Background People with osteoarthritis (OA) frequently consult general practitioners (GPs) for the problem but the care they receive in these consultations is often sub-optimal. The aim of the studies described in this thesis was to enhance GP clinical practice for OA by developing and implementing a model OA consultation for the initial contact between a GP and an older patient presenting with peripheral joint pain. Methods A consensus exercise was undertaken to develop the model OA consultation. This was followed by the development, and delivery in a series of workshops, of a behaviour change intervention to implement the model in practice. Impact of workshops was assessed by before-and-after methods on directly observed GP use of the model OA consultation in video-recorded consultations with simulated patients, and by self-report measures (at baseline, and one and five months after). Learner reactions and delivery in day-to-day practice were assessed. Results The model OA consultation consisted of 25 tasks for assessment and initial management. A four workshop series was developed and delivered to 24 GPs and included didactic, interactive and skills training (with simulated patients) sessions. The workshops addressed barriers and facilitators for change identified in the development of the behaviour change intervention. GP use of the model OA consultation, by 15 GPs whose video-recorded consultations were assessed, was enhanced after workshops compared with before, evidenced by increased use of 14 tasks from a median of 7 tasks before to 11 after. Impact on self-report measures was inconclusive. Learner reactions were positive but delivery in day-to-day practice was limited. Conclusion A before and after study has demonstrated that GP use of a model OA consultation in a simulated setting can be enhanced. Further research and quality improvement initiatives will be needed to enhance use of the model OA consultation in day-to-day practice.

Background: Osteoarthritis (OA) is the commonest long term condition in primary care. Current guidance suggests that much can be done to improve outcomes but existing research suggests doctors and patients are pessimistic about OA treatment. An important question concerns the role of the primary care consultation in this incongruity. This study used a combination of video recorded consultations and post consultation interviews using video-stimulated recall (VSR), to uncover what happens when patients discuss OA with their general practitioners (GPs). Methods: With ethical approval, GP consultations with 190 consenting patients aged ≥ 45 were recorded. Twenty consultations contained reference to OA, and 17 of these patients and their GPs (n=13) participated in post consultation interviews. Analysis involved thematic analysis of videotapes and comparisons of patient and GP interviews with the consultation findings. Results: Osteoarthritis arises in the consultation in complex contexts of multi-morbidity, multiple and varied patient agendas which are often not explicit, and against a background of clinician agendas including time pressures, multiple guidelines and service requirements. Dissonance between doctors and patients was observed and was often underpinned by patient perception of lack of empathy and symptom validation. Doctors and patients often adopt a ‘lay’ construct of OA where joint pain is seen as a normal part of life; this influences doctor and patient behaviour and acts as a significant barrier to formal recognition and hence treatment of the condition. Conclusions: The design of interventions to improve outcomes of patients with OA must take account of the complexity and heterogeneity of presentations in primary care. Osteoarthritis appears to be experiencing an identity crisis, with doctors and patients uncertain of what constitutes OA and when to use the term ‘osteoarthritis’. Further work is needed to identify effective ways of translating best evidence about OA management into effective primary care strategies.

This study investigates a jargon speaker, LT, whose connected speech is composed almost entirely of neologisms. Despite the general intelligibility of his speech, LT is able to produce discrete responses in picture naming tasks. Neologisms were investigated for their phonemic content. Non word responses maintained the normal English distribution of phonemes. Importantly, they also showed greater than chance levels of target relatedness. Analysis of LT's responses to a set of stimuli controlled for their consonant content allowed more detailed investigation of the nature of target and error phonology. A strong influence of phoneme frequency was identified. Higher frequency consonants showed a pattern of frequent but rather indiscriminate use. They often appeared in target related contexts but were also frequently misused in contexts where they were not required by the target phonology. Lower frequency consonants were realised less often. However, their use was restricted to target related contexts and they seldom appeared as error phonology. Further investigation showed that LT's ability to realise target phonology was influenced by the nature of the output task. A semantically primed reading condition resulted in a significant increase in the number of correct responses. Neologistic output showed a significant increase in the ability to realise target phonemes. Patterns of individual consonant use also showed significant changes. High frequency consonants showed a more refined distribution, appearing less frequently as error phonology. Low frequency consonants increased their rate of use but continued to be restricted to target related contexts. The findings of the investigations are discussed. The results are best explained by theories of neologism production which maintain a direct relationship between target and neologistic phonology and which propose a single mechanism underlying the production of both target related and abstruse neologistic output. Interactive activation accounts of lexical processing appear to be well placed to explain LT's output and a preliminary account is offered. Recommendations for the future investigation of neologistic output are made.

