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This paper addresses a central paradox that affects the nature of the student experience in the UK. On the one hand, the marketisation of higher education, with its associated emphasis on performativity indicators, may be seen to have reduced students to numbers, with the attendant consequence that the affective domain of studying and learning has been lost. On the other hand, there is more attention given to student feelings than was ever the case in the past and questions about student satisfaction have become more prominent. This paper will explore this paradox using empirical data gathered from a longitudinal study of ‘non-traditional’ students at one ancient university in Scotland. We indicate the ways in which the tension between the technicist spaces of the neo-liberal university and its empathetic, caring spaces are mediated by students as they make their way through their degrees. We argue that caring relationships with staff are of central importance to students’ well-being and success at university, and that students actively seek to construct support when and where they need it.

Aims and Objectives: to undertake an analysis of UK national daily newspaper coverage of accident and emergency treatment targets, in order to understand if the media could be seen to be creating a scandal. Background: Emergency Department treatment targets have become common in developed countries. In the United Kingdom (UK), hospitals are required to treat and discharge patients within four hours, and statistics are published daily. Breaches of targets are regularly reported by the UK print media. Design: exploratory research of tabloid newspaper articles that reported on four-hour treatment targets in the UK during a seven-month period over the winter of 2014-15 (n=1,317). An interpretivist thematic approach was utilised during analysis. Results: The main ‘problem’ identified by newspapers was the failure to meet the target, rather than negative effects on patient care (where they existed). Proposed solutions were diverse. Many articles did not describe who was to blame for the failure. Conclusion: We conclude that the media created a feeling of scandal, and hypothesise that this is related to political reasons and the availability of data on a daily basis. Relevance to clinical practice: it is important for nursing staff to understand the influence of the media on patients and how stories are reported.

Background: Alcohol consumption has posed well-documented problems for Scottish society in terms of morbidity, mortality, and wider societal costs. Objectives: To investigate the lived experiences and drinking behaviors of people with alcohol-related harm in Scotland against a backdrop of recent economic downturn, falling incomes, welfare reform, and changes to state benefits. Methods: As part of a larger Scottish study (2012–2014) of 639 individuals attending hospital or admitted, relating to an alcohol problem, 20 participants completed semistructured interviews about their drinking and purchasing habits that were subjected to thematic analysis. Conclusions: Key themes elucidated participants’ everyday drink-related behaviors within their local environment including drinking triggers, sourcing alcohol, resourcing alcohol purchase, and views relating to substitution. The majority of participants had experienced reduced income and adapted their alcohol-purchasing behaviors accordingly, including “trading down” to cheaper alcohol. A reduction in food purchasing and heating was a common outcome, as was falling into, or increasing current, debt. More attention should be paid to the prevalence and accessibility of alcohol within local communities. Ultimately, as long as there is highly visible and easily accessible cheap alcohol, heavy drinkers may struggle to undertake positive steps to reduce their damaging consumption levels.

Mental health tribunals are responsible for making decisions about compulsory treatment for individuals considered a risk to themselves and others due to mental disorder. They are generally designed to provide safeguards for individuals subject to compulsory treatment by testing whether national legislative criteria and international human rights standards have been met. Despite this, they have been criticised for being dominated by the medical domain, focusing rigidly on legal criteria and for restricting human rights, including the rights to liberty and access to justice. As a result, questions have arisen over the extent to which mental health tribunals are in‐ deed operating in line with their legislative intentions and international human rights requirements. The aim of this systematic review was to synthesise international evidence on this and to assess the extent to which this is reflected in such literature. A systematic search of the literature was conducted on the 17 April 2018 for articles published between 2000 and 2018 in MEDLINE, CINAHL, PsychINFO, ASSIA and Web of Science. All study designs were included within this review, provided they reported empirical findings. Thirty‐two studies met the inclusion criteria. Eight themes were identified across the literature and these were participation, information and understanding, patient representation, the power of the medical domain, feelings of powerlessness, perceptions of fairness, risk and the impact on relation‐ ships. The findings call into question whether mental health tribunals necessarily operate in compliance with international human rights standards. This article suggests that mental health tribunals may need to do more to safeguard legislative principles and human rights standards that promote patient autonomy.

BackgroundMeta-ethnography is a commonly used methodology for qualitative evidence synthesis. Research has identified that the quality of reporting of published meta-ethnographies is often poor and this has limited the utility of meta-ethnography findings to influence policy and practice.ObjectiveTo develop guidance to improve the completeness and clarity of meta-ethnography reporting.Methods/designThe meta-ethnography reporting guidance (eMERGe) study followed the recommended approach for developing health research reporting guidelines and used a systematic mixed-methods approach. It comprised (1) a methodological systematic review of guidance in the conduct and reporting of meta-ethnography; (2) a review and audit of published meta-ethnographies, along with interviews with meta-ethnography end-users, to identify good practice principles; (3) a consensus workshop and two eDelphi (Version 1, Duncan E, Swinger K, University of Stirling, Stirling, UK) studies to agree guidance content; and (4) the development of the guidance table and explanatory notes.ResultsResults from the methodological systematic review and the audit of published meta-ethnographies revealed that more guidance was required around the reporting of all phases of meta-ethnography conduct and, in particular, the synthesis phases 4–6 (relating studies, translating studies into one another and synthesising translations). Following the guidance development process, the eMERGe reporting guidance was produced, comprising 19 items grouped into the seven phases of meta-ethnography.LimitationsThe finalised guidance has not yet been evaluated in practice; therefore, it is not possible at this stage to comment on its utility. However, we look forward to evaluating its uptake and usability in the future.ConclusionsThe eMERGe reporting guidance has been developed following a rigorous process in line with guideline development recommendations. The guidance is intended to improve the clarity and completeness of reporting of meta-ethnographies, and to facilitate use of the findings within the guidance to inform the design and delivery of services and interventions in health, social care and other fields. The eMERGe project developed a range of training materials to support use of the guidance, which is freely available atwww.emergeproject.org(accessed 26 March 2018). Meta-ethnography is an evolving qualitative evidence synthesis methodology and future research should refine the guidance to accommodate future methodological developments. We will also investigate the impact of the eMERGe reporting guidance with a view to updating the guidance.Study registrationThis study is registered as PROSPERO CRD42015024709 for the stage 1 systematic review.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

IntroductioneHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.MethodsMixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.ResultsSurveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.ConclusionIntervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

PURPOSE:\ud In an earlier randomised controlled trial, we showed that early stage breast cancer patients who received a supervised exercise programme, with discussion of behaviour change techniques, had psychological and functional benefits 6 months after the intervention. The purpose of this study was to determine if benefits observed at 6 months persisted 18 and 60 months later.\ud METHODS:\ud Women who were in the original trial were contacted at 18 and 60 months after intervention. Original measures were repeated.\ud RESULTS:\ud Of the 148 women from the original study who agreed to be contacted again, 114 attended for follow-up at 18 months and 87 at 60 months. Women in the original intervention group reported more leisure time physical activity and more positive moods at 60 months than women in the original control group. Irrespective of original group allocation, women who were more active consistently reported lower levels of depression and increased quality of life compared to those who were less active.\ud CONCLUSIONS:\ud We have shown that there are lasting benefits to an exercise intervention delivered during treatment to breast cancer survivors. Regular activity should be encouraged for women with early stage breast cancer as this can have lasting implications for physical and psychological functioning.

Background Personal asthma action plans (PAAPs) have been guideline recommended for years, but consistently under-issued by health professionals and under-utilised by patients. Previous studies have investigated sub-optimal PAAP implementation but more insight is needed into barriers to their use from the perspective of professionals, patients and primary care teams. Methods A maximum variation sample of professional and patient participants were recruited from five demographically diverse general practices and another group of primary care professionals in one Scottish region. Interviews were digitally recorded and data thematically analysed using NVivo. Results Twenty-nine semi-structured interviews were conducted (11 adults with asthma, seven general practitioners, ten practice nurses, one hospital respiratory nurse). Three over-arching themes emerged: 1) patients generally do not value PAAPs, 2) professionals do not fully value PAAPs and, 3) multiple barriers reduce the value of PAAPs in primary care. Six patients had a PAAP but these were outdated, not reflecting their needs and not used. Patients reported not wanting or needing PAAPs, yet identified circumstances when these could be useful. Fifteen professionals had selectively issued PAAPs with eight having reviewed one. Many professionals did not value PAAPs as they did not see patients using these and lacked awareness of times when patients could have benefited from one. Multi-level compounding barriers emerged. Individual barriers included poor patient awareness and professionals not reinforcing PAAP use. Organisational barriers included professionals having difficulty accessing PAAP templates and fragmented processes including patients not being asked to bring PAAPs to their asthma appointments. Conclusions Primary care PAAP implementation is in a vicious cycle. Professionals infrequently review/update PAAPs with patients; patients with out-dated PAAPs do not value or use these; professionals observing patients’ lack of interest in PAAPs do not discuss these. Patients observing this do not refer to their plans and perceive them to be of little value in asthma self-management. Twenty-five years after PAAPs were first recommended, primary care practices are still not ready to support their implementation. Breaking this vicious cycle to create a healthcare context more conducive to PAAP implementation requires a whole systems approach with multi-faceted interventions addressing patient, professional and organisational barriers. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0352-4) contains supplementary material, which is available to authorized users.

Background: low back pain (LBP) is a major cause of work absence. Assisting individuals back into work is an important part of rehabilitation. Objective: to explore the experiences of individuals returning to work after an episode of sickness absence due to LBP. Participants: Five women employed by a UK University who had returned to work. Method: in this qualitative study, participants underwent semi-structured interviews about their experiences. The transcripts were analysed using interpretative phenomenological analysis. Results: two primary themes emerged 1) perceived pressure to return to work and 2) strategies employed to relieve the pressure to return. Pressure to return to work arose from a number of sources including guilt and a personal work ethic, internally, and from colleagues and management, externally. This pressure led to the individual employing a number of strategies to reduce it. These ranged from a simple denial of health concerns and decision to return to work regardless of their condition, to placing the responsibility of the decision not to return to work onto a significant other, such as a family member or health care professional. Cconclusions: individuals returning to work with LBP experience considerable pressure to return and use a range of strategies to mediate that pressure.

