Fractures of the distal radius are a common injury, affecting younger patients typically through sporting and road traffic accidents, and older osteoporotic patients often due to falls from a standing height. The potential consequences of these fractures are rare but can be catastrophic, with risk of lasting impairment to the patient. This thesis aimed to examine (1) how surgeons decide which patients with a dorsally displaced distal radius fracture need an operation, (2) what is the evidence basis for the two most commonly performed operations for patients with this fracture in the UK, (3) Are electronic and manual goniometers and dynamometers able to reliably assess wrist function in patients and healthy volunteers, (4) Does the patients’ functional outcome correspond with their radiological outcome, and (5) what is the long-term outcome of these patients. A number of research methods were employed to achieve these objectives. A mixed methods approach was deployed, involving observations of nineteen patient/surgeon consultations followed by mini interviews with the consulting surgeons, to gain an insight into which patients with a dorsally displaced distal radius fracture receive an operation in practice. In-depth interviews were undertaken with 14 Orthopaedic surgeons to explore the patient/surgeon/context related factors that contribute to their decision-making.

In this thesis, the development of an anatomically meaningful musculoskeletal model of the human foot with specific application to the Achilles tendon is presented. An in vivo experimental method of obtaining parameter values for the mechanical characteristics of the Achilles tendon and the gastrocnemius muscle is presented incorporating a Hill-type muscle model. The incentive for this work has been to enable the prediction of movement with regard to Achilles tendon motion of healthy volunteers, in order to then compare it with the movement of a pathologic gait and help in preventing Achilles tendon injuries. There are relatively few mathematical models that focus on the characterisation of the human Achilles tendon as part of a muscle-tendon unit in the literature. The mechanical properties of the Achilles tendon and the muscles connected to the tendon are usually calculated or predicted from muscle-tendon models such as the Hill-type muscle models. A significant issue in model based movement studies is that the parameter values in Hill-type muscle models are not determined by data obtained from in vivo experiments, but from data obtained from cadaveric specimens. This results in a complication when those predictive models are used to generate realistic predictions of human movement dynamics. In this study, a model of the Achilles tendon-gastrocnemius muscle is developed, incorporating assumptions regarding the mechanical properties of the muscle fibres and the tendinous tissue in series. Ultrasound images of volunteers, direct measurements and additional mathematical calculations are used to determine the initial lengths of the muscle-tendon complex as well as the final lengths during specific movements of the foot and the leg to parameterise the model. Ground reaction forces, forces on specific joints and moments and angles for the ankle are obtained from a 3D motion capture system. A novel experimental marker placement for the Achilles tendon is developed and generated in the 3D motion capture system. Movement dynamics of the foot are described using Newton’s laws, the principle of superposition and a technique known as the method of sections. Structural identifiability analyses of the muscle model ensured that values for the model parameters could be uniquely determined from perfect noise free data. Simulated model dynamics are fitted to measured movements of the foot. Model values are obtained on an individual subject basis. Model validation is performed from the experimental data captured for each volunteer and from reconstruction of the movements of specific trajectories of the joints, muscles and tendons involved in those movements. The major output of this thesis is a validated model of the Achilles tendon-gastrocnemius muscle that gives specific parameters for any individual studied and provides an integral component in the ultimate creation of a dynamic model of the human body. A new approach that was introduced in this thesis was the coupling of the Achilles tendon force from the musculoskeletal model to the muscle-tendon model and the non-linearity approach studied through a motion capture system. This approach and the new Achilles tendon marker placement is to the best of the author's knowledge, novel in the field of muscle-tendon research.