The purpose of this thesis is to develop the role of magnetic resonance imaging (MRI) in the radiotherapy (RT) planning process. This began by assessing a prototype inline three-dimensional distortion correction algorithm. A number of quality assurance tests were conducted using different test objects and the 3D distortion correction algorithm was compared with the standard two-dimensional version available for clinical use on the MRI system. Scanning patients using MRI in the RT position within an immobilisation mask can be problematic, since the multi-channel head coils typically used in diagnostic imaging, are not compatible with the immobilisation mask. To assess the image quality which can be obtained with MR imaging in the RT position, various MRI quality assurance phantoms were positioned within an immobilisation mask and a series of image quality tests were performed on four imaging coils compatible with the immobilisation mask. It was shown that only the 4-channel cardiac coil delivered comparable image quality to a multi-channel head coil. An investigation was performed to demonstrate how MRI patient position protocols influence registration quality in patients with prostate cancer undergoing radical RT. The consequences for target volume definition and dose coverage with RT planning were also assessed. Twenty patients with prostate cancer underwent a computed tomography (CT) scan in the RT position, a diagnostic MRI scan and an MRI scan in the RT position. The CT datasets were independently registered with the two MRI set-ups and the quality of registration was compared. This study demonstrated that registering CT and MR images in the RT position provides a statistically significant improvement in registration quality, target definition and target volume dose coverage for patients with prostate cancer. A similar study was performed on twenty-two patients with oropharyngeal cancer undergoing radical RT. It was shown that when patients with oropharyngeal cancer undergo an MRI in the RT position there are significant improvements in CT-MR image registration, target definition and target volume dose coverage.

The purpose of this dissertation is to reflect on the author’s published work in the field complementary and alternative medicine, specifically that produced between 1996 and 2005. It examines how the production of this work was influenced by the author’s previous and concurrent experience as a medical journalist and the methodological challenges arising from sourcing complementary and alternative medicine and framing for audiences of broadsheet newspapers and two books – The Which? Guide to Complementary Medicine and Alternative Answers to Asthma & Allergies. It explores how this work relates to scholarship in three key areas: the theory of sourcing, the theory of framing and the study of erroneous beliefs. The author demonstrates that a “perfect storm” – sociologically, culturally and economically – created a narrative that suited the new consumer-­‐driven cult of the empowered individual, which in turn led to most sectors of the print media becoming impervious to any real investigation of the subject.