ObjectivesCell-derived microparticles (MPs) are small plasma membrane-derived vesicles shed from circulating blood cells and may act as novel biomarkers of vascular disease. We investigated the potential of circulating MPs to predict (a) carotid plaque instability and (b) the presence of advanced carotid disease.MethodsThis pilot study recruited carotid disease patients (aged 69.3 ± 1.2 years [mean ± SD], 69% male, 90% symptomatic) undergoing endarterectomy (n = 42) and age- and sex-matched controls (n = 73). Plaques were classified as stable (n = 25) or unstable (n = 16) post surgery using immunohistochemistry. Blood samples were analysed for MP subsets and molecular biomarkers. Odds ratios (OR) are expressed per standard deviation biomarker increase.ResultsEndothelial MP (EMP) subsets, but not any vascular, inflammatory, or proteolytic molecular biomarker, were higher (p < .05) in the unstable than the stable plaque patients. The area under the receiver operator characteristic curve for CD31+41− EMP in discriminating an unstable plaque was 0.73 (0.56–0.90, p < .05). CD31+41− EMP predicted plaque instability (OR = 2.19, 1.08–4.46, p < .05) and remained significant in a multivariable model that included transient ischaemic attack symptom status. Annexin V+ MP, platelet MP (PMP) subsets, and C-reactive protein were higher (p < .05) in cases than controls. Annexin V+ MP (OR = 3.15, 1.49–6.68), soluble vascular cell adhesion molecule-1 (OR = 1.64, 1.03–2.59), and previous smoking history (OR = 3.82, 1.38–10.60) independently (p < .05) predicted the presence of carotid disease in a multivariable model.ConclusionsEMP may have utility in predicting plaque instability in carotid patients and annexin V+ MPs may predict the presence of advanced carotid disease in aging populations, independent of established biomarkers.

Background Long-standing randomised controlled trial (RCT) evidence indicates that asthma action plans can improve patient outcomes. Internationally, however, these plans are seldom issued by professionals or used by patients/carers. To understand how the benefits of such plans might be realised clinically, we previously investigated barriers and facilitators to their implementation in a systematic review of relevant RCTs and synthesised qualitative studies exploring professional and patient/carer views. Our final step was to integrate these two separate studies. Methods First, a theoretical model of action plan implementation was proposed, derived from our synthesis of 19 qualitative studies, identifying elements which, if incorporated into future interventions, could promote their use. Second, 14 RCTs included in the quantitative synthesis were re-analysed to assess the extent to which these elements were present within their interventions (that is, ‘strong’, ‘weak’ or ‘no’ presence) and with what effect. Matrices charted each element’s presence and strength, facilitating analysis of element presence and action plan implementation. Results Four elements (professional education, patient/carer education, (patient/carer and professional) partnership working and communication) were identified in our model as likely to promote asthma plan use. Thirteen interventions reporting increased action plan implementation contained all four elements, with two or more strongly present. One intervention reporting no effect on action plan implementation contained only weakly present elements. Intervention effectiveness was reported using a narrow range of criteria which did not fully reflect the four elements. For example, no study assessed whether jointly developed action plans increased use. Whilst important from the professional and patient/carer perspectives, the integral role of these elements in intervention delivery and their effect on study outcomes was under-acknowledged in these RCTs. Conclusions Our novel approach provides an evidence-base for future action plan interventions. Such interventions need to ensure all elements in our implementation model (patient/carer and professional education to support development of effective partnership working and communication) are strongly present within them and a wider range of criteria better reflecting the realities of clinical practice and living with asthma are used to measure their effectiveness. We now intend to test such a complex intervention using a cluster trial design.

Working models of attachment are internal depictions of self relative to others and have been described in terms of two dimensions: (1) attachment avoidance and (2) attachment anxiety. An exploratory qualitative study was carried out to build understandings about women with Turner Syndrome (TS) and the psychosocial impact their infertility has upon salient relationships. In one-to-one semi-structured interviews, five women with TS were asked: How do you perceive your womanhood and infertility status has affected your relationships with: (1) the opposite sex, (2) siblings and (3) peers? In opposite-sex relationships, infertility status was found to arouse fear of ending up alone and anxiety over engaging in romantic relationships. In sibling relationships, jealousy was expressed in relation to disparity with sister(s) more natural maturation to womanhood, and, within peer relationships, consequences from divulging infertility status created attachment avoidance with friends. Further investigation in this area is merited.

Purpose: this paper aims to critically explore the consequences of how Scotland interprets the UK Misuse of Drugs Act (1971). Scotland prosecutes 24 per cent of people found in possession of illegal drugs for drug “dealing” compared to less than 15 per cent in England and Wales and less than 16 per cent in Northern Ireland.Design/methodology/approach: the paper provides a narrative review in the context of the background of the economic and social costs of illegal drugs in Scotland and compares this with the UK and Northern Ireland.Findings: the explanation for such a wide disparity in numbers of dealers between these countries proposed is that the Scottish police force is comparatively more successful at persuading courts that small quantities of drugs rather than for personal use are in fact for onward sale or supply to others.Practical implications: the police in Scotland have a network of specialist drug units in which officers make decisions in the absence of benchmarks against which to judge quantities of repossessed drugs. Taking this approach, a devolved Scotland's commitment to drug prohibition has resulted in some very curious differences in classifications of prosecutions compared to other countries.Originality/value: the paper explores the consequences of how Scotland deals with the use of illegal drugs and the economic and social costs.

Educators in healthcare face significant challenges trying to improve interprofessional teamworking skills, with a lack of clarity on how to teach and evaluate such skills. Previously, the team objective structured clinical encounter (TOSCE) has been reported as a teaching and assessment tool, but it has been used primarily in homogenous groups of undergraduates. An interprofessional team of educators set out to evaluate the TOSCE as a teaching intervention amongst a large interprofessional group of postgraduate nurses and midwives. After the TOSCE, 83% of participants reported that they were more aware of potential weaknesses in teamworking and 60% felt more able to work in a team. Mean Likert scale ratings were 4/5 for usefulness, enjoyment and relevance. The TOSCE is a feasible tool for teamwork skill assessment in the demanding postgraduate interprofessional setting and requires further investigation to ascertain its potential for formative and summative assessment of skills.

