Primary care-led commissioning and public involvement in the English National Health Service. Lessons from the past.

Background: Patient and Public involvement (PPI) in health care occupies a central place in Western democracies. In England, this theme has been continuously prominent since the introduction of market reforms in the early 1990s. The health care reforms implemented by the current Coalition Government are making primary care practitioners the main commissioners of health care services in the National Health Service, and a duty is placed on them to involve the public in commissioning decisions and strategies. Since implementation of PPI initiatives in primary care commissioning is not new, we asked how likely it is that the new reforms will make a difference. We scanned the main literature related to primary care-led commissioning and found little evidence of effective PPI thus far. We suggest that unless the scope and intended objectives of PPI are clarified and appropriate resources are devoted to it, PPI will continue to remain empty rhetoric and box ticking. Aim: To examine the effect of previous PPI initiatives on health care commissioning and draw lessons for future development. Method: We scanned the literature reporting on previous PPI initiatives in primary careled commissioning since the introduction of the internal market in 1991. In particular, we looked for specific contexts, methods and outcomes of such initiatives. Findings: 1. PPI in commissioning has been constantly encouraged by policy makers in England. 2. Research shows limited evidence of effective methods and outcomes so far. 3. Constant reconfi- guration of health care structures has had a negative impact on PPI. 4. The new structures look hardly better poised to bring about effective public and patient involvement

Real-Time Automatic Segmentation of Optical Coherence Tomography Volume Data of the Macular Region.

Optical coherence tomography (OCT) is a high speed, high resolution and non-invasive imaging modality that enables the capturing of the 3D structure of the retina. The fast and automatic analysis of 3D volume OCT data is crucial taking into account the increased amount of patient-specific 3D imaging data. In this work, we have developed an automatic algorithm, OCTRIMA 3D (OCT Retinal IMage Analysis 3D), that could segment OCT volume data in the macular region fast and accurately. The proposed method is implemented using the shortest-path based graph search, which detects the retinal boundaries by searching the shortest-path between two end nodes using Dijkstra's algorithm. Additional techniques, such as inter-frame flattening, inter-frame search region refinement, masking and biasing were introduced to exploit the spatial dependency between adjacent frames for the reduction of the processing time. Our segmentation algorithm was evaluated by comparing with the manual labelings and three state of the art graph-based segmentation methods. The processing time for the whole OCT volume of 496x644x51 voxels (captured by Spectralis SD-OCT) was 26.15 seconds which is at least a 2-8-fold increase in speed compared to other, similar reference algorithms used in the comparisons. The average unsigned error was about 1 pixel ( approximately 4 microns), which was also lower compared to the reference algorithms. We believe that OCTRIMA 3D is a leap forward towards achieving reliable, real-time analysis of 3D OCT retinal data

A Monolayer of Primary Colonic Epithelium Generated on a Scaffold with a Gradient of Stiffness for Drug Transport Studies

Animal models are frequently used for in vitro physiologic and drug transport studies of the colon, but there exists significant pressure to improve assay throughput as well as to achieve tighter control of experimental variables than can be achieved with animals. Thus, development of a primary in vitro colonic epithelium cultured as high resistance with transport protein expression and functional behavior similar to that of a native colonic would be of enormous value for pharmaceutical research. A collagen scaffold, in which the degree of collagen cross-linking was present as a gradient, was developed to support the proliferation of primary colonic cells. The gradient of cross-linking created a gradient in stiffness across the scaffold, enabling the scaffold to resist deformation by cells. mRNA expression and quantitative proteomic mass spectrometry of cells growing on these surfaces as a monolayer suggested that the transporters present were similar to those in vivo. Confluent monolayers acted as a barrier to small molecules so that drug transport studies were readily performed. Transport function was evaluated using atenolol (a substrate for passive paracellular transport), propranolol (a substrate for passive transcellular transport), rhodamine 123 (Rh123, a substrate for P-glycoprotein), and riboflavin (a substrate for solute carrier transporters). Atenolol was poorly transported with an apparent permeability (Papp) of < 5 × 10-7 cm s-1, while propranolol demonstrated a Papp of 9.69 × 10-6 cm s-1. Rh123 was transported in a luminal direction (Papp,efflux/Papp,influx = 7) and was blocked by verapamil, a known inhibitor of P-glycoprotein. Riboflavin was transported in a basal direction, and saturation of the transporter was observed at high riboflavin concentrations as occurs in vivo. It is anticipated that this platform of primary colonic epithelium will find utility in drug development and physiological studies, since the tissue possesses high integrity and active transporters and metabolism similar to that in vivo

