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Background Collaborative care can effectively support the treatment of depression in people with multiple long-term physical conditions or mental-physical multimorbidity, but long term benefits and costs are unknown. AimsTo explore the long-term effectiveness and cost-effectiveness of collaborative care in people with mental-physical multimorbidity.MethodA cluster randomised trial of 36 general practices in England compared collaborative care with usual care (standard management by primary care staff) for people with depression and comorbid diabetes and/or coronary heart disease. Collaborative care included up to eight sessions of low-intensity psychological therapy with lifestyle/disease management advice (integrated physical and mental health care). Depression symptoms were measured using the symptom checklist-13 depression scale (SCL-D13) 24 months after baseline. The EQ-5D-5L was used to capture health status and calculate quality adjusted life years (QALYs) for the economic evaluation from the perspective of the National Health Service (NHS) in England.Results191 participants were allocated to collaborative care and 196 to usual care. At 24-months the mean SCL-D13 score was 0.27 (95% CI -0.48, -0.06) lower in participants in the collaborative care arm. Collaborative care was also associated with a QALY gain of 0.14 (95% CI 0.06, 0.21); the cost per additional QALY gained was £13,069. There is a 75% probability that collaborative care is cost-effective at a threshold of £20,000/QALY.ConclusionsIntegrated collaborative care effectively reduces depression over the long term and can improve physical functioning. Collaborative care is potentially cost-effective over the long-term at internationally accepted willingness to pay thresholds.

In conventional retinal region detection methods for optical coherence tomography (OCT) images, many parameters need to be set manually, which is often detrimental to their generalizability. We present a scheme to detect retinal regions based on fully convolutional networks (FCN) for automatic diagnosis of abnormal maculae in OCT images. The FCN model is trained on 900 labeled age-related macular degeneration (AMD), diabetic macular edema (DME) and normal (NOR) OCT images. Its segmentation accuracy is validated and its effectiveness in recognizing abnormal maculae in OCT images is tested and compared with traditional methods, by using the spatial pyramid matching based on sparse coding (ScSPM) classifier and Inception V3 classifier on two datasets: Duke dataset and our clinic dataset. In our clinic dataset, we randomly selected half of the B-scans of each class (300 AMD, 300 DME, and 300 NOR) for training classifier and the rest (300 AMD, 300 DME, and 300 NOR) for testing with 10 repetitions. Average accuracy, sensitivity, and specificity of 98.69%, 98.03%, and 99.01% are obtained by using ScSPM classifier, and those of 99.69%, 99.53%, and 99.77% are obtained by using Inception V3 classifier. These two classification algorithms achieve 100% classification accuracy when directly applied to Duke dataset, where all the 45 OCT volumes are used as test set. Finally, FCN model with or without flattening and cropping and its influence on classification performance are discussed.

Objective: To determine the surgery-related and hardware-related complications of deep-brain stimulation (DBS) at a single centre. Methods: 262 consecutive patients (472 electrodes) operated for DBS in our department from February 1996 to March 2003 were retrospectively analysed to document acute adverse events (30 days postoperatively). The data of 180 of these patients were additionally revised to assess long-term complications (352 electrodes, mean follow-up 36.3 (SD 20.8) months). Results: The frequency of minor intraoperative complications was 4.2% (11/262 patients). Transient (0.2%) or permanent (0.4%) neurological deficits, and in one case asymptomatic intracranial haemorrhage (0.2%), were registered as acute severe adverse events caused by surgery. Among minor acute complications were subcutaneous bleeding along the extension wire (1.2%) and haematoma at the pulse generator implantation site (1.2%). Skin infection caused by the implanted material was registered in 15 of 262 patients (5.7%). The infection rate during the first observation period was 1.5% (4/262 patients) and the late infection rate was 6.1% (11/180 patients). Partial or complete removal of the stimulation system was necessitated in 12 of 262 (4.6%) patients because of skin infection. During the long-term observation period, hardware-related problems were registered in 25 of 180 (13.9%) patients. Conclusions: Stereotactic implantation of electrodes for DBS, if performed with multiplanar three-dimensional imaging and advanced treatment planning software, is a safe procedure with no mortality and low morbidity. The main causes for the patients’ prolonged hospital stay and repeated surgery were wound infections and hardware-related complications.

