Comparing environmental impacts of deep-seabed and land-based mining: A defensible framework.

The crises of climate change and biodiversity loss are interlinked and must be addressed jointly. A proposed solution for reducing reliance on fossil fuels, and thus mitigating climate change, is the transition from conventional combustion-engine to electric vehicles. This transition currently requires additional mineral resources, such as nickel and cobalt used in car batteries, presently obtained from land-based mines. Most options to meet this demand are associated with some biodiversity loss. One proposal is to mine the deep seabed, a vast, relatively pristine and mostly unexplored region of our planet. Few comparisons of environmental impacts of solely expanding land-based mining versus extending mining to the deep seabed for the additional resources exist and for biodiversity only qualitative. Here, we present a framework that facilitates a holistic comparison of relative ecosystem impacts by mining, using empirical data from relevant environmental metrics. This framework (Environmental Impact Wheel) includes a suite of physicochemical and biological components, rather than a few selected metrics, surrogates, or proxies. It is modified from the "recovery wheel" presented in the International Standards for the Practice of Ecological Restoration to address impacts rather than recovery. The wheel includes six attributes (physical condition, community composition, structural diversity, ecosystem function, external exchanges and absence of threats). Each has 3-5 sub attributes, in turn measured with several indicators. The framework includes five steps: (1) identifying geographic scope; (2) identifying relevant spatiotemporal scales; (3) selecting relevant indicators for each sub-attribute; (4) aggregating changes in indicators to scores; and (5) generating Environmental Impact Wheels for targeted comparisons. To move forward comparisons of land-based with deep seabed mining, thresholds of the indicators that reflect the range in severity of environmental impacts are needed. Indicators should be based on clearly articulated environmental goals, with objectives and targets that are specific, measurable, achievable, relevant, and time bound.

Increasing reliability of axially compressed cylinders through stiffness tailoring and optimization.

The capabilities of the rapid tow shearing (RTS) process are explored to reduce the well-known imperfection sensitivity of axially compressed cylindrical shells. RTS deposits curvilinear carbon fibre tapes with a fibre-angle-thickness coupling that enables the in situ manufacturing of embedded rings and stringers. By blending the material's elastic modulus and wall thickness smoothly across the cylindrical surface, the load paths can be redistributed favourably with a minimal-design approach that contains part count and weight while ameliorating imperfection sensitivity. A genetic algorithm that incorporates realistic manufacturing imperfections and axial stiffness penalty is used to maximize the 99.9% reliability load of straight fibre (SF) and RTS cylinders. The axial stiffness penalty ensures that reliability does not come at the expense of stiffness. The first-order second-moment method is used to calculate statistical moments that enable an estimate of the 99.9% reliability load. Due to the fibre-angle-thickness coupling of RTS, buckling data are normalized by mass and thickness. Compared to a quasi-isotropic laminate, which corresponds to the optimal eight-layer design for a perfect cylinder, the optimized SF and RTS laminates have a 6% and 8% greater 99.9% normalized reliability load. By relaxing the axial stiffness penalty, the performance benefit can be increased such that SF and RTS cylinders exceed the 99.9% normalized reliability load of an eight-layer quasi-isotropic laminate by 23% and 37%, respectively. Both improvements (with and without penalty functions) stem largely from a reduction in the variance of the buckling-load distribution, thereby demonstrating the potential of fibre-steered cylinders in reducing the imperfection sensitivity of cylindrical shells. This article is part of the theme issue 'Probing and dynamics of shock sensitive shells'.

Stress recovery of laminated non-prismatic beams under layerwise traction and body forces.

Emerging manufacturing technologies, including 3D printing and additive layer manufacturing, offer scope for making slender heterogeneous structures with complex geometry. Modern applications include tapered sandwich beams employed in the aeronautical industry, wind turbine blades and concrete beams used in construction. It is noteworthy that state-of-the-art closed form solutions for stresses are often excessively simple to be representative of real laminated tapered beams. For example, centroidal variation with respect to the neutral axis is neglected, and the transverse direct stress component is disregarded. Also, non-classical terms arise due to interactions between stiffness and external load distributions. Another drawback is that the external load is assumed to react uniformly through the cross-section in classical beam formulations, which is an inaccurate assumption for slender structures loaded on only a sub-section of the entire cross-section. To address these limitations, a simple and efficient yet accurate analytical stress recovery method is presented for laminated non-prismatic beams with arbitrary cross-sectional shapes under layerwise body forces and traction loads. Moreover, closed-form solutions are deduced for rectangular cross-sections. The proposed method invokes Cauchy stress equilibrium followed by implementing appropriate interfacial boundary conditions. The main novelties comprise the 2D transverse stress field recovery considering centroidal variation with respect to the neutral axis, application of layerwise external loads, and consideration of effects where stiffness and external load distributions differ. A state of plane stress under small linear-elastic strains is assumed, for cases where beam thickness taper is restricted to 15 ∘ . The model is validated by comparison with finite element analysis and relevant analytical formulations.