(Macro)-autophagy is a homeostatic process by which eukaryotic cells dispose of protein aggregates and damaged organelles. Autophagy is also used to degrade micro-organisms that invade intracellularly in a process termed xenophagy. Genome-wide association scans have recently identified autophagy genes as conferring susceptibility to Crohn’s disease (CD), one of the chronic inflammatory bowel diseases, with evidence suggesting that CD arises from a defective innate immune response to enteric bacteria. Here we review the emerging role of autophagy in CD, with particular focus on xenophagy and enteric E. coli strains with an adherent and invasive phenotype that have been consistently isolated from CD patients with ileal disease.

A demographic survey of London sex-workers established age, nationality, alcohol/drug use, physical/mental health concerns and whether trafficked or optionally migrated into the industry. There are overt differences between sex-workers—implications for police, health and social workers are that welfare services tailor care to meet individual needs within this population.

Helicobacter pyloriinfection, often acquired in early childhood, is a global cause of undernutrition, gastritis, peptic ulcer disease and gastric carcinoma. This study tested the feasibility of usingH. pylorished in the faeces as a source of DNA for non-invasive epidemiological studies.H. pyloriDNA was chemically recovered and isolated using a specific biotinylated oligonucleotide probe with magnetic capture from 28H. pyloripositive faecal samples obtained from children attending hospital for the investigation of suspectedH. pyloriinfection, together with close family members. Random amplification of polymorphic DNA (RAPD) was subsequently used to discriminate each isolate. 93% of stool samples selected were typeable. Parent, child and sibling samples were compared and similarities determined. Phylogenetic analysis showed thatH. pyloriDNA obtained from the faeces can be used to genotype individual strains, offering a means of studying intrafamilial transfer of this microorganism.

Nurse education is characterised by dissonance, ambiguity and uncertainty. Such a context makes demands on the educator’s authenticity or sense of self. This paper reports an attempt to provide a space where dissonance, ambiguity and uncertainty could be held, tolerated and examined and where authenticity could be recovered or developed through the practice of artistry. Three art workshops were offered to 8 nurse educators over a period of three months. Each of the participants and the co-facilitator were subsequently interviewed. All welcomed the opportunity to find meaning in their practice and to be listened to in a climate of empathy, acceptance and congruence. They undertook novel activities that allowed for discovery and surprise. They explored their sense of self and coined fresh metaphors to communicate their experiences. The paper argues that there is room for approaches to academic staff development that go against the mainstream.

PurposeWithin maternity hospitals midwives are expected to follow the protocol‐driven culture and orders issued by senior staff. Simultaneously, midwives are expected to follow social policy documents and the Midwives Rules and Standards that advocate choice provision for childbearing women. Quality assurors and auditors of clinical practice need to be aware that these two directives sometimes clash. Allegiance to a hierarchical system driven by protocols and orders from the top down, at the same time as providing “woman‐centred” care is often unattainable. In order for a midwife to action the woman's choice, resourceful thinking may be required. This paper aims to examine this issue.Design/ methodology/approachA descriptive interview study set out to discover strategies which midwives use to resolve conflict produced from competing directives. An appraisal of 20 midwives' views were gained from semi‐structured interviews conducted in seven maternity units in the UK. Taking a post‐positivist approach, inductive thematic analysis was used to interpret the data.FindingsThree main categories represented resourceful ways of pleasing both authority and the childbearing woman. Midwives occasionally: are economical with the truth; circumvent face‐to‐face confrontation with senior staff; and persuade women to refuse what they perceive are unnecessary and invasive interventions.Originality/valueThis paper offers unique insights into methods that midwives use to resolve conflicts in direction issued by management. It is important that auditors are aware that midwives sometimes struggle to support the preferences of healthy childbearing women. This reduces job satisfaction, delivery of care and consequently requires address.

This paper outlines a large-scale audit for the enhancement of quality of care and staff and patient safety using passive RFID (Radio Frequency ID) wrist bands, which link to a patient's database, in order to reduce errors in patient care. It has been developed with a collaboration between the University Hospital, Birmingham, UK and Napier University, UK. The key feature of the work is the usage of passive RFID tags as an integral part of a low budget out-of-the box strategic patient information system which should be compatible with most hospital IT systems.

Background Qualitative methods are increasingly used to study the process of clinical trials and patients understanding of the rationale for trials, randomisation and reasons for taking part or refusing. Patients' understandings are inevitably influenced by the recruiting clinician's understanding of the trial, yet relatively little qualitative work has explored clinicians' perceptions and understandings of trials. This study interviewed surgeons shortly after the multi-centre, pragmatic RCT in which they had participated had been completed. Methods We used in-depth interviews with surgeons who participated in the Spine Stabilisation Trial (a pragmatic RCT) to explore their understanding of the trial purpose and how this understanding had influenced their recruitment procedures and interpretation of the results. A purposive sample of eleven participating surgeons was chosen from 8 of the 15 UK trial centres. Results Although the surgeons thought that the trial was addressing an important question there was little agreement about what this question was: although it was a trial of 'equivalent' treatments, some thought that it was a trial of surgery, others a trial of rehabilitation and others that it was exploring what to do with patients in whom all other treatment options had been unsuccessful. The surgeons we interviewed were not aware of the rationale for the pragmatic inclusion criteria and nearly all were completely baffled about the meaning of 'equipoise'. Misunderstandings about the entry criteria were an important source of confusion about the results and led to reluctance to apply the results to their own practice. Conclusion The study suggests several lessons for the conduct of future multi-centre trials. Recruiting surgeons (and other clinicians) may not be familiar with the rationale for pragmatic designs and may need to be regularly reminded about the purpose during the study. Reassurance may be necessary that a pragmatic design is not considered a design fault. We conclude that it does matter if clinicians do not understand the rationale for the trial if, as we have shown here, their perception of the trial aims and methods adversely affects who they recruit; if their views affect what the patients are told; and if they mistakenly view the results as unscientific, unreliable and ultimately irrelevant to their practice.

