A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC)

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 68. See the NIHR Journals Library website for further project information.

Advanced Applications of 3D Dosimetry and 3D Printing in Radiation Therapy

As complex radiotherapy techniques become more readily-practiced, comprehensive 3D dosimetry is a growing necessity for advanced quality assurance. However, clinical implementation has been impeded by a wide variety of factors, including the expense of dedicated optical dosimeter readout tools, high operational costs, and the overall difficulty of use. To address these issues, a novel dry-tank optical CT scanner was designed for PRESAGE 3D dosimeter readout, relying on 3D printed components and omitting costly parts from preceding optical scanners. This work details the design, prototyping, and basic commissioning of the Duke Integrated-lens Optical Scanner (DIOS).

The convex scanning geometry was designed in ScanSim, an in-house Monte Carlo optical ray-tracing simulation. ScanSim parameters were used to build a 3D rendering of a convex ‘solid tank’ for optical-CT, which is capable of collimating a point light source into telecentric geometry without significant quantities of refractive-index matched fluid. The model was 3D printed, processed, and converted into a negative mold via rubber casting to produce a transparent polyurethane scanning tank. The DIOS was assembled with the solid tank, a 3W red LED light source, a computer-controlled rotation stage, and a 12-bit CCD camera. Initial optical phantom studies show negligible spatial inaccuracies in 2D projection images and 3D tomographic reconstructions. A PRESAGE 3D dose measurement for a 4-field box treatment plan from Eclipse shows 95% of voxels passing gamma analysis at 3%/3mm criteria. Gamma analysis between tomographic images of the same dosimeter in the DIOS and DLOS systems show 93.1% agreement at 5%/1mm criteria. From this initial study, the DIOS has demonstrated promise as an economically-viable optical-CT scanner. However, further improvements will be necessary to fully develop this system into an accurate and reliable tool for advanced QA.

Pre-clinical animal studies are used as a conventional means of translational research, as a midpoint between in-vitro cell studies and clinical implementation. However, modern small animal radiotherapy platforms are primitive in comparison with conventional linear accelerators. This work also investigates a series of 3D printed tools to expand the treatment capabilities of the X-RAD 225Cx orthovoltage irradiator, and applies them to a feasibility study of hippocampal avoidance in rodent whole-brain radiotherapy.

As an alternative material to lead, a novel 3D-printable tungsten-composite ABS plastic, GMASS, was tested to create precisely-shaped blocks. Film studies show virtually all primary radiation at 225 kVp can be attenuated by GMASS blocks of 0.5cm thickness. A state-of-the-art software, BlockGen, was used to create custom hippocampus-shaped blocks from medical image data, for any possible axial treatment field arrangement. A custom 3D printed bite block was developed to immobilize and position a supine rat for optimal hippocampal conformity. An immobilized rat CT with digitally-inserted blocks was imported into the SmART-Plan Monte-Carlo simulation software to determine the optimal beam arrangement. Protocols with 4 and 7 equally-spaced fields were considered as viable treatment options, featuring improved hippocampal conformity and whole-brain coverage when compared to prior lateral-opposed protocols. Custom rodent-morphic PRESAGE dosimeters were developed to accurately reflect these treatment scenarios, and a 3D dosimetry study was performed to confirm the SmART-Plan simulations. Measured doses indicate significant hippocampal sparing and moderate whole-brain coverage.

Predictive Risk Modelling for Integrated Care: a Structured Review

If patients at risk of admission or readmission to hospital or other forms of care could be identified and offered suitable early interventions then their lives and long-term health may be improved by reducing the chances of future admission or readmission to care, and hopefully, their cost of care reduced. Considerable work has been carried out in this subject area especially in the USA and the UK. This has led for instance to the development of tools such as PARR, PARR-30, and the Combined Predictive Model for prediction of emergency readmission or admission to acute care. Here we perform a structured review the academic and grey literature on predictive risk tools for social care utilisation, as well as admission and readmission to general hospitals and psychiatric hospitals. This is the first phase of a project in partnership with Docobo Ltd and funded by Innovate UK,in which we seek to develop novel predictive risk tools and dashboards to assist commissioners in Clinical Commissioning Groups with the triangulation of the intelligence available from routinely collected data to optimise integrated care and better understand the complex needs of individuals.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