The role of symmetry in the post-buckling behaviour of structures.

Symmetry plays an integral role in the post-buckling analysis of elastic structures. We show that the post-buckling response of engineering systems with given symmetry properties can be described using a preselected set of buckling modes. Therefore, the main original contribution of this paper is to prove the existence of these influential buckling modes and reveal some insights about them. From an engineering point of view, this study leads to the possibility of reducing computational effort in the analysis of large-scale systems. Firstly, symmetry groups for nonlinear elastic structural problems are discussed. Then, we invoke Curie's principle and describe the relationship between these groups and related pre-buckling and linear buckling deformation patterns. Then, for structural systems belonging to a given symmetry group, we re-invoke Curie's principle for describing the relationship between linear buckling modes and post-buckled deformation of the structure. Subsequently, we furnish a simplified asymptotic description which is obtained by projecting the equilibrium equations onto the subset of the most representative modes. As examples, classic bifurcation problems including isotropic and composite laminate panels under compression loading are investigated. Finally, the accuracy and computational advantages given by this new approach are discussed.

Deleterious localized stress fields: the effects of boundaries and stiffness tailoring in anisotropic laminated plates.

The safe design of primary load-bearing structures requires accurate prediction of stresses, especially in the vicinity of geometric discontinuities where deleterious three-dimensional stress fields can be induced. Even for thin-walled structures significant through-thickness stresses arise at edges and boundaries, and this is especially precarious for laminates of advanced fibre-reinforced composites because through-thickness stresses are the predominant drivers in delamination failure. Here, we use a higher-order equivalent single-layer model derived from the Hellinger-Reissner mixed variational principle to examine boundary layer effects in laminated plates comprising constant-stiffness and variable-stiffness laminae and deforming statically in cylindrical bending. The results show that zigzag deformations, which arise due to layerwise differences in the transverse shear moduli, drive boundary layers towards clamped edges and are therefore critically important in quantifying localized stress gradients. The relative significance of the boundary layer scales with the degree of layerwise anisotropy and the thickness to characteristic length ratio. Finally, we demonstrate that the phenomenon of alternating positive and negative transverse shearing deformation through the thickness of composite laminates, previously only observed at clamped boundaries, can also occur at other locations as a result of smoothly varying the material properties over the in-plane dimensions of the laminate.

The Benefits of Peer Review and a Multisemester Capstone Writing Series on Inquiry and Analysis Skills in an Undergraduate Thesis.

This study examines the relationship between the introduction of a four-course writing-intensive capstone series and improvement in inquiry and analysis skills of biology senior undergraduates. To measure the impact of the multicourse write-to-learn and peer-review pedagogy on student performance, we used a modified Valid Assessment of Learning in Undergraduate Education rubric for Inquiry and Analysis and Written Communication to score senior research theses from 2006 to 2008 (pretreatment) and 2009 to 2013 (intervention). A Fisher-Freeman-Halton test and a two-sample Student's t test were used to evaluate individual rubric dimensions and composite rubric scores, respectively, and a randomized complete block design analysis of variance was carried out on composite scores to examine the impact of the intervention across ethnicity, legacy (e.g., first-generation status), and research laboratory. The results show an increase in student performance in rubric scoring categories most closely associated with science literacy and critical-thinking skills, in addition to gains in students' writing abilities.

Biomimetic photo-actuation: sensing, control and actuation in sun-tracking plants.