Objectives To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain. Design Multicentre randomised controlled trial. Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom. Participants 349 participants aged 18-55 with chronic low back pain of at least one year's duration who were considered candidates for spinal fusion. Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy. Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure. Results 176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was –4.1 (95% confidence interval –8.1 to –0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures. Conclusions Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.

Objective: To evaluate a progressive fitness programme for patients with chronic low back pain. Design: Single blind randomised controlled trial. Assessments were carried out before and after treatment by an observer blinded to the study and included a battery of validated measures. All patients were followed up by postal questionnaire six months after treatment. Setting: Physiotherapy department of orthopaedic hospital. Subjects: 81 patients with chronic low back pain referred from orthopaedic consultants for physiotherapy. The patients were randomly allocated to a fitness programme or control group. Intervention: Both groups were taught specific exercises to carry out at home and referred to a back-school for education in back care. Patients allocated to the fitness class attended eight exercise classes over four weeks in addition to the home programme and backschool. Results: Significant differences between the groups were shown in the changes before and after treatment in scores on the Oswestry low back pain disability index (P Conclusion: There is a role for supervised fitness programmes in the management of moderately disabled patients with chronic low back pain. Further clinical trials, however, need to be established in other centres to confirm these findings. Key messages Key messages Recent research suggests a need for a more dynamic approach with a move away from long term rest towards progressive activity and exercise This study shows that a supervised fitness programme can help to reduce pain and disability and improve patients9 confidence Beneficial effects of treatment were maintained six months after treat- ment when compared with a control group who were advised to exercise independently Simply advising patients with low back pain to exercise is not effective in reducing disability and pain

Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health. For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems. It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research., Highlights • We examined cancer outcomes in six developed countries with comparable healthcare systems. • Clear differences exist in cancer outcomes between countries with comparable healthcare systems. • Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential. • Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.

Younger People with Dementia (YPwD) are those who receive a diagnosis of dementia under the age of 65. In Scotland the number of people with dementia who meet this definition is approximately 3200 (Alzheimer Scotland, 2017). The purpose of this study was to explore the human experience of living with dementia at a younger age and to consider interpretations of well-being as defined by the subjective experience of the participants. At the start of this study there was limited quality research available which explored the lives and experiences of YPwD. At that time there was some recognition within professional groups and practitioners that YPwD would benefit from age appropriate services. This study used an Interpretive Phenomenological design to explore the experiences of YPwD and used in-depth qualitative interviews with eight people who were diagnosed with dementia under the age of 65, to capture their journey through pre-diagnosis, diagnosis and beyond. Interpretive Phenomenological Analysis was utilised for the primary analysis. A secondary analysis was then conducted with the initial findings using Self-determination Theory, Basic Psychological Needs Theory, autonomy, competence and relatedness to identify areas of well-being.The study identified four superordinate themes situated within a four phase transition pathway, which identified how a diagnosis of dementia impacted on the person and the process they underwent following diagnosis. These are:pre-diagnosis phase, living in a changing world, awareness of the changing self, discombobulation; diagnostic phase, anger and relief, the fragmented self, consideration; post diagnostic phase, the challenge of learning to livewith dementia as a younger person, the evolving self, assimilation; and the phase living well beyond dementia, consolidated self, consolidation. The study highlighted that while having a diagnosis of dementia at a younger age is a challenging and devastating experience, it is possible to live a good and productive life beyond the diagnosis of dementia.The secondary analysis using Self-determination Theory, Basic Psychological Needs Theory identified that where the basic psychological needs were supported, this enabled participants to embrace their lives living with and beyond dementia with improved wellbeing. The findings suggest that the basic psychological needs were thwarted in the pre-diagnostic phase and during and immediately after diagnosis, creating feelings of ill-being. The study acknowledges the strong sense of identity around the younger person with dementia and suggests that this group perceive their dementia, and the support they need to live with the condition to be a different experience to that of older people. The ability of a number of the participants to live an active life within a supported community cannot be underestimated, and suggests that this area of care and support needs to be evaluated in light of the changing needs of people living with dementia, particularly those who are diagnosed at such an early part of their lifecycle.

Background: Fifty percent of medications are not taken as prescribed. This is a major public health issue yet there is very limited evidence on the factors associated with medicines adherence in people with mild to moderate Intellectually Disabilities and diabetes (IDD). This study evaluated the frequency of, and factors associated with, medicines non-adherence in this group compared to people without ID but with diabetes (non-IDD).Methods: A systematic review of the literature informed the theoretical model tested. A two-stage, sequential mixed methods study with 111 people with type 1 and 2 diabetes, (IDD = 33, non-IDD = 78) was then carried out. Stage one (quantitative) compared frequency of medication adherence in the group overall, IDD and non-IDD. Univariate and multiple regression analysis evaluated associations between factors (ID, depression, side effects, self-efficacy and perceived level of social support) and medicines non-adherence. Stage two (qualitative) explored findings of stage one with 12 stage one participants’ carers using semi-structured interviews.Results: Data were collected between July 2014 and May 2016. The frequency of medicines adherence was similar in the IDD and non-IDD population (70% vs 62%, p = 0.41). The theoretical model did not predict medicines non-adherence. After controlling for support with medicines and complexity of regime (number of medications and use of insulin), depression was an independent predictor in the non-IDD and group overall (p < 0.001). In the IDD group, perceived side effects was an important, but non-significant, predictor of non-adherence (p = 0.06). Carers’ perceptions of adherence and depression were consistent with stage one findings.Conclusions: Optimising adherence to diabetes medicines is equally challenging in IDD and non-IDD populations. Associations between independent factors and adherence differed between the two groups: in the non-IDD population, depressive symptoms were associated with non-adherence whereas in the IDD population perceived level of side effects appeared most dominant. Due to small sample sizes findings were inconclusive therefore, a sufficiently powered study further investigating the relationship between adherence and side effects in people with ID and diabetes is recommended.