Toxicity profile of bevacizumab in the UK Neurofibromatosis Type 2 cohort

Bevacizumab is considered an established part of the treatment strategies available for schwannomas in patients with Neurofibromatosis Type 2(NF2). In the UK, it is available through NHS National Specialized Commissioning to NF2 patients with a rapidly growing target schwannoma. Regrowth of the tumour on suspension of treatment is often observed resulting in prolonged periods of exposure to bevacizumab to control the disease. Hypertension and proteinuria are common events with bevacizumab use and there are concerns with regards to the long-term risks of prolonged treatment. Dosing, demographic and adverse event(CTCAE 4.03) data from the UK NF2 bevacizumab cohort are reviewed with particular consideration of renal and cardiovascular complications. Eighty patients (48 male:32female), median age 24.5 years (range 11-66years), were followed for a median of 32.7 months (range 12.0–60.2months). The most common adverse events were fatigue, hypertension and infection. A total of 19/80 patients (24%) had either a grade 2 or grade 3 hypertension event and 14/80 patients (17.5%) had proteinuria. Of 36 patients followed for 36 months, 78% were free from hypertension and 86% were free of proteinuria. Logistic regression modeling identified age and induction dosing regime to be predictors of development of hypertension with dose of 7.5mg/kg three weekly and age >30years having higher rates of hypertension. Proteinuria persisted in one of three patients after cessation of bevacizumab. One patient developed congestive heart failure and the details of this case are described. Further work is needed to determine optimal dosing regimes to limit toxicity without impacting on efficacy.

Rebranding Al-Jazeera Children's Channel: The Qatarization Factor

Qatar's rulers established Al-Jazeera Children's Channel in 2005 to nurture Arab and Islamic traditions and values; the channel sought to differentiate itself by ensuring that material would conform to what its management considered to be culturally appropriate guidelines for content. However, having been set up as a child-centred, non-commercial, fully-funded enterprise that aspired to source most of its content within the Arabic-speaking region, its priorities shifted in 2011-13 towards maximizing commercial revenues through foreign imports. In light of the shift, this chapter explores the complex interweaving of commercial and political considerations behind production and commissioning processes. The channel's branding and re-branding shows how a children’s television project can be adopted to reinforce a country’s claim to regional cultural leadership, while being packaged in such a way as to depoliticize that country’s institutions and composition by rooting national identity in a combination of commercial interests and notions of traditional culture.

Market reforms and privatisation in the English National Health Service

The article examines developments in the marketisation and privatisation of the English National Health Service, primarily since 1997. It explores the use of competition and contracting out in ancillary services and the levering into public services of private finance for capital developments through the Private Finance Initiative. A substantial part of the article examines the repeated restructuring of the health service as a market in clinical services, initially as an internal market but subsequently as a market increasing opened up to private sector involvement. Some of the implications of market processes for NHS staff and for increased privatisation are discussed. The article examines one episode of popular resistance to these developments, namely the movement of opposition to the 2011 health and social care legislative proposals. The article concludes with a discussion of the implications of these system reforms for the founding principles of the NHS and the sustainability of the service.

Commodification of health care systems: The Catalan case

Commodification of the public healthcare system has been a growing process in recent decades, especially in universal healthcare systems and in high-income countries like Spain.  There are substantial differences in the healthcare systems of each autonomous region of Spain, among which Catalonia is characterized by having a mixed healthcare system with complex partnerships and interactions between the public and private healthcare sectors.  Using a narrative review approach, this article addresses various aspects of the Catalan healthcare system, characterizing the privatization and commodification of health processes in Catalonia from a historical perspective with particular attention to recent legislative changes and austerity measures.  The article approximates, the eventual effects that commodification and austerity measures will have on the health of the population and on the structure, accessibility, effectiveness, equity and quality of healthcare services.

LOTUS: A low cost, ultraviolet spectrograph

We describe the design, construction and commissioning of LOTUS; a simple, low-cost long-slit spectrograph for the Liverpool Telescope. The design is optimized for near-UV and visible wavelengths and uses all transmitting optics. It exploits the instrument focal plane field curvature to partially correct axial chromatic aberration. A stepped slit provides narrow (2.5x95 arcsec) and wide (5x25 arcsec) options that are optimized for spectral resolution and flux calibration respectively. On sky testing shows a wavelength range of 3200-6300 Angstroms with a peak system throughput (including detector quantum efficiency) of 15 per cent and wavelength dependant spectral resolution of R=225-430. By repeated observations of the symbiotic emission line star AG Peg we demonstrate the wavelength stability of the system is less than 2 Angstroms rms and is limited by the positioning of the object in the slit. The spectrograph is now in routine operation monitoring the activity of comet 67P/Churyumov-Gerasimenko during its current post-perihelion apparition.

Driving Flows in Laboratory Astrophysical Plasma Jets: The Mochi.LabJet Experiment

Thesis (Master's)--University of Washington, 2016-08

Models of the user: designers’ perspectives on influencing sustainable behaviour

Influencing more environmentally friendly and sustainable behaviour is a current focus of many projects, ranging from government social marketing campaigns, education and tax structures to designers’ work on interactive products, services and environments. There is a wide variety of techniques and methods used, intended to work via different sets of cognitive and environmental principles. These approaches make different assumptions about ‘what people are like’: how users will respond to behavioural interventions, and why, and in the process reveal some of the assumptions that designers and other stakeholders, such as clients commissioning a project, make about human nature. This paper discusses three simple models of user behaviour – the pinball, the shortcut and the thoughtful – which emerge from user experience designers’ statements about users while focused on designing for behaviour change. The models are characterised using systems terminology and the application of each model to design for sustainable behaviour is examined via a series of examples.