Although the actuation mechanisms that drive plant movement have been investigated from a biomimetic perspective, few studies have looked at the wider sensing and control systems that regulate this motion. This paper examines photo-actuation-actuation induced by, and controlled with light-through a review of the sun-tracking functions of the Cornish Mallow. The sun-tracking movement of the Cornish Mallow leaf results from an extraordinarily complex-yet extremely elegant-process of signal perception, generation, filtering and control. Inspired by this process, a concept for a simplified biomimetic analogue of this leaf is proposed: a multifunctional structure employing chemical sensing, signal transmission, and control of composite hydrogel actuators. We present this multifunctional structure, and show that the success of the concept will require improved selection of materials and structural design. This device has application in the solar-tracking of photovoltaic panels for increased energy yield. More broadly it is envisaged that the concept of chemical sensing and control can be expanded beyond photo-actuation to many other stimuli, resulting in new classes of robust solid-state devices.

Neural correlates of STN DBS-induced cognitive variability in Parkinson disease.

BACKGROUND: Although deep brain stimulation of the subthalamic nucleus (STN DBS) in Parkinson disease (PD) improves motor function, it has variable effects on working memory (WM) and response inhibition (RI) performance. The purpose of this study was to determine the neural correlates of STN DBS-induced variability in cognitive performance. METHODS: We measured bilateral STN DBS-induced blood flow changes (PET and [(15)O]-water on one day) in the supplementary motor area (SMA), dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC), and right inferior frontal cortex (rIFC) as well as in exploratory ROIs defined by published meta-analyses. STN DBS-induced WM and RI changes (Spatial Delayed Response and Go-No-Go on the next day) were measured in 24 PD participants. On both days, participants withheld PD medications overnight and conditions (OFF vs. ON) were administered in a counterbalanced, double-blind manner. RESULTS: As predicted, STN DBS-induced DLPFC blood flow change correlated with change in WM, but not RI performance. Furthermore, ACC blood flow change correlated with change in RI but not WM performance. For both relationships, increased blood flow related to decreased cognitive performance in response to STN DBS. Of the exploratory regions, only blood flow changes in DLPFC and ACC were correlated with performance. CONCLUSIONS: These results demonstrate that variability in the effects of STN DBS on cognitive performance relates to STN DBS-induced cortical blood flow changes in DLPFC and ACC. This relationship highlights the need to further understand the factors that mediate the variability in neural and cognitive response to STN DBS.

Unilateral vs. bilateral STN DBS effects on working memory and motor function in Parkinson disease.

Bilateral subthalamic nucleus deep brain stimulation (STN DBS) can reduce working memory while improving motor function in Parkinson disease (PD), but findings are variable. One possible explanation for this variability is that the effects of bilateral STN DBS on working memory function depend in part on functional or disease asymmetry. The goal of this study was to determine the relative contributions of unilateral DBS to the effects seen with bilateral DBS. Motor (Unified Parkinson Disease Rating Scale Part III, UPDRS) and working memory function (Spatial Delayed Response, SDR) were measured in 49 PD patients with bilateral STN DBS while stimulators were Both-off, Left-on, Right-on and Both-on in a randomized, double-blind manner. Patients were off PD medications overnight. Effects of unilateral DBS were compared to effects of bilateral STN DBS. Mean UPDRS and SDR responses to Left-on vs. Right-on conditions did not differ (p>.20). However, improvement in contralateral UPDRS was greater and SDR performance was more impaired by unilateral DBS in the more affected side of the brain than in the less affected side of the brain (p=.008). The effect of unilateral DBS on the more affected side on contralateral UPDRS and SDR responses was equivalent to that of bilateral DBS. These results suggest that motor and working memory function respond to unilateral STN DBS differentially depending on the asymmetry of motor symptoms.

Minimum mass vascular networks in multifunctional materials.

A biomimetic analysis is presented in which an expression for the optimum vessel diameter for the design of minimum mass branching or vascular networks in engineering applications is derived. Agreement with constructal theory is shown. A simple design case is illustrated and application to more complex cases with branching networks of several generations discussed. The analysis is also extended into the turbulent flow regime, giving an optimization tool with considerable utility in the design of fluid distribution systems. The distribution of vessel lengths in different generations was also found to be a useful design variable. Integrating a network into a structure is also discussed. Where it is necessary to adopt a non-optimum vessel diameter for structural integration, it has been shown that small deviations from the minimum mass optimum can be tolerated, but large variations could be expected to produce a punitive and rapidly increasing mass penalty.

Onset of submarine debris flow deposition far from original giant landslide.