Introduction: Numerous methods exist for the assessment of the female breast. Traditionally, a subjective approach was taken for surgical planning and evaluation of the postoperative outcome. Several objective methods have been developed to support this procedure, among which are laser scanning, MRI, mammography, ultrasound and photography. Recently, 3D imaging technology has been developed. Material & Method: 3D breast assessment by multiple stereophotogrammetry was examined. A custom-made imaging system with eight digital cameras arranged in four camera pods was utilised. This system was used for breast capture, resulting in eight images obtained by the cameras. The merging of these images and 3D image construction was carried out by C3D software and the volume assessment of the 3D images was made using breast analysis tool (BAT) software, developed by Glasgow University. A validation study was conducted. Nine plaster models were investigated and their volume determined by 3D stereophotogrammetry and water displacement method. Water displacement was considered to be the gold standard for comparison. The plaster models were specially made in order to represent a variety of shapes and sizes of the female breast. Each plaster model was examined 10 times by each method. Further, the volumes of the breasts of six female volunteer live models were investigated by the same two methods and the results compared. A special focus was placed on the reproducibility of the assessment. Each live model was captured with the 3D capture system three times at two different time points after retaking a special pose in a custom-made positioning frame. Altogether, each live model was captured six times, resulting in six 3D images, each of which was measured three times with BAT software. A patient study was conducted in 44 patients after unilateral immediate breast reconstruction with Latissimus dorsi flap and no contra-lateral surgery. Each patient underwent 3D imaging with the multiple stereophotogrammetry system. During capture, the special pose in the custom-made positioning frame was taken by the patient’s leaning forward almost horizontally with the upper body for the breasts to rise off the chest wall to enable full breast coverage by the cameras. 3D images were constructed with C3D software and volumes measured with BAT. For each patient, one 3D image was constructed and measured four times with BAT software. In addition to the volume determination, a shape analysis was conducted. For this purpose, 10 landmarks were determined according to recommendations in the literature. Two landmarks, sternal notch and xiphoid, were marked, forming an imaginary midline between each other and four landmarks on each breast, i.e. the medial and lateral ends of the infra-mammary fold, and the most prominent and most inferior breast points were utilised for symmetry assessment between the right and left breasts. Each landmark was recorded four times by the operator on the 3D image and three-dimensional coordinates obtained. By assessment of the left and right breasts a breast asymmetry score was calculated. Firstly, breast asymmetry was assessed objectively on the 3D images through the centroid size, which was determined as the square root of the sum of squared Euclidian distances from each landmark to the centroid. The centroid was the geometric mean of the landmarks. Secondly, asymmetry was assessed through breast volume by application of BAT software. Thirdly, asymmetry was examined through the landmarks themselves by investigation of the mismatch of the landmark configuration of one breast and its relabelled and matched reflection. The non-operated and reconstructed sides were compared and landmarks were recorded by the operator in three dimensions in four repeated tests. A decomposition of the total landmark asymmetry into its factors was conducted by fixation of the surface of the non-operated side and translation, rotation and scaling of the surface of the reconstructed side. For comparison, a subjective breast assessment was conducted by six expert observers who rated the results after breast reconstruction by subjective qualitative assessment of the symmetry in 2D images of the same 44 patients in six poses. For this purpose the Harris scale was utilised, providing a score of 1 to 4 for poor to excellent symmetry. Results: The results revealed that differences in the obtained volumes in the plaster models were not significant. In contrast, differences in the breast volumes measured in the live models were significant. The examination of the reproducibility revealed that overall reproducibility obtained by stereophotogrammetry was better than that obtained by water displacement. No correlation between breast size and reproducibility of the measurements was found. The results of the patient study demonstrated that the reproducibility of the landmarks was within 5 mm. There was a non-significant difference of the centroid sizes between both breasts. There was a significant difference of the volumes between the two breasts, with the non-operated side being larger than the reconstructed side. Volume was considered to be a more accurate measure for comparison of both breasts than centroid size as it was based on thousands of data points for the calculation as opposed to only four points of the centroid size. The statistical analysis of the landmark data provided a mathematical formula for determination of the breast asymmetry score. The average asymmetry score, derived by landmark assessment as the degree of mismatch between both sides, was 0.052 with scores ranging from 0.019 (lowest score) to 0.136 (highest score). The decomposition of the landmark-based asymmetry revealed that location was the most important factor contributing to breast asymmetry, ahead of intrinsic breast asymmetry, orientation and scale. When investigating the subjective assessment, the inter-observer agreement was good or substantial. There was moderate agreement on the controls and fair to substantial intra-observer agreement. When comparing the objective and subjective assessments, it was found that the relationship between the two scores was highly significant. Conclusion: We concluded that 3D breast assessment by multiple stereophotogrammetry was reliable for a comparative analysis and provided objective data to breast volume, shape and symmetry. A breast asymmetry score was developed, enabling an objective measurement of breast asymmetry after breast reconstruction. 3D breast assessment served as an objective method for comparison to subjective breast assessment.

Background: Depression is a common presenting problem for older adults and Over General Memory (OGM) has also been found to be linked to depression. Recently it has been proposed that deficits in Executive Functioning (EF) could explain OGM (Williams et al., 2007). Despite studies in both child and adult populations, this hypothesis has yet to be tested in a depressed older adult sample. Aims: The main aim was to test the EF hypothesis for OGM in a depressed sample of adults aged 65 years and older. Additional aims were to add to the growing literature base investigating the relationship between the three variables (depression, OGM and EF) within an older adult population. Methods: 14 depressed older adults and 15 non-depressed older adults completed a series of EF neuropsychological tests and the Autobiographical Memory Test (AMT). Miyake et al.’s (2000) 3 facets model of EF was used to define EF. The Trail Making Test was used to test for ‘shifting’ ability, The Color-Word Inference Test was used to test for ‘inhibition’ and the Random Number Generation Test was used to test for ‘updating’. Results: Shifting ability was found to account for the relationship between depression and OGM within a sample of older adults. Although indications are that inhibition may also account for OGM the finding was narrowly non-significant. Updating was not found to account for the relationship between depression and OGM. Additionally, depressed individuals were found to have more OGM and EF deficits (shifting and inhibition only) than their non-depressed counterparts. OGM and deficits in EF (shifting and inhibition only) were found to be significantly positively correlated. Conclusions: Relationships between depression, OGM and EF in an older adult population were found. There is partial support for the EF hypothesis of OGM in older adults, as shifting ability was found to account for the relationship between depression and OGM. Findings indicate that inhibition may be a key element in explaining this relationship, although further research is needed to clarify this using larger sample sizes. Further research should aim to address certain methodological limitations of this study, such as larger sample sizes and using multiple neuropsychological tests per executive functioning ability.