Growth mindset and school burnout symptoms in young adolescents: the role of vagal activity as potential mediator

Experiencing school burnout symptoms can have negative consequences for learning. A growth mindset, the belief that human qualities such as intelligence are malleable, has previously been correlated with fewer school burnout symptoms in late adolescents. This might be because adolescents with a stronger growth mindset show more adaptive self-regulation strategies and thereby increasing resilience against academic setbacks. Here we confirmed in a sample of 426 Dutch young adolescents (11–14 years old; 48% female) that this relationship between growth mindset and school burnout symptoms holds after controlling for other potential predictors of school burnout symptoms such as academic achievement, school track, gender, and socio-economic status. Our second aim was to increase our understanding of the mechanism underlying the relation between mindset and school burnout, by measuring physiological resilience (vagal activity, a measure of parasympathetic activity, also known as heart rate variability or HRV) in a subsample (n = 50). We did not find any relation between vagal activity and growth mindset or school burnout symptoms, nor could we establish a mediating effect of vagal activity in their relation. In conclusion, we found evidence for a potential protective effect of a growth mindset on school burnout symptoms in young adolescents, but not for physiological resilience (vagal activity) as an underlying mechanism. The protective effect of growth mindset as confirmed in our younger sample can be leveraged in interventions to prevent increasing school burnout symptoms

A Method of Drusen Measurement Based on the Geometry of Fundus Reflectance

BACKGROUND: The hallmarks of age-related macular degeneration, the leading cause of blindness in the developed world, are the subretinal deposits known as drusen. Drusen identification and measurement play a key role in clinical studies of this disease. Current manual methods of drusen measurement are laborious and subjective. Our purpose was to expedite clinical research with an accurate, reliable digital method. METHODS: An interactive semi-automated procedure was developed to level the macular background reflectance for the purpose of morphometric analysis of drusen. 12 color fundus photographs of patients with age-related macular degeneration and drusen were analyzed. After digitizing the photographs, the underlying background pattern in the green channel was leveled by an algorithm based on the elliptically concentric geometry of the reflectance in the normal macula: the gray scale values of all structures within defined elliptical boundaries were raised sequentially until a uniform background was obtained. Segmentation of drusen and area measurements in the central and middle subfields (1000 μm and 3000 μm diameters) were performed by uniform thresholds. Two observers using this interactive semi-automated software measured each image digitally. The mean digital measurements were compared to independent stereo fundus gradings by two expert graders (stereo Grader 1 estimated the drusen percentage in each of the 24 regions as falling into one of four standard broad ranges; stereo Grader 2 estimated drusen percentages in 1% to 5% intervals). RESULTS: The mean digital area measurements had a median standard deviation of 1.9%. The mean digital area measurements agreed with stereo Grader 1 in 22/24 cases. The 95% limits of agreement between the mean digital area measurements and the more precise stereo gradings of Grader 2 were -6.4 % to +6.8 % in the central subfield and -6.0 % to +4.5 % in the middle subfield. The mean absolute differences between the digital and stereo gradings 2 were 2.8 +/- 3.4% in the central subfield and 2.2 +/- 2.7% in the middle subfield. CONCLUSIONS: Semi-automated, supervised drusen measurements may be done reproducibly and accurately with adaptations of commercial software. This technique for macular image analysis has potential for use in clinical research

Combined pars plana vitrectomy and Baerveldt glaucoma implant placement for refractory glaucoma

To evaluate outcomes of combined pars plana vitrectomy and Baerveldt glaucoma implant (PPV-BGI) placement for refractory glaucoma