Morbidity following hip and knee arthroplasty has previously been poorly recorded. This is the first time the Post-Operative Morbidity Survey (POMS) has been used for this purpose. The POMS identifies clinically significant morbidity using indicators of organ system dysfunction rather than traditional diagnostic categories. The most common types of morbidity following hip and knee arthroplasty are infection and renal morbidity. Pulmonary, pain and gastro-intestinal morbidity are less common. Cardiovascular, wound, neurological and haematological morbidity are least common. Many arthroplasty patients remain in hospital without morbidity. The POMS identifies these patients and thus has potential as a prospective bed utilisation tool. To be used for this purpose, the POMS must identify all clinically significant morbidity. Mobility is an important factor for safe discharge of arthroplasty patients. Addition of a ‘mobility’ domain could improve the utility of POMS as a bed utilisation tool following orthopaedic surgery. This study showed no association between post-operative morbidity defined by the POMS and longer-term patient-reported outcome measures (PROMs). This study does not support the POMS as an early surrogate marker of long-term PROMs in orthopaedic patients. The wound domain of the POMS has a high specificity, reasonable sensitivity, high negative predictive value and low positive predictive value compared to the inpatient ASEPSIS (Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, inpatient Stay over 14 days) score. The wound domain of POMS could be replaced with a validated definition of wound infection such as ASEPSIS. On the same series of orthopaedic patients, surgical site infection (SSI) rate according to the Centres for Disease Control (CDC) definition was 15.45%, according to the Nosocomial Infection National Surveillance Scheme (NINSS) definition was 11.32% and according to the ASEPSIS definition was 8.79%. This highlights the need for a consistent definition of SSI.

Facial palsy is a devastating condition. The gold standard treatment for chronic unilateral facial palsy is a functional muscle transfer reinnervated by a branch of the contralateral facial nerve via a cross-facial nerve graft. However, the few published long-term clinical series indicate that the outcome is unpredictable. Approximately half of all patients achieve a clinically satisfactory result, the rest experiencing underactivity or overactivity of the transferred muscle. Previous work using an animal model of functional muscle transfer has established that altering donor motor input to heterotopically transferred muscle correlates with reinnervation and force production, the corollary being that standardising donor motor input should standardise outcome. However there is presently no way of delivering a consistent motor input to a functional muscle transfer. The interposed nerve graft has been identified as potentially able to regulate motor input reaching a functional muscle transfer, ultimately controlling force production and clinical outcome. This project tests the hypothesis in an animal model that an interposed nerve graft of low axon regenerate transmitting capacity can standardise the outcome of functional muscle transfers despite variability in motor input, by comparing reinnervation of and force production by functional muscle transfers reinnervated with different sized motor inputs via high and low capacity interposed nerve grafts. Force production is measured in vivo after recovery of transplanted muscle, and reinnervation is measured by nerve morphometry of both the interposed nerve graft and the neural pedicle to transplanted muscle. In support of the study hypothesis, both reinnervation and force production data suggest that outcome correlates with donor nerve magnitude only when a high capacity interposed nerve graft is used, this correlation being lost when using a low capacity interposed nerve graft. The implications for human facial reanimation surgery are discussed.

Ischaemia Reperfusion (IR) injury is a major cause of morbidity and mortality following orthotopic liver transplantation. Remote Ischaemic Preconditioning (RIPC) reduces IR injury in small animal models. The mechanism remains unclear. The aim of this thesis was to explore the mechanism of RIPC and its clinical relevance to liver transplant recipients. Following a literature review a study was performed on optimal end points for clinical studies modulating IR injury in liver transplantation. Day 3 AST level was strongly associated with early post operative morbidity and mortality. A pilot randomised controlled trial of limb RIPC (3 cycles 5 minutes) in 40 liver transplant recipients was performed. Recruitment was successful and the intervention found to be safe and well tolerated. There was no significant difference in day 3 AST. CD4+T cell IFNγ and TNFα production was found to be significantly upregulated in patients post-reperfusion but not affected by RIPC. IFNγ and IL-2 were produced by a CD3-ve HLADR+ve cell population. Monocyte chemoattractant protein-1 (MCP-1) levels were significantly elevated following reperfusion and correlated with clinical outcomes. The T cell response to RIPC was further investigated in a murine model of RIPC and warm liver IR injury. The model demonstrated a reduction in warm liver IR injury following RIPC. Intrahepatic CD4+ T cell TNFα production was significantly increased following reperfusion and reduced by RIPC. Monocytes were recruited to the post ischaemic liver as demonstrated in the human clinical trial. MCP-1 levels and monocyte recruitment were significantly reduced following RIPC in the mouse. In conclusion clinical benefit of RIPC in OLT recipients was not achieved in this pilot study. The RIPC stimulus may be sub-optimal. CD4+T cells and monocytes were shown to have a key role in both the human and animal studies and their manipulation may provide new opportunities for modulating liver IR injury.