Submarine landslides can generate sediment-laden flows whose scale is impressive. Individual flow deposits have been mapped that extend for 1,500 km offshore from northwest Africa. These are the longest run-out sediment density flow deposits yet documented on Earth. This contribution analyses one of these deposits, which contains ten times the mass of sediment transported annually by all of the world's rivers. Understanding how this type of submarine flow evolves is a significant problem, because they are extremely difficult to monitor directly. Previous work has shown how progressive disintegration of landslide blocks can generate debris flow, the deposit of which extends downslope from the original landslide. We provide evidence that submarine flows can produce giant debris flow deposits that start several hundred kilometres from the original landslide, encased within deposits of a more dilute flow type called turbidity current. Very little sediment was deposited across the intervening large expanse of sea floor, where the flow was locally very erosive. Sediment deposition was finally triggered by a remarkably small but abrupt decrease in sea-floor gradient from 0.05 degrees to 0.01 degrees. This debris flow was probably generated by flow transformation from the decelerating turbidity current. The alternative is that non-channelized debris flow left almost no trace of its passage across one hundred kilometres of flat (0.2 degrees to 0.05 degrees) sea floor. Our work shows that initially well-mixed and highly erosive submarine flows can produce extensive debris flow deposits beyond subtle slope breaks located far out in the deep ocean.

Measuring clinical performance using routinely collected clinical data.

Following the well-publicized problems with paediatric cardiac surgery at the Bristol Royal Infirmary, there is wide public interest in measures of hospital performance. The Kennedy report on the BRI events suggested that such measures should be meaningful to the public, case-mix-adjusted, and based on data collected as part of routine clinical care. We have found that it is possible to predict in-hospital mortality (a measure readily understood by the public) using simple routine data-age, mode of admission, sex, and routine blood test results. The clinical data items can be obtained at a single venesection, are commonly collected in the routine care of patients, are already stored on hospital core IT systems, and so place no extra burden on the clinical staff providing care. Such risk models could provide a metric for use in evidence-based clinical performance management. National application is logistically feasible.

The use of routine laboratory data to predict in-hospital death in medical admissions.

The ability to predict clinical outcomes in the early phase of a patient's hospital admission could facilitate the optimal use of resources, might allow focused surveillance of high-risk patients and might permit early therapy. We investigated the hypothesis that the risk of in-hospital death of general medical patients can be modelled using a small number of commonly used laboratory and administrative items available within the first few hours of hospital admission. Matched administrative and laboratory data from 9497 adult hospital discharges, with a hospital discharge specialty of general medicine, were divided into two subsets. The dataset was split into a single development set, Q(1) (n=2257), and three validation sets, Q(2), Q(3) and Q(4) (n(1)=2335, n(2)=2361, n(3)=2544). Hospital outcome (survival/non-survival) was obtained for all discharges. An outcome model was constructed from binary logistic regression of the development set data. The goodness-of-fit of the model for the validation sets was tested using receiver-operating characteristics curves (c-index) and Hosmer-Lemeshow statistics. Application of the model to the validation sets produced c-indices of 0.779 (Q(2)), 0.764 (Q(3)) and 0.757 (Q(4)), respectively, indicating good discrimination. Hosmer-Lemeshow analysis gave chi(2)=9.43 (Q(2)), chi(2)=7.39 (Q(3)) and chi(2)=8.00 (Q(4)) (p-values of 0.307, 0.495 and 0.433) for 8 degrees of freedom, indicating good calibration. The finding that the risk of hospital death can be predicted with routinely available data very early on after hospital admission has several potential uses. It raises the possibility that the surveillance and treatment of patients might be categorised by risk assessment means. Such a system might also be used to assess clinical performance, to evaluate the benefits of introducing acute care interventions or to investigate differences between acute care systems.

Comparison of P-POSSUM risk-adjusted mortality rates after surgery between patients in the USA and the UK.

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) criteria have been used to assess surgical risk in patients in the UK. The aim was to determine how applicable these criteria are to patients undergoing surgery in the USA. METHODS: Two cohorts of patients undergoing major non-cardiac surgery were followed prospectively in the USA (n = 1056) and the UK (n = 1539). Each patient was assigned a risk score for preoperative physiological status and operative severity using the established POSSUM criteria. Death in hospital was the primary outcome measure. For each patient a predicted risk of death was calculated from Portsmouth POSSUM (P-POSSUM) methodology using an established equation. The relationships between predicted and observed mortality rates in each cohort were investigated by means of multivariate logistic regression. RESULTS: Within each cohort, an increase in risk estimated by P-POSSUM predicted an increase in observed mortality rate (P < 0.001). For any given risk level, however, mortality rates were significantly higher in the UK cohort than in the US cohort (odds ratio 4.50 (95 per cent confidence interval 2.81 to 7.19); Z = 6.25, P < 0.001). CONCLUSION: An increase in predicted risk, based on the P-POSSUM methodology, was associated with a higher mortality rate in patients from both countries. However, risk-adjusted mortality rates following major surgery were four times higher in the UK cohort. These marked differences warrant validation in a larger number of centres.