The use of anaesthetic rooms as the standard site of anaesthetic induction in the United Kingdom has been criticised and debated over several decades, and yet practice has remained largely unchanged. The impacts of the anaesthetic room on cost, efficiency, patient experience, and patient safety are either conflicting or unknown. This research utilised a systems approach to evaluate the efficacy of anaesthetic rooms and make recommendations for the improvement of both the design and practice of surgical suites in the UK. The study incorporated mixed methods to investigate the qualitative and quantitative benefits of anaesthetic rooms for all stakeholders. A survey of consultant anaesthetists investigated current practice and attitudes regarding the use of anaesthetic rooms and the importance of various types of ‘evidence’ for affecting change in practice. This study revealed the wide diversity of current anaesthetic practice and the factors that influence the selection of the site of induction. A second study, which used interviews with anaesthetists and perioperative managers explored the decision making surrounding the continued use of anaesthetic rooms and the relationship between design and practice. Factors influencing the perpetuation of anaesthetic rooms were shown to exist systemically across individual, organisational, and external levels. Willingness to change and the relevance of evidence for decision making is discussed. In a third study, a modified participatory design Delphi was used to investigate the decision making priorities of multiple anaesthetic room stakeholders to reach a consensus for the design of theatres in a new fictional hospital. The novel Delphi technique presented conflicting research findings to participants in order to require them to evaluate and come to agreement regarding the incorporation of anaesthetic rooms. A critique of this method is presented along with suggestions for future application. A cost-benefit analysis of anaesthetic rooms was then conducted in one NHS Trust. This was supplemented by ethnographic observations of its surgical suites to provide context to the historical timing data gathered retrospectively for financial and productive evaluations. The cost-benefit analysis revealed that there are missed opportunities associated with anaesthetic rooms, as downtime and delay mean that the potential financial gain and return on investment of anaesthetic rooms cannot be realised. An investigation of patient experience with surgical anaesthesia was conducted through a multi-part questionnaire evaluating patients’ expectations, anxiety, and satisfaction with their anaesthetic care. The study focused on the impact of the site of induction on patient experience and revealed that anaesthetic rooms do not appear to have a significant effect on patient anxiety and satisfaction. Opportunities for improving patient experience were identified, with the majority of these being unrelated to the site of induction of anaesthesia. Through a number of separate studies, this research provides a complete evaluation of anaesthetic rooms. It has identified the contradictions between stated priorities for anaesthetic rooms that stakeholders report and the actual choices that they make for the use and design of surgical suites. The human factors methods and systems approach that has been taken to this thesis has shown that it is a valuable way of investigating deeply embedded practices in healthcare. In addition, this research has set forth a novel method for integrating four dominant paradigms of healthcare improvement. The integration of participatory ergonomics and evidence-based practice may provide a useful method for reaching consensus of contentious issues, aligning systems design with individual and organisational priorities, and encouraging evidence evaluation as a part of the decision making process.

Blunt thoracic trauma followed by aortic rupture (BTAR), is a unique injury to the aorta (which is the main output of blood from the heart). BTAR could be explained as a compression of the rib cage, (produced by a trauma to the chest), which affects the internal organs and injure the aorta in a specific spot. This thesis work will analyze the mechanism of this injury. A hypothesis has been developed to explain the mechanism of BTAR, if the mechanism is known an external device could be designed to prevent it. In this thesis, numerical simulations will be performed as a way to recreate BTAR and prove that the mechanism is not due to only one assumption, instead of being a complex trauma, it triggers different mechanisms. The study starts with an explanation of the trauma and a rough rationale for the mechanisms proposed in this work. Literature has been reviewed marking the starting point for this research. This first chapter concludes with the methodology that will take place and how will be studied throughout the chapters. A validation of the mechanical properties and material model is performed on the first simulation of the second chapter. Once the mechanical properties and material model have been validated, a simulation to prove the first mechanism proposed is performed. A scar at the inner aspect of the aortic isthmus will generate a concentration of stress, if the tissue is subjected to an increment of pressure. A simulation of a bubble inflation test