Over the past 30 years, Senior and Advanced Nurse Practitioners (SNPs/ANPs) have been introduced into the healthcare arena across the world. The international literature reports such roles have created tensions within healthcare systems (Smith 2000; Tye & Ross 2000; Scholes & Vaughan 2002). However, over the past three decades the root causes of such tensions remain still to be addressed. The literature reports the consistent entrenched reluctance to collaboratively engage with SNP/ANP roles (Cummings et al. 2003; Reay et al. 2003; Davies 2006). This led to the aims of my Constructivist Grounded Theory (CGT) study, which were to discover why there continues to be tensions surrounding Senior and Advanced Nurse Practitioner roles in healthcare, in addition to attempting to generate a substantive theory to provide a foundation in which a hypothesis could be tested across a wider arena. Arising from these aims were three research questions which were explored in three phases. The first research question, posed in phase 1, was ‘where are tensions created by Senior and Advanced Practitioner roles from a service user and healthcare team perspective?’ This led to in-depth interviews taking place with service users (n=12) and members of the healthcare team (n=18). Theoretical sampling consisted of medical staff (n=9), nursing staff (n=7) and Allied Health Professionals (n=2). Data were considered saturated when no new data could be identified and the main categories with focused codes were coherent. The second research question, posed in phase 2 of my study, was ‘where do tensions remain apparent in service and what meanings and actions are attributed to them?’ The method of Grounded Theory Ethnography was employed, which gave priority to interactions rather than the setting. This method consisted of a 3 stepped approach, employing participative observation and individual interviews. In total, 13 periods of observation were undertaken, which equated to 64 hours of observation within different sites. The emergent categories from this phase built upon the categories from phase 1. In phase 3 the research question posed was ‘what are the interpretations of Senior and Advanced Nurse Practitioners on interactions with the healthcare team and service users?’ Six focus groups and one paired interview enabled the development of the core category “Status Games”. This subsumed the main categories from each phase and incorporated common themes and patterns across all data. This core category was further verified with five individual interviews and no new properties emerged. This core category reflected the data across all phases effectively. Interpretative theorising incorporated advanced memos across all 3 phases of my study and enabled the development of a substantive theory. Social psychological game theory and underpinning script theory, which is part of the Transactional Analysis Paradigm, provided the theoretical lens to interpret what was grounded in the data. This led to the development of two new concepts, the first was status games which incorporated game analysis and highlighted ulterior transactions which have not been previously reported in the literature. The second was the professional script concept, which it is theorised underpins status games. This is also new and has not been conceptualised in the Transactional Analysis or healthcare literature. This theoretical framework illustrated that status games which fulfil professional script are being played out with awareness. It is proposed that by recognising these concepts, this will reduce tensions with SNP/ANP roles and lead to improved patient-centred care. As Vandra (2009) reports by recognising the processes and actions of communication it is possible to bring ulterior transactions into full awareness and prevent games, thus problems with communication. This led to the development of the substantive theory in this study which is: ‘The tensions generated by SNP/ANP roles stem from playing status games to fulfil professional script which requires to be recognised and acknowledged by the healthcare team in order to change the status quo and culture’. Whilst social psychological game and script theories can provide an underpinning understanding of social games and life scripts for individuals, the status game concept which emerged from my study expands our knowledge and provides a unique understanding surrounding the impact of professional script in healthcare organisations. It is hypothesised that this script has led to status games, which is central to the tensions surrounding SNP/ANP roles.

The heart is a fundamental aspect of the human body. Significant work has been undertaken to better understand the characteristics and mechanisms of this organ in past research. Greater understanding of the heart not only provides advances in medicine but also enables practitioners to better assess the health risk of patients. This thesis approaches the study of the heart from a health informatics perspective. The questions posed in this thesis is whether research is capable of describing and modelling heart data from a statistical perspective, along with exploring techniques to improve the accuracy of clinical risk assessment algorithms that rely on this data.The contributions of this thesis may be grouped into two main areas: statistical analysis, modelling and simulation of heart data; and improved risk assessment accuracy of the Early Warning Score (EWS) algorithm using a quartile-based technique. Statistical analysis of heart data, namely RR intervals, contributes to more informed understanding of the underlying characteristics of the heart and is achieved using null-hypothesis testing through the Anderson-Darling (AD) test statistic. The modelling process of heart data demonstrates methodologies for simulation of this data type, namely individual distribution modelling and normal mixture modelling, and contributes to assessing techniques that are most capable of modelling this type of data.For improved accuracy on the EWS algorithms, a quartiles technique, inspired by anomaly-based intrusion detection systems, is presented which enables customisation of risk score thresholds for each patient defined during a training phase. Simulated heart data is used to evaluate the standard EWS algorithm against the quartile-based approach. The defined metric of accuracy ratio provides quantitative evidence on the accuracy of the standard EWS algorithm in comparison with the proposed quartile based technique.Statistical analysis in this thesis demonstrates that samples of heart data can be described using normal, Weibull, logistic and gamma distribution within the scope of two minute data samples. When there is strong evidence to suggest that RR intervals analysed fits a particular distribution, individual modelling technique is the ideal candidate whilst normal mixture modelling is better suited for long-term modelling, i.e. greater than two minutes of heart data. In comparative evaluation of the standard EWS algorithm and the quartile-based technique using modelled heart data, greater accuracy is demonstrated in the quartiles-based technique for patients whose heart rate is healthy, but outside the normal ranges of the general population.

