Concordance with urgent referral guidelines in patients presenting with any of six 'alarm' features of possible cancer: a retrospective cohort study using linked primary care records

BACKGROUND: Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral. METHODS: We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals. RESULTS: 48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia. CONCLUSIONS: Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process

Saccadic selection and crowding in visual search:stronger lateral masking leads to shorter search times

We investigated the role of crowding in saccadic selection during visual search. To guide eye movements, often information from the visual periphery is used. Crowding is known to deteriorate the quality of peripheral information. In four search experiments, we studied the role of crowding, by accompanying individual search elements by flankers. Varying the difference between target and flankers allowed us to manipulate crowding strength throughout the stimulus. We found that eye movements are biased toward areas with little crowding for conditions where a target could be discriminated peripherally. Interestingly, for conditions in which the target could not be discriminated peripherally, this bias reversed to areas with strong crowding. This led to shorter search times for a target presented in areas with stronger crowding, compared to a target presented in areas with less crowding. These findings suggest a dual role for crowding in visual search. The presence of flankers similar to the target deteriorates the quality of the peripheral target signal but can also attract eye movements, as more potential targets are present over the area

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordData availability statement: Data may be obtained from a third party and are not publicly available. Routinely collected patient electronic health data was provided by CPRD. Access to data from CPRD is subject to a licence agreement and protocol approval from the Independent Scientific Advisory Committee (ISAC).Background Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral. Methods We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014–2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals. Results 48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18–24 vs 55–64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia. Conclusions Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.Cancer Research U

Performance of neural networks for localizing moving objects with an artificial lateral line

Fish are able to sense water flow velocities relative to their body with their mechanoreceptive lateral line organ. This organ consists of an array of flow detectors distributed along the fish body. Using the excitation of these individual detectors, fish can determine the location of nearby moving objects. Inspired by this sensory modality, it is shown here how neural networks can be used to extract an object's location from simulated excitation patterns, as can be measured along arrays of stationary artificial flow velocity sensors. The applicability, performance and robustness with respect to input noise of different neural network architectures are compared. When trained and tested under high signal to noise conditions (46 dB), the Extreme Learning Machine architecture performs best with a mean Euclidean error of 0.4% of the maximum depth of the field D, which is taken half the length of the sensor array. Under lower signal to noise conditions Echo State Networks, having recurrent connections, enhance the performance while the Multilayer Perceptron is shown to be the most noise robust architecture. Neural network performance decreased when the source moves close to the sensor array or to the sides of the array. For all considered architectures, increasing the number of detectors per array increased localization performance and robustness

Recurrent governance challenges in the implementation and alignment of flood risk management strategies: a review

In Europe increasing flood risks challenge societies to diversify their Flood Risk Management Strategies (FRMSs). Such a diversification implies that actors not only focus on flood defence, but also and simultaneously on flood risk prevention, mitigation, preparation and recovery. There is much literature on the implementation of specific strategies and measures as well as on flood risk governance more generally. What is lacking, though, is a clear overview of the complex set of governance challenges which may result from a diversification and alignment of FRM strategies. This paper aims to address this knowledge gap. It elaborates on potential processes and mechanisms for coordinating the activities and capacities of actors that are involved on different levels and in different sectors of flood risk governance, both concerning the implementation of individual strategies and the coordination of the overall set of strategies. It identifies eight overall coordination mechanisms that have proven to be useful in this respect

Warm-Start AlphaZero Self-Play Search Enhancements

Recently, AlphaZero has achieved landmark results in deep reinforcement learning, by providing a single self-play architecture that learned three different games at super human level. AlphaZero is a large and complicated system with many parameters, and success requires much compute power and fine-tuning. Reproducing results in other games is a challenge, and many researchers are looking for ways to improve results while reducing computational demands. AlphaZero's design is purely based on self-play and makes no use of labeled expert data ordomain specific enhancements; it is designed to learn from scratch. We propose a novel approach to deal with this cold-start problem by employing simple search enhancements at the beginning phase of self-play training, namely Rollout, Rapid Action Value Estimate (RAVE) and dynamically weighted combinations of these with the neural network, and Rolling Horizon Evolutionary Algorithms (RHEA). Our experiments indicate that most of these enhancements improve the performance of their baseline player in three different (small) board games, with especially RAVE based variants playing strongly

Predictors of early recurrence after resection of colorectal liver metastases

BACKGROUND: Early recurrence after resection of colorectal liver metastases (CLM) is common. Patients at risk of early recurrence may be candidates for enhanced preoperative staging and/or earlier postoperative imaging. The aim of this study was to determine if there are any risk factors that specifically predict early liver-only and systemic recurrence. METHODS: Retrospective analysis of prospective database of patients undergoing liver resection (LR) for CLM from 2004 to 2006 was undertaken. Early recurrence was defined as occurring within 18 months of LR. Patients were classified into three groups: early liver-only recurrence, early systemic recurrence and recurrence-free. Preoperative factors were compared between patients with and without early recurrence. RESULTS: Two hundred and forty-three consecutive patients underwent LR for CLM. Twenty-seven patients (11%) developed early liver-only recurrence. Dukes C stage and male sex were significantly associated with early liver-only recurrence (P < 0.05). Sixty-six patients (27%) developed early systemic recurrence. Tumour size ≥3.6 cm and tumour number (>2) were significantly associated with early systemic recurrence (P < 0.001). CONCLUSIONS: It is possible to stratify patients according to the risk of early liver-only or systemic recurrence after resection of CLM. High-risk patients may be candidates for preoperative MRI and/or computed tomography-positron emission tomography (CT-PET) scan and should receive intensive postoperative surveillance

A mixed-methods study to define Textbook Outcome for the treatment of patients with uncomplicated symptomatic gallstone disease with hospital variation analyses in Dutch trial data

Background: International consensus on the ideal outcome for treatment of uncomplicated symptomatic gallstone disease is absent. This mixed-method study defined a Textbook Outcome (TO) for this large group of patients. Methods: First, expert meetings were organised with stakeholders to design the survey and identify possible outcomes. To reach consensus, results from expert meetings were converted in a survey for clinicians and for patients. During the final expert meeting, clinicians and patients discussed survey outcomes and a definitive TO was formulated. Subsequently, TO-rate and hospital variation were analysed in Dutch hospital data from patients with uncomplicated gallstone disease. Results: First expert meetings returned 32 outcomes. Outcomes were distributed in a survey among 830 clinicians from 81 countries and 645 Dutch patients. Consensus-based TO was defined as no more biliary colic, no biliary and surgical complications, and the absence or reduction of abdominal pain. Analysis of individual patient data showed that TO was achieved in 64.2% (1002/1561). Adjusted-TO rates showed modest variation between hospitals (56.6-74.9%). Conclusion: TO for treatment of uncomplicated gallstone disease was defined as no more biliary colic, no biliary and surgical complications, and absence or reduction of abdominal pain.TO may optimise consistent outcome reporting in care and guidelines for treating uncomplicated gallstone disease