Background: The role of admission blood glucose level on the prognosis of patients with intracerebral haemorrhage has not been elucidated. Objective: To examine this association on the basis of an epidemiologically representative patient material. Methods: 249 500 people living in the catchment area of the Central Hospital of Central Finland. The diagnosis of ICH was established if verified by cranial computed tomography (CT) or autopsy. Results: Of the 416 patients who fulfilled the diagnostic criteria, 30 died before admission and 386 were admitted to the Central Hospital. All 329 patients (290 nondiabetics and 39 diabetics) with both admission blood glucose and cranial CT data were included in the study. The mean blood glucose level was 10.6 mmol/l for nondiabetics who died on the day of onset, 8.6 mmol/l for those dying during days 1 to 28, and 6.8 mmol/l for the 28 day survivors. The corresponding figures for diabetics were 13.9 mmol/l, 12.5 mmol/l, and 9.3 mmol/l. In both nondiabetics and diabetics, patients who died had significantly higher mean glucose than the 28 day survivors (p

Objectives: Ischaemic stroke is a frequent heterogeneous multifactorial disease that is affected by a number of genetic mutations and environmental factors. We hypothesised the clinical importance of the interactions between common, unfavourable genetic mutations and clinical risk factors in the development of ischaemic stroke. Methods: The Factor V Leiden G1691A (Leiden V), the prothrombin G20210A, the methylenetetrahydrofolate reductase C677T (MTHFR C677T) mutations, the angiotensin converting enzyme I/D (ACE I/D), and apolipoprotein allele e4 (APO e4) genotypes were examined by the polymerase chain reaction (PCR) technique in 867 ischaemic stroke patients and 743 healthy controls. Logistic regression models were used to estimate the roles of the co-occurrences of the clinical risk factors and common genetic mutations in ischaemic stroke. Results: The Leiden V mutation in combination with hypertension or diabetes mellitus increased the risk of ischaemic stroke. We found synergistic effects between the ACE D/D and MTHFR 677TT genotypes and drinking or smoking. The presence of the APO e4 greatly facilitated the unfavourable effects of hypertension, diabetes mellitus, smoking, or drinking on the incidence of ischaemic stroke. Conclusion: In certain combinations, pairing of common unfavourable genetic factors, which alone confer only minor or non-significant risk, with clinical risk factors can greatly increase the susceptibility to ischaemic stroke.

Background: Secondary prevention of stroke has been shown to dramatically reduce recurrence and has been described as suboptimal. Objective: To analyse patients’ awareness and knowledge about cerebrovascular risk factors (CVRF) and their influence on CVRF control. Methods: Patients (n = 164) who were attending a stroke outpatient clinic for the first time after hospital discharge (3 months) for a first stroke were asked to answer a short questionnaire including questions on awareness and knowledge of CVRF, visits to a CVRF specialist, number of visits to a general practitioner, adherence to drug treatments, cigarette smoking and cessation. Results: CVRF were spontaneously mentioned as relevant for their stroke by only13% of patients. A specialist was visited by only one-third of the patients and a general practitioner was not visited at all by 27% of the patients since their stroke. Awareness was inversely correlated with older age and good recovery. More than half of the patients had high blood pressure (≥140 mmHg for systolic and ≥90 mmHg for diastolic values) at the time of follow-up. These high values were correlated with poor awareness. Appropriate secondary stroke prevention measures were not received by one-fourth of the patients; this was also correlated with poor awareness. Conclusions: CVRF control is not optimal and is at least partially related to patients’ awareness and knowledge and suboptimal medical follow-up. Older patients and patients with excellent recovery are at particular risk for poor awareness and CVRF control.

There have been considerable advances in the past few years in our understanding of how chronic kidney disease (CKD) predisposes to acute kidney injury (AKI) and vice versa. This review shows, however, that few studies have focused on the elderly or conducted stratified analysis by age. It does appear that elderly patients with estimated glomerular filtration rate (eGFR) 45–59 ml/min/1.73 m2 are at higher risk for AKI compared with their counterparts with eGFR >60 ml/min/1.73 m2. This is a similar relationship to that seen in younger patients, although effect size appears smaller. As the incidence of AKI has been increasing over the past several years, the proportion of elderly patients surviving after AKI has also been increasing. Since AKI heightens the risk for the development and acceleration of CKD, this implies significant public health concerns with regard to the absolute number of elderly persons developing incident CKD.