Rheumatoid Arthritis (RA) is a systemic autoimmune disease that develops when the immune system loses tolerance to self, resulting in effector cells erroneously causing joint damage. Despite advances in biological therapy there is currently no cure for RA. Regulatory T-cells (Tregs) can regulate a broad range of immune effector cells when specific antigens (Ag) activate them through their individual T cell receptors (TCR). Using retroviral gene transfer, Tregs can be modified to express a chosen disease-related TCR, producing an Ag-specific Treg population that can target and suppress inflammatory arthritis in murine models. In this study the aim was to validate a reproducible method of generating Ag-specific Tregs from human peripheral blood. The results of this research demonstrates the successful TCR transduction into isolated human Treg cells. This was achieved by completing the outlined objectives to optimise the transduction process and the isolation of Tregs from peripheral blood. By sorting on the CD4+CD25+CD127dim cell population, Tregs were isolated and the purity of the population demonstrated by the high percentage of FoxP3 expressing cells. The results further show that FoxP3 is maintained after the transduction process. It is now necessary to demonstrate the working functional capacity of the transduced Tregs using a robust antigen-specific suppression assay. With the future goal of transitioning this approach into a human clinical setting, the method requires further validation to prove a reproducible method of generating Ag-specific Tregs from human peripheral blood taken from RA patients. This has implications for the advancement for adoptive Treg therapy to treat RA and other autoimmune diseases and will highlight the necessity of considering treatments in the context of an inflammatory environment. It will be important to understand the nature of any defects in the Treg subsets and how these might be corrected.

Microspheres have become an important material in the biomedical and environmental sciences, particularly for use in the detection of pathogenic microorganisms and toxins as well as for use as carriers in drug delivery. In this study, their use in microbial detection, with particular emphasis on immunochromatographic assays, was investigated. Two main types of microspheres were studied: colloidal gold and polymeric. The original plan to combine the use of colloidal gold and fluorescentdye-labelled PMMA microspheres as a signal generator, in order to enhance detection signals and improve detection limit, was abandoned when preliminary detection experiments showed that the use of colloidal gold was not so beneficial after all, taking into account the amount of light lost to absorption by the gold particles. Therefore, it was decided to use Rhodamine B-labelled PMMA microspheres. PMMA particles, both unlabelled and internally labelled with Rhodamine B, were synthesised by emulsion polymerisation and yielded monodisperse particles of around 200 nm and 300 nm, respectively. An attempt to co-polymerise MMA with HEMA to form 200 nm-sized monodisperse P(MMA-HEMA) microspheres in order to create functional –OH groups on the microsphere surface to be used in chemical covalent coupling with monoclonal antibodies resulted in aggregated microspheres and non-uniform particles, and were therefore not used for covalent coupling. Attachment of monoclonal antibodies onto the surface of Rhodamine-B labelled PMMA microspheres by passive adsorption also resulted in aggregated particles. Diffusion and detection experiments were carried out on the Rhodamine-B labelled PMMA microspheres. Diffusion of PMMA microspheres along a nitrocellulose strip was found to be 42% slower than the diffusion of colloidal gold along a nitrocellulose strip. Using a spectrophotometer, detection experiments were performed on dilutions of an original stock solution of 1% w/v PMMA in distilled water. The detection limit was found to be of the order of 10-3. This study has investigated the materials that constitute an immunochromatographic assay and has illustrated some of the complications associated with the synthesis of copolymer microspheres and immobilisation of antibodies onto their surfaces. Further work on how to improve on the methods discussed in this study have also been recommended.

Exercise is currently recommended for indivduals with type 1 diabetes since it is associated with physiological and psychological benefits (American Diabetes Association Position Statement, 2004; American College of Sports Medicine, 2010).However participation in exercise can increase the risk of experiencing hypoglyceamia, both during exercise and recovery (Rabasa-Lhoret et al., 2001). Through discussions with practitioners that work with individuals that have type 1 diabetes, the development of clear evidence -based guidelines regarding adjustments in insulin doses and carbohydrate intake may help prevent the risk of exercise induced hypoglyceamia.Specifically, there are limited evidence based guidelines for participation in intermittent high intensity exercise (IHE), which represents activity patterns of team and field based sports. Consequently, the aim of this thesis is to investigate the effects of a structured intervention for insulin and carbohydrate adjustment on blood glucose responses during and after IHE that replicates team and field based sports in individuals with type 1 diabetes.Seven well-controlled participants with type 1 diabetes were tested on three separate occasions and interstitial glucose concentration was measured up to breakfast the following day on each occasion using a Continuous Glucose Monitor (CGM). The first phase of this study compared a 30% post-exercise fast-acting analogue insulin reduction on the blood glucose responses to an afternoon bout of IHE (40 minutes of cycles of walking for 5 minutes at 40% O V 2 max, jogging for 3 minutes at 70% O V 2 max and sprinting for 5 seconds at 125% O V 2 max) vs. continuous moderate intensity exercise (40 minutes at 50% O V 2 max). Results showed there was no significant difference between the CGM readings for moderate or IHE (p= 0.59) at any point during the 40minute exercise protocols and up to breakfast the following day. There was a significant change in interstitial blood glucose concentration over time regardless of exercise condition (p< 0.001). Regardless of exercise condition both moderate and IHE is characterised by the risk of Late Onset Post-Exercise Hypoglycaemia (LOPEH). In addition there appears to be a problem of hyperglycaemia, particularly two-four hours after the meal and insulin reduction.The second phase of the study compared the blood glucose responses to a 30% vs. a 50% post-exercise fast-acting analogue insulin reduction after a bout of afternoon IHE in individuals with type 1 diabetes. There was no significant difference in interstitial blood glucose responses as measured by CGM between the two insulin reductions and 50% insulin reduction is no better for the prevention of LOPEH than the 30% reduction after IHE (p= 0.06). Blood glucose responses were similar for the same IHE on two separate occasions and there was a significant decrease in in interstitial blood glucose concentration as measured by CGM from 0-40 minutes of exercise (p= 0.002). As observed in phase 1, the problem of hyperglycaemia was also evident.In conclusion, there are two main high-risk periods for the development of hypoglycaemia associated with IHE. The first is immediately after exercise and the second later on during the night. In addition hyperglycaemia seems to be a problem for up to four hours following the evening meal after exercise. It is important to make patients aware of this, in order to prevent the long term complications associated with such. Regardless, individuals vary in their responses to exercise and individual strategies to combat hypoglycaemia may be required. A number of limitations are acknowledged within this study, however is they were eradicated, future research of this kind could have implications for the development of guidelines for the management of blood glucose concentration during and after IHE.