Osservatore e controllore sensorless ad elevate prestazioni per propulsione elettrica di Unmanned Aerial Vehicles

Negli ultimi anni, tra le varie tecnologie che hanno acquisito una sempre maggiore popolarità e diffusione, una di particolare rilevanza è quella degli Unmanned Aerial Vehicles. Di questi velivoli, quelli che stanno riscuotendo maggiore successo sono i multirotori, alimentati esclusivamente da azionamenti elettrici disposti in opportune posizioni della struttura. Particolari sforzi sono stati recentemente dedicati al miglioramento di questa tecnologia in termini di efficienza e precisione, tuttavia quasi sempre si trascura la vitale importanza dello sfruttamento efficiente dei motori elettrici. La tecnica di pilotaggio adottata nella quasi totalità dei casi per questi componenti è il BLDC sensorless, anche se la struttura si dimostra spesso essere PMSM, dunque inadatta all’uso di questa strategia. Il controllo ideale per i PMSM risulterebbe essere FOC, tuttavia per l'implementazione sensorless molti aspetti scontati nel BLDC devono essere affrontati, in particolare bisogna risolvere problemi di osservazione e identificazione. Durante la procedura di avviamento, efficienti strategie di self-commissioning vengono adottate per l’identificazione dei parametri elettrici. Per la fase di funzionamento nominale viene proposto un osservatore composto da diversi componenti interfacciati tra loro tramite un filtro complementare, il tutto al fine di ottenere una stima di posizione e velocità depurata dai disturbi. In merito al funzionamento in catena chiusa, vengono esposte valutazioni preliminari sulla stabilità e sulla qualità del controllo. Infine, per provare la validità degli algoritmi proposti, vengono mostrati i risultati delle prove sperimentali condotte su un tipico azionamento per UAV, pilotato da una scheda elettronica progettata appositamente per l’applicazione in questione. Vengono fornite inoltre indicazioni sull’implementazione degli algoritmi studiati, in particolare considerazioni sull’uso delle operazioni a virgola fissa per velocizzare l'esecuzione.

Growth and Characterization of III-V Semiconductor Materials for MOCVD Reactor Qualification and Process Control

Metalorganic chemical vapor deposition is examined as a technique for growing compound semiconductor structures. Material analysis techniques for characterizing the quality and properties of compound semiconductor material are explained and data from recent commissioning work on a newly installed reactor at the University of Illinois is presented.

What's the Matter with Extended Techniques? Getting Beyond the Stigma in the Horn and Percussion Repertoire

For this project I prepared a series of recitals featuring music for horn and percussion, in which the horn part featured extended horn techniques. For this project, I considered anything beyond the open or muted horn an extended technique. These techniques range from the common hand-stopped note passages to complex new techniques involving half-valves, multi-phonics, and more, for new sounds desired by the composer. There are several pieces written for solo horn and percussion, with ensembles ranging from simple duets to solo horn with a full percussion ensemble. However, few include extended techniques for the horn. All of these select pieces are lesser known because of their difficulty, primarily because of the challenge of the extended techniques requested by the composer. In the introduction to this paper I give a brief background to the project, where the current repertoire stands, and my experiences with commissioning works for this genre. I then give a brief history and how-to on the more common extended techniques, which were found in almost every piece. I separated these techniques so that they could be referenced in the performance notes without being extremely repetitive in their description. Then follows the main performance notes of the repertoire chosen, which includes a brief description of the piece itself and a longer discussion for performers and composers who wish to learn more about these techniques. In this section my primary focus is the extended techniques used and I provide score samples with permission to further the education of the next musicians to tackle this genre. All works performed for this project were recorded and accompany this paper in the Digital Repository at the University of Maryland (DRUM). The following works were included in this project: o Howard J. Buss, Dreams from the Shadows (2015) o Howard J. Buss, Night Tide (1995) o George Crumb, An Idyll for the Misbegotten, trans. Robert Patterson (1986/1997) o Charles Fernandez, Metamorphosis: A Horn’s Life, “Prenatal and Toddler” (2016, unfinished) o Helen Gifford, Of Old Angkor (1995) o Douglas Hill, Thoughtful Wanderings… (1990) o Pierre-Yves Level, Duetto pour Cor en Fa et Percussion (1999) o David Macbride, Elegy for Horn and Timpani (2009) o Brian Prechtl, A Song of David (1995) o Verne Reynolds, HornVibes (1986) o Pablo Salazar, Cincontar (2016) o Mark Schultz, Dragons in the Sky (1989) o Faye-Ellen Silverman, Protected Sleep (2007) o Charles Taylor, Sonata for Horn and Marimba (1991) o Robert Wolk, Tessellations (2016) With this project, I intend to promote these pieces and the techniques used to encourage more works written in this style, and reveal to fellow horn players that the techniques should not prevent these great works from being performed. Due to the lack of repertoire, I successfully commissioned new pieces featuring extended techniques, which were featured in the final recital.