A robust lesion boundary segmentation algorithm using level set methods

This paper addresses the issue of accurate lesion segmentation in retinal imagery, using level set methods and a novel stopping mechanism - an elementary features scheme. Specifically, the curve propagation is guided by a gradient map built using a combination of histogram equalization and robust statistics. The stopping mechanism uses elementary features gathered as the curve deforms over time, and then using a lesionness measure, defined herein, ’looks back in time’ to find the point at which the curve best fits the real object. We compare the proposed method against five other segmentation algorithms performed on 50 randomly selected images of exudates with a database of clinician demarcated boundaries as ground truth

Using shape entropy as a feature to lesion boundary segmentation with level sets

Accurate lesion segmentation in retinal imagery is an area of vast research. Of the many segmentation methods available very few are insensitive to topological changes on noisy surfaces. This paper presents an extension to earlier work on a novel stopping mechanism for level sets. The elementary features scheme (ELS) in [5] is extended to include shape entropy as a feature used to ’look back in time’ and find the point at which the curve best fits the real object. We compare the proposed extension against the original algorithm for timing and accuracy using 50 randomly selected images of exudates with a database of clinician demarcated boundaries as ground truth. While this work is presented applied to medical imagery, it can be used for any application involving the segmentation of bright or dark blobs on noisy images

The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient’s priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman’s concept of ‘frames’ to present an examination of how doctors’ and patients’ sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients’ understanding of the goal-setting consultation, GPs actively aligning with patients’ framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided “telling cases” of goal-setting interactions, where doctors and patients need to negotiate each other’s perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations

Scaling functional status within the interRAI suite of assessment instruments

Abstract Background As one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies. Methods A secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments. Results Using items from interRAI’s suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community. Conclusions An integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.http://deepblue.lib.umich.edu/bitstream/2027.42/112435/1/12877_2013_Article_932.pd

Synthesis and vectorial functionalisation of pyrazolo[3,4- c ]pyridines

Heterocycles are a cornerstone of fragment-based drug discovery (FBDD) due to their prevalence in biologically active compounds. However, novel heterocyclic fragments are only valuable if they can be suitably elaborated to compliment a chosen target protein. Here we describe the synthesis of 5-halo-1H-pyrazolo[3,4-c]pyridine scaffolds and demonstrate how these compounds can be selectively elaborated along multiple growth-vectors. Specifically, N-1 and N-2 are accessed through protection-group and N-alkylation reactions; C-3 through tandem borylation and Suzuki–Miyaura cross-coupling reactions; C-5 through Pd-catalysed Buchwald–Hartwig amination; and C-7 through selective metalation with TMPMgCl.LiCl followed by reaction with electrophiles or transmetalation to ZnCl2 and Negishi cross-coupling. Linking multiple functionalisation strategies emulates a hit-to-lead pathway and demonstrates the utility of pyrazolo[3,4-c]pyridines to FBDD

Setting goals with patients living with multimorbidity: qualitative analysis of general practice consultations

Background Establishing patient goals is widely recommended as a way to deliver care that matters to the individual patient with multimorbidity, who may not be well served by single-disease guidelines. Though multimorbidity is now normal in general practice, little is known about how doctors and patients should set goals together. Aim To determine the key components of the goal-setting process in general practice. Design and setting In-depth qualitative analysis of goal-setting consultations in three UK general practices, as part of a larger feasibility trial. Focus groups with participating GPs and patients. The study took place between November 2016 and July 2018. Method Activity analysis was applied to 10 hours of video-recorded doctor-patient interactions to explore key themes relating to how goal setting was attempted and achieved. Core challenges were identified and focus groups were analysed using thematic analysis. Results A total of 22 patients and five GPs participated. Four main themes emerged around the goal-setting process: patient preparedness and engagement; eliciting and legitimising goals; collaborative action planning; and GP engagement. GPs were unanimously positive about their experience of goal setting and viewed it as a collaborative process. Patients liked having time to talk about what was most important to them. Challenges included eliciting goals from unprepared patients, and GPs taking control of the goal rather than working through it with the patient. Conclusion Goal setting required time and energy from both parties. GPs had an important role in listening and bearing witness to their patients' goals. Goal setting worked best when both GP and patient were prepared in advance

Call for special issue papers: Global public health — contributions of traditional, complementary, and integrative medicine in primary care

