TALK© is a communication tool which aims to guide multi-professional clinical teams learning and improving quality of patient care and patient safety together. It is a simple and practical approach to multi-professional structured feedback and debriefing, to be used after unplanned learning events in clinical environments. Debriefing is the process of an individual or team formally reflecting on their performance after a particular task, a shift or a critical event (World Health Organisation 2009). TALK proposes an easy way to guide a constructive conversation between team members whenever new insights might be learnt from clinical experience. This includes cases or sessions in which things went well but also near misses and untoward events. Patient safety is far too often threatened by unidentified system flaws, poor practices, weaknesses in team communication and lack of appropriate action after critical events. The relevance of a culture of safety and communication is emphasized by WHO advocating debriefing in its Human Factors review, 2009. This RISE project will consist of three phases; firstly secondees will contribute to parallel implementation processes in specified units across the 3 participating countries and will undertake research to better understand the benefits of structured debriefing, communication and organisational culture. Secondly, using the data generated from the research study, further training materials will be developed and translated to support the wider deployment of the TALK tool. Thirdly, the TALK tool will be widely disseminated as a structured debriefing tool and implemented across and beyond all participating partners and its impact will be assessed.

Abstracts are not currently available in GtR for all funded research. This is normally because the abstract was not required at the time of proposal submission, but may be because it included sensitive information such as personal details.

High Tibial Osteotomy (HTO) surgery is performed as a treatment for people who have osteoarthritis (OA) affecting one side of their knee. It realigns the joint to redistribute joint loading and relieve pain. It is used by some clinicians as a valuable joint preserving intervention for patients who are too young for a total knee replacement. It is also occasionally used in asymptomatic patients to prevent further mal-alignment of the knee. To prolong the life of the joint, the angle of joint alignment correction must be sufficient to reduce loads on the medial compartment, whilst not excessively loading the lateral compartment. In current clinical practice, the angle of correction is estimated from standing static x-rays. However, dynamic gait measurements, in particular the knee adduction moment, are reported to be more highly related to clinical outcome than measures of static knee alignment. The proposed research aims to develop a method to quantify the optimum correction angle, based on a patients preoperative gait biomechanics. If new methods of calculating the correction angle can be found that improve longevity of the joint, the procedure as a service may be adopted more widely. This proposal also aims to evaluate associated changes in the forces acting through the joint using models that consider the effects of muscle forces on the joint. A patient specific dynamic model from the University of Florida will be employed in this research. This model was developed to predict the changes in knee adduction moment following HTO surgery using pre-operative gait data and the angles of correction measured from standard long leg x-rays. This research will test whether optimised models, calibrated to each patient, can predict post-surgery knee adduction moments using HTO surgical parameters. This will be the first implementation of this software using pre and post-operative patient data. This software will be adapted to determine the changes in tibial geometry required to produce the optimum post-operative knee adduction moment. The ability to calculate the optimum angles of correction based on a patient's pre-operative gait will form the basis of a new clinical tool. As part of the proposed research, open-source software (OpenSim) will be employed to investigate changes in joint reaction forces following HTO surgery. A model will be adapted for this purpose. This will be the first implementation of a musculoskeletal model to investigate changes in joint reaction forces for patients undergoing HTO and will provide a basis for further development. Joint reaction forces calculated pre-operatively and how they change post-operatively will be compared to a healthy cohort. This will provide information on the changes in loading in the knee and thus the efficacy of HTO surgery in restoring normal knee joint loading. The end product of this research will be a new tool for bespoke surgical planning and outcome measures detailing the efficacy of HTO surgery. It will enhance the biomechanical understanding of HTO realignment and demonstrate the usefulness of dynamic measurements and musculoskeletal modelling.