Towards a national clinical minimum data set for general surgery.

BACKGROUND: Measurement and comparison of surgical performance is accepted as necessary and inevitable. Risk-stratified (case-mix adjusted) models of clinical outcomes form a metric with which to assess performance, but require accurate data. Collecting such data in the clinical environment is time consuming and difficult. This study aimed to construct effective models, for operative and non-operative admissions, from routine clinical data residing in hospital computers, so minimizing data collection and quality problems, and facilitating national implementation. METHODS: Data for 3181 non-operative emergency, 5039 elective and 3043 emergency operative admissions for the 2 years beginning 1 August 1997 were used to generate logistic regression equations for risk of death, which were applied prospectively to the following 3 years' data. RESULTS: The models use urea, haemoglobin, white blood cell count, sodium, potassium, age on admission, sex, British United Provident Association (BUPA) Operative Severity Score (for operative admissions) and, implicitly, mode of admission and mortality at discharge. All three models successfully stratified risk into five or more bands. CONCLUSION: Effective models of mortality, applicable to all general surgical admissions, can be constructed from existing routine clinical data, largely obtained from a single venesection. The data set is a candidate national clinical minimum data set.

Comparison of the ex vivo chemosensitivity of uveal and cutaneous melanoma.

Cutaneous and uveal melanoma both have a poor prognosis and chemotherapy is usually unsuccessful. We have previously reported the activity of a number of cytotoxic agents against metastatic cutaneous and primary choroidal uveal melanoma using an ex vivo adenosine triphosphate (ATP)-based chemosensitivity assay (ATP-TCA). In this study we compare the results obtained with the two types of melanoma. Cutaneous melanoma deposits in skin and lymph nodes (n = 58) and choroidal melanomas (n = 77) were tested using the ATP-TCA. Analysis of the data based on an arbitrary threshold for sensitivity shows that both types of melanoma exhibit heterogeneity of sensitivity to all the agents and combinations tested. With all the single agents except gemcitabine, cutaneous melanomas showed greater sensitivity in the assay, though this did not achieve statistical significance. This was also true with the drug combinations, with the exception of treosulfan + gemcitabine, which had similar activity in each type of melanoma. Of all the single agents tested, doxorubicin (47% of specimens classed as sensitive), vinorelbine (43%), treosulfan (41%) and paclitaxel (33%) showed the greatest activity with cutaneous melanoma. In the uveal melanoma samples, mitoxantrone (33%), gemcitabine (22%) and treosulfan (21%) showed the greatest activity. In contrast to the cutaneous melanomas, 13% of the uveal melanomas were sensitive to paclitaxel, 4% were sensitive to doxorubicin and 11% were found to be sensitive to vinorelbine. Both tumour types showed greater sensitivity to combinations of cytotoxic agents. The combination of treosulfan + gemcitabine was universally effective, with 72% of cutaneous melanomas and 80% of uveal melanomas exhibiting activity at the level selected to indicate sensitivity in the assay, though this will not necessarily indicate a similar level of clinical sensitivity.

Consumer satisfaction with services in a regional psychiatric hospital: a collaborative research project in Kentucky.

Consumer satisfaction with mental health services is a dimension of outcome. This report is on a university and state mental health department research project that involved development of the Kentucky Consumer Satisfaction Instrument (KY-CSI) and a retrospective, cross-sectional study designed to measure consumer satisfaction with services at a regional psychiatric hospital. Triangulation of methods guided the survey of participants (N = 189) near discharge from the hospital during a 6-month period. Research associates, who were former consumers of mental health services, collected data during face-to-face interviews. Most participants were unemployed White men. Factor analysis indicated the 19-item instrument was unidimensional; Cronbach's alpha was 0.90. Multiple regression indicated predictors of satisfaction were levels of education and diagnosis. As education increased, satisfaction decreased; participants with a diagnosis of bipolar disorder tended to be more satisfied than those with other diagnoses. Analysis of qualitative data combined with standardized summary of KY-CSI items indicated participants were most satisfied with opportunities to talk with other patients and least satisfied about lack of involvement of people with whom they lived in discharge planning. Study findings guided recommendations for quality of care and additional studies at other hospital sites.

