This thesis is an exploratory qualitative study using an ethnographic approach to explore the use of interventions during the second stage of labour among healthcare professionals and what may be influencing their use within two large government hospitals in Jeddah, Saudi Arabia. Data collection methods included participant observations of 19 labours and births and semi-structured interviews with 29 healthcare professionals comprising obstetricians [n=10], midwives [n=12], nurses [n=6] and nurse-midwife [n=1]. In addition, the hospital labour and delivery ward policies and guidelines from those hospitals were collected. Data collection took place over a two-month period in 2011 at King’s Hospital, and a two month period in 2012 at City Hospital (pseudonyms), after seeking ethical approval from City University and from each of the hospitals involved in the study. All participant observations, interviews, field notes (diary), and hospital documentation was recorded using a word processing package (Word 2010) and then transferred into qualitative data analysis software (QDAS) (Atlas.ti 7) which was used for organising and coding interviews transcripts, observations field notes and hospital policy documents. The findings from this PhD confirm that the influences on use of interventions during childbirth are complex. The findings revealed a number of rationalisations that professionals give for the many interventions used during labour and birth. Primary interventions used routinely included continuous Electronic Foetal Monitoring (EFM), bladder catheterisation, intravenous infusion, denial of companionship, episiotomy practice, lithotomy position, limitations on mobility and on duration of second stage of labour, directed pushing. Rates of instrumental delivery and Caesarean section were increasing. Thematic analysis of the data identified two core and inter-related explanatory themes in relation to the use of interventions observed during the second stage of labour in Jeddah: ways of seeing childbirth and power. The findings demonstrate the influence of a hierarchical system of control, the impact of the medical model, and the role of power in medical surveillance and fear culture on the use of interventions during the second stage of labour.

INTRODUCTION Heart function can be impaired by rhythm disturbances (cardiac arrhythmia), illustrated by electrocardiogram (ECG) recordings. Computerised arrhythmia diagnosis is well established for ECG’s but less for intracardiac electrophysiological (EP) testing. Accurate diagnosis is pre-requisite for delivering appropriate treatment to patients however existing algorithms misdiagnose a proportion of arrhythmias. Studies suggested artificial intelligence (AI) classifiers are accurate using ECG and intracardiac electrogram features and reviews suggested new features might augment diagnosis. This study aimed to develop an accurate cardiac rhythm diagnostic algorithm for electrophysiological (EP) studies with potential application as a generic rhythm classifier. METHOD An ethically approved prospective clinical study collected clinical history, right atrial and right ventricular intracardiac electrograms, beat-to-beat cardiac stroke volume, body motion and body temperature data during EP studies. An iterative system development life-cycle was used, including knowledge management and classifier development sub-processes. Domain expert knowledge and clinical arrhythmia diagnosis were modelled, synthesised as AI classifiers and used to classify cardiac rhythms. RESULTS Data collected from 65 patients was pre-processed into instances for classifier inputs. Decision tree, naïve Bayes, neural network, support vector machine and inference engine classifiers developed using Matlab showed good performance and were combined as a production system in a mixture-of-experts multi-classifier system. 18 different rhythms were classified, with the naïve Bayes classifier used to classify 11 rhythms, decision tree 4 rhythms, neural network and support vector machine one each, unclassified instances by the inference engine classifier and final class allocation using decision rule. Production system showed overall correct clasification rate 0.960; error 0.040; mean sensitivity 0.855; mean specificity 0.977; mean κ 0.767; mean positive predictive value 0.792; mean negative predictive value 0.975; mean Pearson’s phi 0.787, with P < 0.004 (equivalent to P = 0.05 for 18 way Bonferroni comparison) supporting no difference with the gold standard. Correct classification, sensitivity, specificity, Cohen’s kappa and positive predictive value showed values of 1.0 for inappropriate sinus tachycardia, focal atrial tachycardia and ventricular tachycardia and > 0.9 for sinus node dysfunction and atrio-ventricular nodal/ junctional tachycardias. Temperature, accelerometry and QT interval were assessed as features by a comparison of algorithm performances with each feature removed and found not to affect classification performance. An evaluation showed 10 beat analysis performed better than 5 beat analysis. CONCLUSIONS Modelling of the clinical diagnosis process produced an AI based mixture-of-experts multi-classifier system, which accurately diagnosed different 18 cardiac rhythms. The naïve Bayes classifier performed best and classified 11 rhythms. Features for clinical symptoms and predisposing factors, atrial electrogram morphology and changes in stroke volume were found to influence rhythm classification. High performances encourage further development and potential future improvements include: a larger sample dataset; inclusion of His and coronary sinus electrograms; data mining for unknown features with significant influence on diagnosis; binary classification. The aim to classify rhythm using artificial intelligence suitable for use during EP studies was satisfied and the research hypothesis that it outperformed current algorithms was accepted. The system was likely to be able to accept updates but needs conversion as a precursor to use in a live clinical environment.