The software package Brainvisa (www.brainvisa.tnfo) offers a wide range of possibilities for cortical analysis using its automatic sulci recognition feature. Automated sulci identification is an attractive feature as the manual labelling of the cortical sulci is often challenging even for the experienced neuro-radiologists. This can also be of interest in fMRI studies of individual subjects where activated regions of the cortex can simply be identified using sulcal labels without the need for normalization to an atlas. As it will be explained later in this thesis, normalization to atlas can especially be problematic for pathologic brains. In addition, Brainvisa allows for sulcal morphometry from structural MR images by estimating a wide range of sulcal properties such as size, coordinates, direction, and pattern. Morphometry of abnormal brains has gained huge interest and has been widely used in finding the biomarkers of several neurological diseases or psychiatric disorders. However mainly because of its complexity, only a limited use of sulcal morphometry has been reported so far. With a wide range of possibilities for sulcal morphometry offered by Brainvisa, it is possible to thoroughly investigate the sulcal changes due to the abnormality. However, as any other automated method, Brainvisa can be susceptible to limitations associated with image quality. Factors such as noise, spatial resolution, and so on, can have an impact on the detection of the cortical folds and estimation of their attributes. Hence the robustness of Brainvisa needs to be assessed. This can be done by estimating the reliability and reproducibility of results as well as exploring the changes in results caused by other factors. This thesis is an attempt to investigate the possible benefits of sulci identification and sulcal morphometry for functional and structural MRI studies as well as the limitations of Brainvisa. In addition, the possibility of improvement of activation localization with functional MRI studies is further investigated. This investigation was motivated by a review of other cortical-based analysis methods, namely the cortical surface-based methods, which are discussed in the literature review chapter of this thesis. The application of these approaches in functional MRI data analysis and their potential benefits is used in this investigation.

Objectives: To explore whether a semi–structured post-traumatic amnesia (PTA) assessment interview (PTA-I) provides a practicable but equivalent estimation of PTA in patients attending the Emergency Department (ED) with head injury (HI) compared to the established Westmead PTA Scale Revised (R-WPTAS). Procedure: PTA was assessed using the R-WPTAS (includes a visual memory component) and the PTA-I (includes retrospective and verbal memory components), in patients attending an ED with (n=30) or without (n= 30) HI. Outcome measures were the Post-concussion Syndrome Checklist (PCSC) and the Glasgow Coma Scale (GCS). McNemar’s Tests and Chi-square analyses were used to determine the results. Results: The verbal memory component overestimated PTA in the control group by 24 %. Overall, the PTA-I did not discriminate between HI and control participants. However the retrospective PTA assessment embedded within the PTA-I did, with 100 % accuracy. Conclusions: The use of a verbal memory component to assess PTA in the ED is not supported by the results of this study. A retrospective PTA assessment appears to allow more accurate decision making regarding the admission criteria used in the ED and has advantages over the R-WPTAS: fewer test materials and no repeat assessments required to achieve an estimate of PTA duration.