Evidence for three distinct hydrogenase activities in Rhodospirillum rubrum.

Inducer, inhibitor, and mutant studies on three hydrogenase activities of Rhodospirillum rubrum indicate that they are mediated by three distinct hydrogenase enzymes. Uptake hydrogenase mediates H2 uptake to an unknown physiological acceptor or methylene blue and is maximally synthesized during autotrophic growth in light. Formate-linked hydrogenase is synthesized primarily during growth in darkness or when light becomes limiting, and links formate oxidation to H2 production. Carbon-monoxide-linked hydrogenase is induced whenever CO is present and couples CO oxidation to H2 evolution. The enzymes can be expressed singly or conjointly depending on growth conditions, and the inhibitor or inducer added. All three hydrogenases can use methyl viologen as the mediator for both the H2 evolution and H2 uptake reactions while displaying distinct pH optima, reversibility, and sensitivity to C2H2 gas. Yet, we present evidence that the CO-linked hydrogenase, unlike the uptake hydrogenase, does not link to methylene blue as the electron acceptor. These differences allow conditions to be established to quantitatively assay each hydrogenase independently of the others both in vivo and in vitro.

Heterogeneity of chemosensitivity of metastatic cutaneous melanoma.

Advanced melanoma has a poor prognosis and chemotherapy provides little benefit for most patients. This may be related to heterogeneity of chemosensitivity as well as frequent constitutive resistance to individual cytotoxic drugs. We have therefore examined the heterogeneity of chemosensitivity in metastatic cutaneous melanoma specimens using an ex vivo ATP-based chemosensitivity assay (ATP-TCA). Melanoma deposits (n=55) in skin or lymph node were tested using the ATP-TCA, performed in three separate laboratories. Analysis of the data collected (based on an arbitrary sensitivity index < 300) shows considerable heterogeneity of chemosensitivity. The most active single cytotoxic agents in the assay were identified as cisplatin, treosulfan, paclitaxel, vinblastine, gemcitabine and mitoxantrone. There was also a limited direct inhibition of melanoma cell growth by interferon-alpha2b, although this agent is known to have a number of indirect biological antitumor effects. Exposure of tumor cells to combinations of drugs at the concentrations tested as single agents showed the most active combinations to be treosulfan+gemcitabine, cisplatin+paclitaxel and vinblastine+paclitaxel. There was considerable heterogeneity of chemosensitivity: some tumors responded well to one agent or combination, while others showed no response to this and instead responded to one of the alternatives tested. Occasional highly resistant tumors showed no response to any of the single agents or combinations tested. The degree of heterogeneity observed suggests that the ATP-TCA could be used to select patients who might benefit from specific chemotherapeutic agents alone or in combination. This provides the rationale for future randomized controlled trials of ATP-TCA-directed chemotherapy versus physician's choice to determine whether assay-directed chemotherapy can improve patient response and survival.

POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity.

BACKGROUND: There is a need for an accurate measure of surgical outcomes so that hospitals and surgeons can be compared properly regardless of case mix. POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) uses a physiological score and an operative severity score to calculate risks of mortality and morbidity. In a previous small study it was found that Portsmouth POSSUM (P-POSSUM; a modification of the POSSUM system) provided a more accurate prediction of mortality. METHODS: Some 10000 general surgical interventions (excluding paediatric and day cases) were studied prospectively between August 1993 and November 1995. The POSSUM mortality equation was applied to the full 10000 surgical episodes. The 10000 patients were arranged in chronological order and the first 2500 were used as a training set to produce the modified P-POSSUM predictor equation. This was then applied prospectively to the remaining 7500 patients arranged chronologically in five groups of 1500. RESULTS: The original POSSUM logistic regression equation for mortality overpredicts the overall risk of death by more than twofold and the risk of death for patients at lowest risk (5 per cent or less) by more than sevenfold. The P-POSSUM equation produced a very close fit with the observed in-hospital mortality. CONCLUSION: P-POSSUM provides an accurate method for comparative surgical audit.