Aim: To assess the efficacy of automated ''disease/no disease'' grading for diabetic retinopathy within a systematic screening programme. Methods: Anonymised images were obtained from consecutive patients attending a regional primary care based diabetic retinopathy screening programme. A training set of 1067 images was used to develop automated grading algorithms. The final software was tested using a separate set of 14 406 images from 6722 patients. The sensitivity and specificity of manual and automated systems operating as ''disease/no disease'' graders (detecting poor quality images and any diabetic retinopathy) were determined relative to a clinical reference standard. Results: The reference standard classified 8.2% of the patients as having ungradeable images (technical failures) and 62.5% as having no retinopathy. Detection of technical failures or any retinopathy was achieved by manual grading with 86.5% sensitivity (95% confidence interval 85.1 to 87.8) and 95.3% specificity (94.6 to 95.9) and by automated grading with 90.5% sensitivity (89.3 to 91.6) and 67.4% specificity (66.0 to 68.8). Manual and automated grading detected 99.1% and 97.9%, respectively, of patients with referable or observable retinopathy/maculopathy. Manual and automated grading detected 95.7% and 99.

Ecological dynamics characterizes adaptive behavior as an emergent, self-organizing property of interpersonal interactions in complex social systems. The authors conceptualize and investigate constraints on dynamics of decisions and actions in the multiagent system of team sports. They studied coadaptive interpersonal dynamics in rugby union to model potential control parameter and collective variable relations in attacker-defender dyads. A videogrammetry analysis revealed how some agents generated fluctuations by adapting displacement velocity to create phase transitions and destabilize dyadic subsystems near the try line. Agent interpersonal dynamics exhibited characteristics of chaotic attractors and informational constraints of rugby union boxed dyadic systems into a low dimensional attractor. Data suggests that decisions and actions of agents in sports teams may be characterized as emergent, self-organizing properties, governed by laws of dynamical systems at the ecological scale. Further research needs to generalize this conceptual model of adaptive behavior in performance to other multiagent populations.

Aims: National screening programmes for diabetic retinopathy using digital photography and multi-level manual grading systems are currently being implemented in the UK. Here, we assess the cost-effectiveness of replacing first level manual grading in the National Screening Programme in Scotland with an automated system developed to assess image quality and detect the presence of any retinopathy. Methods: A decision tree model was developed and populated using sensitivity/specificity and cost data based on a study of 6722 patients in the Grampian region. Costs to the NHS, and the number of appropriate screening outcomes and true referable cases detected in 1 year were assessed. Results: For the diabetic population of Scotland (approximately 160 000), with prevalence of referable retinopathy at 4% (6400 true cases), the automated strategy would be expected to identify 5560 cases (86.9%) and the manual strategy 5610 cases (87.7%). However, the automated system led to savings in grading and quality assurance costs to the NHS of £201 600 per year. The additional cost per additional referable case detected (manual vs automated) totalled £4088 and the additional cost per additional appropriate screening outcome (manual vs automated) was £1990. Conclusions: Given that automated grading is less costly and of similar effectiveness, it is likely to be considered a cost-effective alternative to manual grading. S ystematic screening for diabetic retinopathy has been identified as a cost-effective use of health service resources.1-4 The Health Technology Board for Scotland recommended a national screening programme using digital photography and a multi-level manual grading system (fig 1), which is currently being implemented in Scotland.5 Similar programmes are also underway in England, Wales and Northern Ireland.With 161 946 individuals recorded on diabetes registers in Scotland, 6 manual grading is a resource-intensive activity. Current policy is implemented by capturing digital images at local screening centres, which are then sent electronically to one of nine regional grading centres. However, a system of automated grading could provide cost savings to the NHS. Our research group recently developed and evaluated an automated grading system that can assess digital retinal images for quality 8 and the presence of retinopathy. 9This system could thereby potentially replace manual level 1 grading. The purpose of this paper is to assess the costeffectiveness of replacing this manual disease/no disease grading with the automated system, in the context of the three-level grading system used in Scotland (fig 1). A decision tree model was developed to compare NHS grading costs and screening outcomes over a one-year period for these two alternative strategies.

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The authors examined whether, similar to collective agent behaviors in complex, biological systems (e.g., schools of fish and colonies of ants), performers in team sports displayed functional coordination tendencies, based on local interaction rules during performance. To investigate this issue, they used videogrammetry and digitizing procedures to observe interpersonal interactions in common 4 versus 2 + 2 subphases of the team sport of rugby union, involving 16 participants aged between 16 and 17 years of age. They observed pattern-forming dynamics in attacking subunits (n = 4 players) attempting to penetrate 2 defensive lines (n = 2 players in each). Data showed that within each attacking subunit, the 4 players displayed emergent functional grouping tendencies that differed between the 2 defensive lines. Results confirmed that grouping tendencies in attacking subunits of team games are sensitive to different task constraints, such as relative positioning to nearest defenders. It was concluded that running correlations were particularly useful for measuring the level of interpersonal coordination in functional grouping tendencies within attacking subunits.