The 2018 Declaration of Astana* issued by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) represents a landmark step for all of primary health care, public health, and traditional complementary and integrative medicine. It brings together the priorities of the WHO’s 1978 Alma-Ata Declaration, the international importance of universal health coverage, and the ongoing efforts of the global community to reach UNICEF’s Sustainable Development Goals. It is the first global primary health care document to explicitly acknowledge the value and importance of traditional medicine systems in achieving successful primary health services; ‘success’ being underpinned by specific commitments and evaluated by key success measures**. The Declaration explicitly refers to the application of traditional knowledge and the appropriate inclusion of traditional medicines as factors that will drive the success of primary care. However, the Declaration also makes commitments and identifies other success drivers that, despite not being directly linked to traditional and integrative care, are equally relevant. These omissions represent potentially untapped and overlooked opportunities for meaningful engagement to improve primary care

The competencies of registered nurses working in care homes: a modified Delphi study

BACKGROUND: Registered Nurses (RNs) working in UK care homes receive most of their training in acute hospitals. At present the role of care home nursing is underdeveloped and it is seen as a low status career. We describe here research to define core competencies for RNs working in UK care homes. METHODS: A two-stage process was adopted. A systematic literature review and focus groups with stakeholders provided an initial list of competencies. The competency list was modified over three rounds of a Delphi process with a multi-disciplinary expert panel of 28 members. RESULTS: Twenty-two competencies entered the consensus process, all competencies were amended and six split. Thirty-one competencies were scored in round two, eight were agreed as essential, one competency was split into two. Twenty-four competencies were submitted for scoring in round three. In total, 22 competencies were agreed as essential for RNs working in care homes. A further ten competencies did not reach consensus. CONCLUSION: The output of this study is an expert-consensus list of competencies for RNs working in care homes. This would be a firm basis on which to build a curriculum for this staff group

Can goal-setting for patients with multimorbidity improve outcomes in primary care? Cluster randomised feasibility trial

Introduction: Goal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice. Objective: To assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial. Design and setting: Cluster-randomised controlled feasibility trial of goal-setting compared to control in six general practices. Participants: Adults with 2 or more long term health conditions and at risk of unplanned hospital admission. Interventions: General Practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation six months later. The control group received usual care planning. Outcome measures: Health-related quality of life (EQ5D5L), capability (ICEpop CAPability measure for Older people (ICECAP-O)), patient assessment of chronic illness care (PACIC) and health care use. All consultations were video or audio-recorded, and focus groups were held with participating GPs and patients. Results: Fifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years 54% were female and the median number of prescribed medications was 13, compared to 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 minutes in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting, felt it delivered more patient-centred care and highlighted the importance of training. Conclusions: This goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness

Predicting risk of hospital and emergency department use for home care elderly persons through a secondary analysis of cross-national data

Abstract Background Older adults remain the highest utilization group with unplanned visits to emergency departments and hospital admissions. Many have considered what leads to this high utilization and the answers provided have depended upon the independent measures available in the datasets used. This project was designed to further understanding of the reasons for older adult ED visits and admissions to acute care hospitals. Methods A secondary analysis of data from a cross-national sample of community residing elderly, 60 years of age or older, and most of whom received services from a local home-care program was conducted. The assessment instrument used in this study is the interRAI HC (home care), designed for use in assessing elderly home care recipients. The model specification stage of the study identified the baseline independent variables that do and do not predict the follow-up measure of hospitalization and ED use. Stepwise logistic regression was used next to identify characteristics that best identified elders who subsequently entered a hospital or visited an ED. The items generated from the final multivariate logistic equation using the interRAI home care measures comprise the interRAI Hospital-ED Risk Index. Results Independent measures in three key domains of clinical complications, disease diagnoses and specialized treatments were related to subsequent hospitalization or ED use. Among the eighteen clinical complication measures with higher, meaningful odds ratios are pneumonia, urinary tract infection, fever, chest pain, diarrhea, unintended weight loss, a variety of skin conditions, and subject self-reported poor health. Disease diagnoses with a meaningful relationship with hospital/ED use include coronary artery disease, congestive heart failure, cancer, emphysema and renal failure. Specialized treatments with the highest odds ratios were blood transfusion, IV infusion, wound treatment, radiation and dialysis. Two measures, Alzheimer’s disease and day care appear to have a protective effect for hospitalization/ED use with lower odds ratios. Conclusions Examination into “preventable” hospitalizations and re-hospitalizations for older adults who have the highest rates of utilization are occurring beneath an umbrella of assuring the highest quality of care and controlling costs. The interRAI Hospitalization-ED Risk Index offers an effective approach to predicting hospitalization utilization among community dwelling older adults.http://deepblue.lib.umich.edu/bitstream/2027.42/109520/1/12913_2014_Article_519.pd