Many millions of people in the UK suffer problems with their spine or back. These problems incur a very high cost, both socially and economically, and we need to find ways of preventing or solving them. But to achieve this, we need high-quality tools that can help us understand how healthy spines function and what happens when they develop problems. Our project is concerned with developing and testing 'image-driven subject-specific spine models' which have the potential to provide a tool for determining forces in the spine. Determining the force that an individual spine is experiencing is essential for understanding spine function. Abnormal forces are linked to many problems, including manual handling injury, disc degeneration, and back pain. Measuring force directly in the spine, however, is very invasive. Models provide a non-invasive method but, to provide accurate assessments, they need to include information about the individual (subject-specific). The subject-specificity is essential because everyone has unique anatomy and tissues, and uses their spines differently. We have successfully piloted a modelling approach for measuring spinal force that includes subject-specific anatomy and spinal motion. The method involves using medical imaging not only to provide information on an individual's anatomy but also to observe the movement of their spine during activity. The observed motion is then applied to the model and force calculated. The use of spinal motion to drive models is a relatively recent innovation that we, and other groups, have shown to be feasible. It has several benefits, including the ability to identify localised forces within the spine and avoiding the need to model unknown muscle forces. In the proposed project, our first goal is to extend our pilot work by including subject-specific tissue properties in our models. Very few models of the spine include subject-specific tissue properties. However, we know tissues vary a lot between individuals and having subject-specific properties will increase the accuracy of our models. We will, therefore, develop a method for estimating tissue properties from medical imaging data. Models will be created from specimens that have been tested to determine their mechanical response. We will then learn how we can use the image data to set tissue properties that allow our models to reproduce the measured mechanical response. Our subsequent goals are to test our image-driven subject-specific modelling method rigorously and develop them for real application. Subject-specific models have many potential applications for determining forces, but these applications differ in their tolerance for error. We will, therefore, evaluate and characterise the magnitude and sources of error in our models. Initially, we will use specimens which can be mechanically tested so that we can compare model results to forces measured in the specimens. We will use this information to improve our methods for collecting data from people then we will perform more testing of our method using volunteers who we will ask to perform specified activities. Again we will compare our model results to the expected forces. The development and testing of our image-driven subject-specific spine models will provide a new tool for determining forces in the spine. It will also provide new tools for measuring and modelling spine movement and quantifying the properties of the spinal tissues. But more than this, our project will pave the way to a real understanding of how the spine functions and how problems in the spine can be prevented or treated more effectively.

The offer, interpretation and consequences of genetic testing raise complex issues for counsellors, patients and families. These have received much attention but one important area that is little understood is how patients come to a decision about taking a genetic test (or not). Much is known about how people retrospectively describe their decision-making process and the effects of genetic knowledge on themselves and their families but less is known about how counsellors discuss the implications of taking genetic tests with patients and much less is known about how people make their decisions. By following people during this process, we aim to improve our understanding of how their thinking develops and the other people and factors that influence this. This is particularly important at a time when ever more information about genetics is communicated online, in newspapers and in popular culture, and as families gain more experience of dealing with genetics services. Our proposal is to focus on cases where the decision to take a genetic test is for the patient to make, supported by genetic counselling but without a clinical recommendation, as the genetic test result is of limited clinical utility. Using multiple methods, we propose to examine the communicative context in which patients make their decisions and how their thinking unfolds in this context. We will focus on the experiences of three groups of patients: patients seeking predictive genetic testing for a neuro-degenerative condition (e.g. Huntington's Disease, HD); patients seeking predictive genetic testing for a condition where testing has little utility or it is deferred; and prospective parents seeking pre-natal genetic testing, either for a known familial risk or following an antenatal foetal anomaly ultrasound scan. These cases will illuminate different experiences that patients may have in deciding on a genetic test. The case of HD will show how a patient settles on a decision to take a test knowing a 'bad' outcome foretells a future of impairment. The predictive test of little or deferred utility will mostly involve young adults and will illuminate the experience of wrestling with a decision in a formative period in life with no immediate clinical implications. Prospective parents working with the genetics service in light of a familial risk of a genetic condition will illuminate the importance of personal and family experience in the decision process, while those referred after an ultrasound anomaly scan will shed light on the experience of adjusting to unexpected information in a short period of time. In each case, patients and their families are faced with complex information about tests, testing pathways and potential outcomes. By following people as they make their decision we will observe the clinical encounters and the patients will gather information on their own thoughts, on what people are saying to them, and what other information they are seeking or interacting with. While fully aware of the need for great ethical sensitivity in this enquiry, we will document how genetic information from outside the clinic (as framed by scientists, marketers, journalists, charities and special interest groups) is brought into the clinic discussion and the patients' reports of their own thinking. The conversations between patients and counsellors in clinic are important to this process, but this conversation is increasingly relativized by rapidly evolving scientific insights and supplemented by outside perspectives. Combining insights from all involved will enable us to develop our understanding of how patients come to their decision, and the effect of outside ideas and framings on this process. Simultaneously, by comparing the thinking of the different groups of patients, we will gain insight into the effect of different experiences of time on this thinking, and explore whether and how these reflections might be facilitated by decision support tools.