This thesis investigates the effects of various inflammatory stimuli, including cytokines and air pollution particles, on the expression and secretion of various proinflammatory proteins in the lung epithelial cell line A549. The pro-inflammatory proteins investigated were C-reactive protein (CRP), fibrinogen, and heat shock protein 70 (Hsp70), all of which are known to be produced during inflammation andare also known risk factors for cardiovascular disease. These proteins were investigated because inhalation of particulate air pollution has been associated with increased cardiovascular disease and mortality. The production of these proteins in the lung may be involved in a systemic inflammatory response which increases the plasma levels of these proteins and other cardiovascular risk factors thereforeincreasing the susceptibility for cardiovascular events. Alternatively, localised CRP functions as an opsonin, while fibrinogen and its degradation products are involved in the recruitment of neutrophils and leukocytes to the lung.Both CRP and fibrinogen are known to be produced in hepatocytes in response to cytokines. Chapter 3 investigates the effect of cytokine treatment of the A549 cellswhich shows that CRP and fibrinogen can be induced in this cell line by various cytokines. CRP was found to be induced by the cytokines ILI b, IL6, IL8, TNF(a and IFN7 with increased effects shown by simultaneous treatment with two cytokines. Fibrinogen was found to be induced mainly by IL6, but fibrinogen levels were alsoslightly increased by ILlb; simultaneous treatments of IL6 with either ILlb or TNF(a reduced the effect of IL6 treatment. Treatment of A549 cells with IL6 and IL8 simultaneously induced a synergistic effect.After establishing that cytokines induce the expression of CRP in A549 cells, the effects of particulate air pollution on pro-inflammatory protein expression were then investigated (chapter 4). The cells were treated with carbon black (CB), ultrafine CB (ufCB), and iron chloride (FeC13) to find out what effect these air pollution components and PM10 would have on the expression of CRP, fibrinogen, Hsp70 and the transcription factor NFKB and its inhibitor IKB. NFKB is known be activated by PM10 and is involved in the signalling of pro-inflammatory responses. All the particulate treatments induced a pro-inflammatory response with expression and secretion of CRP, fibrinogen, and Hsp70, whereas the soluble metal treatment had little effect. The metal salt FeC13w as used to treat the cells since it has been suggested that PM10 may mediate its effect through the presence of transition metals which are implicated in oxidant generation. The particulate exposures were also associated with the activation and nuclear translocation of NFKB indicating the involvement of NFKB and IxB in the induction of the pro-inflammatory response.Investigations into the mechanisms by which the particles induced the proinflammatory response are discussed in chapter 5. Firstly, investigations into the effect of particles on the secretion of the pro-inflammatory proteins were carried out; these indicated that particles were capable of inducing the secretion of CRP, flbrinogen and Hsp70. Investigations into the transcriptional mechanisms of proinflammatory protein expression were carried out using specific inhibitors. CRP and fibrinogen were induced in an NFKB dependent manner, while Hsp70 was produced as a result of activation of the JAK/STAT pathway. The effect of oxidative stress being induced as a result of particle exposure was investigated using antioxidants. This showed a reduction in the amount of intracellular and secreted CRP, fibrinogen and Hsp70 in the presence of antioxidants, indicating that oxidative stress was involved. This correlated with a reduction in the levels of intracellular ATP. Finally in chapter 6 the effects of proteins secreted from A549 cells on the monocytelike cell line MM6 were examined. This was carried out as a model of the effects of secreted pro-inflammatory proteins from the lung epithelium on other cells. It was found that CRP and fibrinogen were able to induce the activation of NFkB in MM6 cells, indicating that secretion of these proteins during lung inflammation could have an effect on other resident lung cells. Conditioned medium from A549 cells was also found to induce the expression of pro-inflammatory proteins including CRP, fibrinogen, Hsp70, IL6, IL8 and TNFcc. The A549 conditioned medium also appeared to induce a stress response and cellular damage in MM6 cells, thereby potentially exacerbating the inflammatory response.These results indicate that pro-inflammatory proteins can be produced in lung epithelial cells in response to particle exposure as a result of oxidative stress. They may be involved in the progression of localised lung inflammation and in the systemic response to particulate air pollution.