This research investigates the materiality and scope, within the religious landscape of Egyptian archaeology, of Werethekau “Great of Magic”, as attested from the third millennium BC to the fourth century BC as (a) a term for different material objects (crowns, and vulture and cobra amulets), (b) epithet of other deities, and (c) name for a separate goddess. My research foundation is the corpus of dynastic period attestations of the compound weret+hekau as most secure tangible starting-point. In this study I explore the idea of the transformation of a ritual object into an epithet of other deities and finally into a separate deity with her own cult. I consider in turn the iconography of Werethekau, her epithets, her crucial role in the coronation, and her cult. Her iconography reveals aspects of her identity (name, form, function), relationship with other deities, attributes, gestures, and issues associated with gender. The epithets of Werethekau outline her divine presence in the linguistic dimension; here I introduce a new methodology for identifying ‘epithet hierarchy’. Her principal epithet was “lady/mistress of the palace”, demonstrating an intimate connection with kingship. Similarly, coronation scenes show her as the deity charged with crowning the ruler, alongside solar deities. My dataset contradicts assertions by Egyptologists that Werethekau had no priests or cult; indeed, a series of sources for priests, temples, and offerings, add up to a strong definition of cult. In sum, context-focussed study of (i) distribution of sources for the name, (ii) iconography, (iii) epithets, and (iv) cult, gives a specific map of the places and times where Werethekau was considered a separate deity, and where she was not. In the process, the study establishes models for future research into ancient Egyptian religion, by identifying specific criteria for two dominant questions: what is a deity? and what is a cult?

The aims of this thesis were to validate staging laparoscopy, laparoscopic ultrasonography (LapUS), and laparoscopic peritoneal cytology (LPC) in the staging of patients presenting with pancreatic or periampullary carcinoma. A series of studies was performed over a period of 52 months between 1991 and 1995 to evaluate the efficacy of these techniques. A systematic method for LapUS examination of the liver, biliary tree and pancreas was devised. In Study 1, the ability of LapUS to image defined anatomical landmarks was evaluated during (i) laparoscopic cholecystectomy, and (ii) staging laparoscopy for pancreatic malignancy. Satisfactory imaging of all anatomical structures considered important was shown to be feasible using LapUS. In Study 2, staging laparoscopy with LapUS was performed in forty patients with pancreatic or periampullary carcinomas otherwise considered to be potentially resectable on the basis of transabdominal ultrasonography (USS) and/or computerised tomography (CT). Occult metastatic lesions were demonstrated by laparoscopy in 14 patients (35%). Following LapUS, staging information in addition to that obtained from laparoscopy alone was obtained in 20 patients (53%), and changed the decision regarding tumour resectability in 10 patients (25%). Laparoscopy with LapUS was more sensitive and accurate than laparoscopy alone in identifying tumour unresesctability (88% and 89% versus 50% and 65%). Study 3 comprised a prospective 'blind' comparison of USS, CT, laparoscopy with LapUS and selective visceral angiography (SVA) in the TNM staging of fifty patients with pancreatic or periampullary cancer. The unique role of staging laparoscopy in the detection of intraabdominal metastatic disease was verified by its significantly superior sensitivity and negative predictive value compared with USS and CT. In the evaluation of T stage, laparoscopy with LapUS was significantly less likely to overstage tumour compared with USS or CT. Reliable determination of N stage was not achieved by any investigation. When all these factors were considered, laparoscopy with LapUS was shown to be superior to other investigations in identifying tumour resectability, and significantly more reliable than CT in determining tumour unresectability.

