

Background: Cardiovascular disease is a major comorbidity of rheumatoid arthritis (RA) and a leading cause of death. Chronic systemic inflammation involving tumour necrosis factor alpha (TNF) could contribute to endothelial activation and atherogenesis. A number of anti-TNF therapies are in current use for the treatment of RA, including certolizumab pegol (CZP), (Cimzia ®; UCB, Belgium). Anti-TNF therapy has been associated with reduced clinical cardiovascular disease risk and ameliorated vascular function in RA patients. However, the specific effects of TNF inhibitors on endothelial cell function are largely unknown. Our aim was to investigate the mechanisms underpinning CZP effects on TNF-activated human endothelial cells. Methods: Human aortic endothelial cells (HAoECs) were cultured in vitro and exposed to a) TNF alone, b) TNF plus CZP, or c) neither agent. Microarray analysis was used to examine the transcriptional profile of cells treated for 6 hrs and quantitative polymerase chain reaction (qPCR) analysed gene expression at 1, 3, 6 and 24 hrs. NF-κB localization and IκB degradation were investigated using immunocytochemistry, high content analysis and western blotting. Flow cytometry was conducted to detect microparticle release from HAoECs. Results: Transcriptional profiling revealed that while TNF alone had strong effects on endothelial gene expression, TNF and CZP in combination produced a global gene expression pattern similar to untreated control. The two most highly up-regulated genes in response to TNF treatment were adhesion molecules E-selectin and VCAM-1 (q 0.2 compared to control; p > 0.05 compared to TNF alone). The NF-κB pathway was confirmed as a downstream target of TNF-induced HAoEC activation, via nuclear translocation of NF-κB and degradation of IκB, effects which were abolished by treatment with CZP. In addition, flow cytometry detected an increased production of endothelial microparticles in TNF-activated HAoECs, which was prevented by treatment with CZP. Conclusions: We have found at a cellular level that a clinically available TNF inhibitor, CZP reduces the expression of adhesion molecule expression, and prevents TNF-induced activation of the NF-κB pathway. Furthermore, CZP prevents the production of microparticles by activated endothelial cells. This could be central to the prevention of inflammatory environments underlying these conditions and measurement of microparticles has potential as a novel prognostic marker for future cardiovascular events in this patient group. Disclosure statement: Y.A. received a research grant from UCB. I.B. received a research grant from UCB. S.H. received a research grant from UCB. All other authors have declared no conflicts of interes

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Letter to the World

This short animated film interprets and represents themes from the poet Emily Dickinson’s life and works. Underpinned by interdisciplinary research into Dickinson’s experiments with hybridity and dual identities, the film investigates the poet’s reduction and enlargement of territories and spheres of influence, her poetic egotism, lucid descriptions of miniature worlds and Nature, her mathematical precision, and ultimately, her triumph over Death through the legacy of her mind. The film expands interdisciplinary research into the substantially underdeveloped applications of animation and sound design to the interpretation and representation of literary figures, and is innovative in contributing to broader debates on new forms of literary criticism. Developed with Professor Suzie Hanna (Norwich University of the Arts) and Dr Sally Bayley (Oxford University), the film refers to a rich supply of contemporary artistic and cultural influences referenced in Dickinson's poetry and letters, informed by primary and secondary research. Hanna and Simmons developed the visual and sonic aspects of the research respectively, drawing on Bayley’s expertise and specialist knowledge. The soundtrack examines Dickinson’s ‘auditory imagination’, drawing on T.S. Eliot’s writing on Matthew Arnold (1933) and Judy Small’s research into Dickinson’s artistic design, musical background and poetics (1990). Against backdrops of American civil war, nature and domestic confinement, the sound design dismantles Dickinson’s voice as an inner attunement of mind, employing Kant’s writing on the concept of ‘Stimmung’ (1790) as a condition for cognition. The film was produced for the 2010 ‘Emily Dickinson International Conference’, Oxford (2010), at which both the film and the underpinning research were presented. Following its initial screening, the film was presented at the ‘Sylvia Plath Symposium 2012’, Indiana University (2012) and ‘6th Berlin ZEBRA Poetry Film Festival’ (2012). The research was also disseminated at the ‘Transatlantic Exchanges’ conference, Plymouth University (2010) and ‘American Imagetext’ conference, University of East Anglia (2011)