with the insertion of a patch, which varies in diameter and stiffness is performed on this second chapter, finding an intensity factor of 1.53, 1.43 and 1.66 in diameters of 1 mm, 2 mm and 3 mm respectively, these values represents a concentration of stress and strain at the border of the patch and the aorta. This is shown in the second chapter which validates the mechanism that a scar at the aortic isthmus, due to the closure of the Ductus Arteriosus, will weaken the aortic wall. The third chapter compares two ways of geometry generation. With an increment of internal pressure first in a high pressure range having the highest error before 150 kPa, hence a normal physiological pressure range was simulated and a dramatic increase of errors started at 18.7 kPa, the outermost layer of the aorta shows the highest values. To achieve these a 10 mm specimen from the descending aorta was generated by two methods; a geometric approximated model designed with a Computational Assisted Design software, and a segmented model, which was designed by segmenting 3D medical images. The simulation of the third chapter demonstrates that the aorta changes its cross section when it is subjected to hypertension values, therefore the fourth chapter tests the architecture of the thoracic aorta when is subjected to a pressure range which includes the different levels of hypertension. For this analysis the aorta is divided into four different sections, ascending aorta, descending aorta, external aortic isthmus and internal aortic isthmus. The internal part of the aortic isthmus, at the innermost layer, shows higher stress values with less displacement. On the displacement analysis, the descending aorta shows a value at 18.7 kPa of 0.6 x 10^-3 m and the internal part of the aortic isthmus of 0.2 x 10^-3 m, for the stress values the descending aorta shows a value of 0.4 MPa and the internal part of the aortic isthmus of 0.35 MPa. The last chapter employs the finite element method with a fluid solid interaction, and a smooth particle hydrodynamics formulation for the blood. This simulation uses a geometric approximation of the chest including the sternum and spine, heart and a three layered aorta. This model is subjected to different values of speed, introduced at the sternum, which will compress the heart recreating a blunt thoracic trauma. For this analysis, the aorta is also divided into the same zones as in the fourth chapter. It is shown that at a velocity of 20 m x s^-1 values of pressure higher than 270 kPa (rupture pressure validated on the second chapter) and stress values higher than 1819.2 kPa experimental minimum ultimate stress [Pearson et. al., 2008] (tested and validated on the second chapter) are located at the inner aspect of the aortic isthmus of the intima layer. When the four results chapters are analysed together, it can be seen that the architecture of the aorta changes during hypertension values, and the concentration of stress and strain changes from the adventitia layer to the Intima layer, due to the change of the cross section geometry. This thesis concludes that a mechanism of a BTAR is too complex to explain only by one mechanism, therefore a conjunction of numerical simulations test and validate a multivariate hypothesis proposed. The limitations of this thesis are also explored in the final chapter, with a proposal of a future work, to keep track with the research, and could design an external device to prevent people from dying in car crashes due to BTAR.

Arteriovenous fistula (AVF) are widely considered to be the optimal form of vascular access for haemodialysis incurring fewer complications, superior patency, better dialysis quality and a lower mortality than tunnelled central venous catheters (TCVCs). The use of TCVCs is associated with a six-fold increase in the risk of systemic sepsis, long-term morbidity from central vein stenosis and a higher risk of cardiovascular and all-cause mortality compared to AVF. Despite the relative success of strategies such as “Fistula First” and the best practice target in England and Wales (with simultaneous improvement in prevalent autologous access use) there has been no associated improvement in incident vascular access rates. The importance of “getting it right from the start” cannot be overemphasized. Patients who start dialysis via a line are more likely to remain with a line. Data from the UK Renal Registry indicate that 59.8% of patients starting on a TCVC remain dialysing via a TCVC at 3 months and >40% still have their TCVC after 1 year. The legacy of poor early vascular access decision-making remains with the patient throughout their life on dialysis. This thesis sought to evaluate methods for improving vascular access within the incident patient cohort. A multifaceted approach was taken to address several key themes: 1. TCVC complications and central vein stenosis: avoiding problems for the future. 2. Predicting maturation in incident dialysis patients. 3. Promoting maturation: strategies to optimise maturation. 4. Right access, right patient, right time: individualised, patient-centred care. 5. ‘Crashlanders’: managing patients who present without prior warning. The emphasis of this work was directed towards finding pragmatic, patient-focussed solutions to clinically relevant problems. The dogma of “Fistula First at all costs” is challenged.