Nutritional deficiency amongst hospitalised patients is common, and is often unrecognised and untreated. Over the last decade there has been a ro le-out of a number of strategies to standardise and improve the quality of perioperative care in surgical patients. Many such strategies have been gathered together under the umbrella term ERAS or enhanced recovery after surgery. We examine the evidence for specific elements of many such programmes, focusing particularly upon the provision of nutrition. We review the evidence for parenteral, enteral and oral nutritional support in the perioperative and postoperative period. The body of this work comprises four main projects; three clinical experiments and one original literature review. With data suggesting early feeding is preferential to 'nil by mouth' in terms of morbidity and hospital length of stay we set out to determine the most important periods in which to provide nutritional support by assessing the temporal relationship between nutrition provision and surgery. In Experiment One, a prospective four-armed double-blind randomised control trial, patients were allocated to one of four nutritional interventions: control pre-op/control post-op, active pre-op/control post-op, active pre-op/active post-op and control preop/ active post-op. Patients were either given pre-op® or placebo preoperatively, or fortifresh® or placebo postoperatively according to allocation. The provision of parenteral nutrition (PN) to 'stressed' patients often results in hyperglycaemia, which may be detrimental. In animal models small amounts of enteral nutrition (EN) improve intestinal integrity and stimulate intestinal incretin production, which may lead to improved glucose control. In Experiment Two, a prospective randomized control trial, we set out to assess if combining EN with PN results in improved glucose homeostasis rather than PN given alone. In undertaking this far-reaching work it was clear that the focus of nutritional supplementation has to date centred upon hospital inpatients. As part of this thesis a systematic review was undertaken reviewing the evidence for nutritional support in the community setting post-discharge.

A study was undertaken to derive specific indications for surgery in patients with chronic critical lower limb ischaemia, and to determine the extent to which practice throughout Scotland conformed with these indications. Consensus methods provide an explicit and systematic method of deriving indications from published evidence and clinical experience. A review was undertaken of the published literature on outcomes following arterial reconstruction and primary major amputation, in terms of life-expectancy, limb-salvage, healing, reoperation, social and physical functioning, quality of life and cost-effectiveness. Thereafter, consensus indications were agreed using a modified Delphi method in which a postal questionnaire was completed by 29 vascular surgeons on two occasions, with feedback between the rounds. This method has been used previously to develop indications for coronary artery bypass grafting and carotid endarterectomy. Use of a postal questionnaire avoids physical constraints on the selection of panellists, whilst also ensuring that undue weight is not given to the most dominant or vocal participants. Respondents indicated the appropriateness of arterial reconstruction and primary major amputation for 218 case-scenarios comprising all possible combinations of clinical and angiographic findings. Agreement was reached on 31 appropriate indications for major amputation and 65 for arterial reconstruction. The consensus indications were then compared with actual clinical practice in a stratified random sample of ten Scottish hospitals. Four hundred primary major amputations and arterial reconstruction operations were reviewed retrospectively. The clinical findings for 7 (4%) arterial reconstruction operations and 48 (24%) major amputations did not conform to the indications agreed by the Delphi method. The proportion of operations conforming to the agreed indications differed significantly by size of unit (p<0.05). The study demonstrated that consensus could be reached on indications for surgery in patients with chronic critical lower limb ischaemia. The proportion of procedures conforming to the indications varied between units, suggesting that differences in clinical decision-making were apparent.