Digital imaging has long been available in radiology in the form of computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Initially the transition to general radiography was slow and fragmented but in the last 10-15 years in particular, huge investment by the manufacturers, greater and cheaper computing power, inexpensive digital storage and high bandwidth data transfer networks have lead to an enormous increase in the number of digital radiography systems in the UK. There are a number of competing digital radiography (DR) technologies, the most common are computer radiography (CR) systems followed by indirect digital radiography (IDR) systems. To ensure and maintain diagnostic quality and effectiveness in the radiology department appropriate methods are required to evaluate and optimise the performance of DR systems. Current semi-quantitative test object based methods routinely used to examine DR performance suffer known short comings, mainly due to the subjective nature of the test results and difficulty in maintaining a constant decision threshold among observers with time. Objective image quality based measurements of noise power spectra (NPS) and modulation transfer function (MTF) are the ‘gold standard’ for assessing image quality. Advantages these metrics afford are due to their objective nature, the comprehensive noise analysis they permit and in the fact that they have been reported to be relatively more sensitive to changes in detector performance. The advent of DR systems and access to digital image data has opened up new opportunities in applying such measurements to routine quality control and this project initially focuses on obtaining NPS and MTF results for 12 IDR systems in routine clinical use. Appropriate automatic exposure control (AEC) device calibration and a reproducible measurement method are key to optimising X-ray equipment for digital radiography. The uses of various parameters to calibrate AEC devices specifically for DR were explored in the next part of the project and calibration methods recommended. Practical advice on dosemeter selection, measurement technique and phantoms were also given. A model was developed as part of the project to simulate CNR to optimise beam quality for chest radiography with an IDR system. The values were simulated for a chest phantom and adjusted to describe the performance of the system by inputting data on phosphor sensitivity, the signal transfer function (STF), the scatter removal method and the automatic exposure control (AEC) responses. The simulated values showed good agreement with empirical data measured from images of the phantom and so provide validation of the calculation methodology. It was then possible to apply the calculation technique to imaging of tissues to investigate optimisation of exposure parameters. The behaviour of a range of imaging phosphors in terms of energy response and variation in CNR with tube potential and various filtration options were investigated. Optimum exposure factors were presented in terms of kV-mAs regulation curves and the large dose savings achieved using additional metal filters were emphasised. Optimum tube potentials for imaging a simulated lesion in patient equivalent thicknesses of water ranging from 5-40 cm thick for example were: 90-110kVp for CsI (IDR); 80-100kVp for Gd2O2S (screen /film); and 65-85kVp for BaFBrI. Plots of CNR values allowed useful conclusions regarding the expected clinical operation of the various DR phosphors. For example 80-90 kVp was appropriate for maintaining image quality over an entire chest radiograph in CR whereas higher tube potentials of 100-110 kVp were indicated for the CsI IDR system. Better image quality is achievable for pelvic radiographs at lower tube potentials for the majority of detectors however, for gadolinium oxysulphide 70-80 kVp gives the best image quality. The relative phosphor sensitivity and energy response with tube potential were also calculated for a range of DR phosphors. Caesium iodide image receptors were significantly more sensitive than the other systems. The percentage relative sensitivities of the image receptors averaged over the diagnostic kV range were used to provide a method of indicating what the likely clinically operational dose levels would be, for example results suggested 1.8 µGy for CsI (IDR); 2.8 µGy for Gd2O2S (Screen/film); and 3.8 µGy for BaFBrI (CR). The efficiency of scatter reduction methods for DR using a range of grids and air gaps were also reviewed. The performance of various scatter reduction methods: 17/70; 15/80; 8/40 Pb grids and 15 cm and 20 cm air gaps were evaluated in terms of the improvement in CNR they afford, using two different models. The first, simpler model assumed quantum noise only and a photon counting detector. The second model incorporated quantum noise and system noise for a specific CsI detector and assumed the detector was energy integrating. Both models allowed the same general conclusions and suggest improved performance for air gaps over grids for medium to low scatter factors and both models suggest the best choice of grid for digital systems is the 15/80 grid, achieving comparable or better performance than air gaps for high scatter factors. The development, analysis and discussion of AEC calibration, CNR value, phosphor energy response, and scatter reduction methods are then brought together to form a practical step by step recipe that may be followed to optimise digital technology for clinical use. Finally, CNR results suggest the addition of 0.2 mm of copper filtration will have a negligible effect on image quality in DR. A comprehensive study examining the effect of copper filtration on image quality was performed using receiver operator characteristic (ROC) methodology to include observer performance in the analysis. A total of 3,600 observations from 80 radiographs and 3 observers were analysed to provide a confidence interval of 95% in detecting differences in image quality. There was no statistical difference found when 0.2 mm copper filtration was used and the benefit of the dose saving promote it as a valuable optimisation tool.