This research focuses on the development of optical fibre sensors that can be applied during critical care. The sensors developed are: (i) an optical fibre humidity sensor based on the deposition of a hygroscopic film onto the distal tip of the fibre and forming a Fabry-Pêrot cavity; (ii) chemical functionalization of U-shaped fibres and Long Period Gratings (LPGs). Fibre Bragg Gratings (FBGs) are only used for temperature monitoring in this work. The current trends in a new generation of humidity sensors suggest that electronic-based technologies could be soon replaced by photonic sensors due to better response times. Optical fibre technology has been considered as a promising platform for providing engineering solutions to unmet clinical needs. For example, anaesthetized patients are transferred from the induction room to the MRI room and taken back, with the need for continuous monitoring of vital signs such as respiration, but some technologies lack compatibility with MRI fields. In the operating room, patients are under anaesthesia, intubated and mechanically ventilated, but some under-humidification or over-humidification of the ventilation air causes secondary effects. Anaesthesiologists rely on total intravenous anaesthesia (TIVA) and monitoring of vital signs as indicators of unconsciousness; current investigations have shown that there is a need to measure the concentration of propofol in real time directly from the blood or breath of patients. Similarly, patients in the intensive care unit (ICU) after surgery require continuous monitoring of diverse biochemical parameters. In this research, the application of optical fibre sensors is demonstrated as an engineering solution for some of these clinical challenges. The simultaneous measurement of humidity and temperature with an optical fibre sensor, a biosensor for propofol detection and another for protein detection were fabricated and demonstrated in this work. The sensitivity, response time and hysteresis of a novel optical fibre humidity sensor has been investigated over a humidity range of 5% Relative Humidity (RH) to 95% RH using a controlled bench-top set-up. The optical fibre humidity sensor proposed has a very simple and low cost porous structured sensing element obtained with poly(allylamine hydrochloride) (PAH) and silica (SiO2) using the layer-by-layer (LbL) fabrication method. The fast response of the sensor (1.13 ± 0.3 s) enabled changes in humidity in individual breaths to be resolved. After calibration, the performance of the sensor was evaluated in the breathing circuit of a mechanical ventilator and respiratory equipment where its faster response allowed monitoring of breath to breath humidity levels during different modes of ventilation. It also has the capability to provide absolute humidity (AH) measurements when an FBG is included for simultaneous temperature measurements. An LPG sensor anchored with SiO2 core and gold (Au) shell nanoparticles has been investigated as a biosensing platform for protein detection. The well-known protein interaction between biotin and streptavidin (SV) was used as a proof of concept. The proposed sensor presented Langmuir adsorption to SV concentrations with a limit of detection (LoD) down to 15.13 nM and a lowest detected concentration of 2.5 nM. In addition, U-shaped fibres and LPGs functionalized with host-guest imprinted TiO2 thin films were used to test propofol detection in aqueous solutions. These sensors also presented Langmuir adsorption in the mili-molar range in aqueous solutions and a lowest detected concentration of 0.65 uM. Detection limits of propofol were improved with the addition of mesoporous silica nanoparticles (MSNs) and inorganic molecular imprinting to allow detection down to 99 nM in aqueous solution and 30 ppb in gaseous phase. In conclusion, this research has successfully demonstrated the use of novel optical fibre sensors in laboratory and real conditions through embedding the developed sensors in critical care equipment usually used during anaesthesia.

Osteoarthritis of the knee is a common condition, affecting more than 10% of the population aged over 55 years. It can lead to pain, functional loss, and a reduction in the quality of life. Total knee replacement is a common procedure for those with severe osteoarthritis with over 90,000 procedures performed each year in the UK; however, around 20% of patients are dissatisfied with the outcome. How to identify these patients pre-operatively is a research priority, as set out by the British Orthopaedic Association, Arthritis Research U.K., and the National Institute for Health and Care Excellence. The effect such an advance would have on patients’ decision-making is not known. Therefore, in this thesis I set out to understand the factors important to patients when contemplating a knee replacement, how an outcome prediction tool could affect that process, and then go on to develop an prognostic model for use in patients considering a total knee replacement. I first performed a systematic review of factors that influence patient’s decision-making; I then describe two qualitative projects, the first developed a model of decision-making, the second investigated how providing predictions of outcome could affect expectations and decision-making. This information, combined with a systematic review of the factors that affect outcome in knee replacements, allowed me to develop a multicentre cohort study designed to generate a prognostic model. This study recruited 600 patients, and the linear regression model accounts for 36% of the variability in outcome – more than any previous study. This thesis provides a better understanding of patients’ decision-making, which should facilitate doctor-patient communication. I describe a model that can predict more variability in outcome than any previous models. The usefulness of the model in individual prediction and potential future areas of study include how more variability could be incorporated, how to develop such a model into a prediction tool, and other approaches to addressing poor outcomes after total knee replacement.