Background and Research Aims: Cognitive behaviour therapy (CBT) has become an increasingly popular frontline treatment in Child and Adolescent Mental Health Services (Benjamin et al., 2011) and treatment efficacy with children has received significant empirical attention (Graham & Reynolds, 2013). The adaptation of CBT for children has led to the development of tasks intended to assess core CBT skills (such as distinguishing between and linking thoughts, feelings and behaviours, Quakley, 2002). The aim of this study is to explore the relationship between three developmental modalities (executive functioning, empathy and theory of mind) and performance on tasks assessing CBT skill. The developmental modalities were hypothesised to be related to both the demands placed on children by the CBT skills tasks, and to children’s ability to engage in CBT. Method: A quasi-experimental correlational design was employed. Eighty-eight normally developing children between five and eight years old were assessed. Individual assessment with each child included three measures of CBT skill (Quakley, 2002), the Tower of London assessment (Shallice, 1982), age appropriate first and second order theory of mind tasks (Liddle and Nettle, 2006) and a brief measure of IQ (Wechsler, 1999; 2003). In addition one parent of each child was asked to provide parent-report data on their child. This included measures assessing empathy, executive functioning and their child’s overall strengths and weaknesses. Results: Initial exploration of potential confounding variables identified significant effects of age and general intelligence on performance on the both CBT skills tasks and measures of executive functioning, empathy and theory of mind. Through investigation of the research hypotheses, small but significant findings were identified between superior performance on the CBT skills tasks and higher child assessed executive functioning and theory of mind ability. However these results were not maintained when age and IQ were controlled for. No significant relationships were identified between performance of the CBT skills tasks and parent-rated executive functioning or empathy. Conclusions: The results of this study suggest that children’s ability to demonstrate CBT skill is not related to executive functioning, empathy or theory of mind, however CBT skill was significantly influenced by children’s age and IQ. A number of methodological considerations are discussed that suggest that these findings should be interpreted cautiously. Future research should seek to address identified methodological limitations and investigate the validity of the CBT skills tasks employed.

The impact of the UK’s multilingual and multicultural society today can be seen in its healthcare services and have contributed towards shaping communication skills training as a core part of the UK undergraduate medical curriculum. NHS complaints statistics involving perceived staff attitudes have remained high, despite extensive communication skills training. Furthermore, foreign doctors have received a higher proportion of complaints than UK doctors. Finally, how linguistic and social factors shape the conveyance and perception of attitudes related to professionalism in medical communication remains poorly understood. The ultimate aim of this study was to ascertain if speech prosody contributes to the perception of professionalism in medical communication. Research questions on the role of speech prosody in conveying professional attitudes in medical communication, the prosodic differences between native and non-native English speaking medical students in a simulated clinical interaction, and the influence of prosodic features on listeners’ perceptions of professional attitudes were addressed. A set of acoustic parameters representing the speech prosody of native and non-native medical students in the simulated clinical setting was analysed. A perceptual experiment was then carried out to investigate the factors affecting perceived professionalism in extracts of the analysed simulated clinical interaction. The examined acoustic parameters were found to be sensitive to the English language background and the task within the simulated consultation. Interestingly, the attitudinal information associated with some of these acoustic parameters were perceived by listeners and were reflected by higher professional scale scores in the perceptual experiment, even after adjusting for the English language background. The factors of training level and consultation task also emerged to be affecting professional scale scores. Initial findings have confirmed that speech prosody plays a role in terms of contributing towards the perception of professionalism in medical communication. Incorporating how messages are delivered to patients into current models of communication skills training may have positive outcomes.

Stroke is the largest cause of adult disability in the UK and stroke survivors commonly present with a partial or complete loss of movement. Physical therapy interventions as part of movement rehabilitation after stroke aim to facilitate a return to participation in activities of daily living. It has been proposed that the processes that underpin both movement recovery following stroke and motor learning are the same. By embedding physical therapies within a motor learning context it is possible that the effects of the therapy could be enhanced. Yet the application of motor learning principles within the field of movement rehabilitation after stroke is fragmented and supported by evidence of their application in studies with healthy volunteers. This thesis aims to carry out a systematic review of the evidence for the effectiveness of the application of motor learning principles in movement rehabilitation after stroke and to combine this with findings from a feasibility study of Functional Strength Training. These findings will be used to design a novel intervention embedding FST within a motor learning context. Organisation and synthesis of the systematic review was guided by the development of a motor learning framework. Interpretation of the findings from the review showed some evidence in favour of the application of motor learning principles. A phase II randomised controlled trial of FST to the upper limb and lower limb in people within six months and five years after stroke showed evidence of feasibility for both interventions but indicated efficacy of the upper limb intervention only (p=0.046). These findings were combined to inform the design and delivery of a novel intervention, testing for proof of concept for this intervention is now required. This thesis suggests an alternative approach to the development of physical therapy interventions after stroke, however consensus for this needs to be achieved.