Introduction One option for repair of abdominal aortic aneurysms with inadequate length of infrarenal neck is fenestrated Endovascular Aneurysm Repair. Significant complications may be caused by stent-graft migration and component distraction which are both resisted by fixation force and provoked by haemodynamic distraction force. The hypotheses tested in this thesis are that larger angulation of vessels is associated with greater distraction force and that greater distraction force is associated with higher incidence of migration and component distraction. Method Interobserver variation of a new method of angle measurement was compared with the standard method currently in use in our unit. Computer models of complete fenestrated stent-grafts and their individual components (proximal body, distal body and limb extensions) were then constructed based on the postoperative computed tomography scans of 54 patients. Computational Fluid Dynamic analysis in steady state was used to quantify the distraction force acting on each device. Blood pressure was kept constant at 160mmHg and the impact of morphological features upon distraction force was assessed. To test the second hypothesis, patient-specific blood pressures were used to obtain in situ distraction forces that were then related to the incidence of migration and component distraction. Results There were no significant differences between the old and new methods of angle measurement (p=.723, WSR). Inlet cross-sectional area (XSA) exhibited a strong, positive correlation with total RDF in complete stent-grafts, proximal body and distal body components. Outlet angulation ≥45° was significantly associated with greater total RDF in complete stent-grafts and limb extension components (Median total RDF in complete stent-grafts with angle < 45° = 2.6N vs 6.2N in those ≥45°, p < .001. Limb extensions: 1.4N vs 2.1N, p = .004, MWU). There was no significant difference between total RDF acting on the proximal or distal bodies that underwent migration or component distraction versus those that did not. Limb extensions that were observed to migrate were exposed to significantly greater total RDF compared to those that did not migrate (Median total RDF 2.9N, range 2.7-6.3N versus 1.6N, range 0.4-3.8N, p = .003, MWU). Conclusions For a given blood pressure XSA was the most important morphological determinant of total RDF. Outlet angulation of complete stent-grafts and limb extensions was associated with significantly greater total RDF. In limb extensions, greater distraction force was significantly associated with migration. The results suggest caution when planning distal seal in ectatic iliac vessels.

Pancreaticoduodenectomy with or without adjuvant chemotherapy remains the only modality of possible cure in patients with cancer involving the head of the pancreas and the periampullary region. While mortality rates after pancreaticoduodenectomy have improved considerably over the course of the last century, morbidity remains high. Patient selection is of paramount importance in ensuring that major surgery is offered to individuals who will most benefit from a pancreaticoduodenectomy. Moreover, identifying preoperative risk factors provides potential targets for prehabilitation and optimisation of the patient's physiology before undertaking surgery. In addition to this, early identification of patients who are likely to develop postoperative complications allows for better allocation of critical care resources and more aggressive management high risk patients. Cardiopulmonary exercise testing is becoming an increasingly popular tool in the preoperative risk assessment of the surgical patient. However, very little work has been done to investigate the role of cardiopulmonary exercise testing in predicting complications after pancreaticoduodenectomy. The impact of jaundice, systemic inflammation and other preoperative clinicopathological characteristics on cardiopulmonary exercise physiology has not been studied in detail before in this cohort of patients. The overall aim of the thesis was to examine the relationships between preoperative clinico-pathological characteristics including cardiopulmonary exercise physiology, obstructive jaundice, body composition and systemic inflammation and complications and the post-surgical systemic inflammatory response in patients undergoing pancreaticoduodenectomy. Chapter 1 reviews the existing literature on preoperative cardiopulmonary exercise testing, the impact of obstructive jaundice, perioperative systemic inflammation and the importance of body composition in determining outcomes in patients undergoing major surgery with particular reference to pancreatic surgery. Chapter 2 reports on the role of cardiopulmonary exercise testing in predicting postoperative complications after pancreaticoduodenectomy. The results demonstrate that patients with V˙O2AT less than 10 ml/kg/min are more likely to develop a postoperative pancreatic fistula, stay longer in hospital and less likely to receive adjuvant therapy. These results emphasise the importance of aerobic fitness to recover from the operative stress of major surgery without significant morbidity. Cardiopulmonary exercise testing may prove useful in selecting patients for intensive prehabilitation programmes as well as for other optimisation measures to prepare them for major surgery. Chapter 3 evaluates the relationship between cardiopulmonary exercise physiology and other clinicopathological characteristics of the patient. A detailed analysis of cardiopulmonary exercise test parameters in jaundiced versus non-jaundiced patients demonstrates that obstructive jaundice does not impair cardiopulmonary exercise physiology. This further supports emerging evidence in contemporary literature that jaundiced patients can proceed directly to surgery without preoperative biliary drainage. The results of this study also show an interesting inverse relationship between body mass index and anaerobic threshold which is analysed in more detail in Chapter 4. Chapter 4 examines the relationship between preoperative cardiopulmonary exercise physiology and body composition in depth. All parameters measured at cardiopulmonary exercise test are compared against body composition and body mass index. The results of this chapter report that the current method of reporting V˙O2, both at peak exercise and anaerobic threshold, is biased against obese subjects and advises caution in the interpretation of cardiopulmonary exercise test results in patients with a high BMI. This is particularly important as current evidence in literature suggests that postoperative outcomes in obese subjects are comparable to non-obese subjects while cardiopulmonary exercise test results are also abnormally low in this very same cohort of patients. Chapter 5 analyses the relationship between preoperative clinico-pathological characteristics including systemic inflammation and the magnitude of the postoperative systemic inflammatory response. Obstructive jaundice appears to have an immunosuppressive effect while elevated preoperative CRP and hypoalbuminemia appear to have opposite effects with hypoalbuminemia resulting in a lower response while elevated CRP in the absence of hypoalbuminemia resulted in a greater postoperative systemic inflammatory response. Chapter 6 evaluates the role of the early postoperative systemic inflammatory response in predicting complications after pancreaticoduodenectomy and aims to establish clinically relevant thresholds for C-Reactive Protein for the prediction of complications. The results of this chapter demonstrate that CRP levels as early as the second postoperative day are associated with complications. While post-operative CRP was useful in the prediction of infective complications, this was the case only in patients who did not develop a post-operative pancreatic fistula. The predictive ability of inflammatory markers for infectious complications was blunted in patients with a pancreatic fistula. Chapter 7 summarises the findings of this thesis, their place in current literature and future directions. The results of this thesis add to the current knowledge regarding the complex pathophysiological abnormalities in patients undergoing pancreaticoduodenectomy, with specific emphasis on the interaction between cardiopulmonary exercise physiology, obstructive jaundice, systemic inflammation and postoperative outcomes. The work presented in this thesis lays the foundations for further studies aimed at improving outcomes after pancreaticoduodenectomy through the development of individualised, goal-directed therapies that are initiated well before this morbid yet necessary operation is performed.

Introduction: Free tissue transfer using an abdominal tissue flap is a commonly used method of breast reconstruction. However, there are well recognised complications including venous congestion, fat necrosis and flap loss associated with the perfusion of these flaps. Post-operative aesthetic outcome assessment of such breast reconstructions have also proven to be difficult with current methods displaying poor inter-rater reliability and patient correlation. The aim of this research was to investigate potential improvements to the post-operative outcome of free abdominal tissue transfer breast reconstruction by assessing the effects of vascular augmentation interventions on flap perfusion and to assess the use of real-time digital video as a post-operative assessment tool. Methods: An in-vivo pilot study carried out on 12 patients undergoing DIEP flap breast reconstruction assessed the effect on Zone IV perfusion, using LDI and ICG angiography, of vascular augmentation of the flap using the contralateral SIEA and SIEV. A further animal experimental study was carried out on 12 Sprague Dawley rats to assess the effects on main pedicle arterial blood flow and on Zone I and Zone IV perfusion of vascular augmentation of the abdominal flap using the contralateral vascular system. A separate post-operative assessment study was undertaken on 35 breast reconstruction patients who evaluated their own reconstructions via patient questionnaire and underwent photograph and real-time digital video capture of their reconstructions with subsequent panel assessment. Results: Our results showed that combined vascular augmentation of DIEP flaps, using both the SIEA and SIEV together, led to an increase in Zone IV perfusion. Vascular augmentation of the rat abdominal flaps also led to a significant increase in Zone I/IV perfusion, but the augmentation procedure resulted in a decreased main pedicle arterial blood flow. Our post-operative assessment study revealed that real-time digital video footage led to greater inter-rater agreement with regards to cosmesis and shape than photography and also correlated more with patient self-assessment. Conclusion: Vascular augmentation of abdominal free tissue flaps using the contralateral vascular system results in an increase to Zone IV perfusion, however this may lead to decreased main pedicle arterial blood flow. Real-time digital video is a valid post-operative aesthetic assessment method of breast reconstruction outcome and is superior to static photography when coupled with panel assessment.