The introduction of chemical, biological, radiation and nuclear personal protective equipment (CBRN-PPE) across the National Health Service (NHS), in 2007, represented an increase in the capacity to treat patients following a CBRN incident. However, little was known on what impact the NHS CBRN-PPE would have on skill performance. To date a number of studies have evaluated various skills performed whilst wearing a range of CBRN-PPE, none of which resembles the NHS CBRN-PPE. This gap in the evidence prompted a series of research studies addressing the following research question, ‘What airway and vascular access skills can be performed whilst wearing the NHS issued chemical, biological, radiation, and nuclear personal protective equipment? The resulting nine published peer-reviewed papers are presented with a critical commentary in three chapters: Chapter 3 (Papers 1 to 4) assesses what clinical skills can be performed using the NHS CBRN-PPE; Chapter 4 (Papers 5 & 6) explores clinicians’ views on the preferences and experiences of airway management whilst wearing CBRN-PPE; and Chapter 5 (Papers 7 to 9) evaluates the optimal strategies of airway management whilst wearing the NHS CBRN-PPE. Chapter 6 is a summary of the findings presented in this thesis and presents a number of new research questions to further expand our knowledge-base, regarding skill performance whilst wearing NHS CBRN-PPE, reflecting the developmental nature of this area of research. The research contained in this thesis utilises a combination of randomised controlled trials, interviews and questionnaires, to ascertain the impact of the NHS CBRN-PPE on skill completion. Papers 1 to 4 recruited a group of mixed clinicians allowing subgroup analysis observing for inter-professional differences regarding skill performance. Whereas, Papers 7 to 9 recruited student paramedics ensuring similar levels of airway management skills, thereby isolating prior expertise as a variable. The research presented in this thesis has been used during simulation training as part preparations for the 2012 Olympics, in the development of a CBRN training DVD and incorporated into a textbook. The results have also been shared with NHS England working party on CBRN-PPE and, are being incorporated into CBRN treatment protocols by an overseas ambulance service.

Aims: The overall aim of the thesis is to study the Health-Related Quality of Life (HRQoL) in Adult Congenital Heart Disease (ACHD). The thesis examines the impact of ACHD on HRQoL, the demographic, clinical, and psychosocial factors associated with HRQoL, and changes in these factors over time. Methods: The thesis consists of three studies, including a cross-sectional, a longitudinal, and a qualitative. Three hundred and fourteen individuals, from four diagnostic groups (Simple, Tetralogy of Fallot-ToF, Transposition of the Great Arteries-TGA, & Single Ventricle-SV) were recruited from The Heart Hospital, London and completed the cross-sectional study. Clinical measures were collected by a consultant cardiologist and participants completed a range of psychosocial measures, including generic and disease-specific measures of HRQoL. One-sample t-tests were conducted to examine differences between the whole sample and diagnostic groups and general population norms and ANOVAs for differences between the four diagnostic groups in HRQoL. Hierarchical multiple regressions were employed to examine the factors associated with HRQoL. One hundred and eighty eight participants completed the longitudinal study (mean follow-up: 3.3 years). Changes in HRQoL and other psychosocial variables were explored using Hierarchical Linear Models (HLM). Semi-structured interviews were conducted with twelve participants to explore their experiences. Results: Participants reported diminished HRQoL in some physical and psychosocial domains. The SV group reported poorer physical and psychosocial HRQoL in various domains compared with the general population norms and some of the other diagnostic groups, whilst the Simple group reported impaired psychosocial HRQoL. Illness perceptions explained the largest proportion of variance in generic (physical and psychosocial) and disease-specific HRQoL. After accounting for demographic and clinical characteristics, psychosocial factors including perceptions about the symptoms and consequences of ACHD, the use of self-blame as a coping strategy, and mood were independently associated with HRQoL. Clinical factors, HRQoL, coping, and social support remained stable over time, whilst some changes were observed in illness perceptions and anxiety. The qualitative interviews provided further insight into the physical, psychosocial, and occupational consequences of ACHD, the people’s efforts to adjust to their condition and treatment and gain perspective, and the role of their social environment. Discussion: The theoretical and clinical implications of the findings are discussed. People with ACHD may benefit from routine psychological assessment and provision of clear and timely information and interventions addressing negative illness perceptions, depression, and anxiety.

Objectives: To evaluate the accuracy of the four main Intensive Care severity of illness scoring models using a large Scottish database, and to investigate different strategies for improving their accuracy in a Scottish setting. Method: Twenty two out of 25 general adult Intensive Care Units in Scotland collected data for two and half years to allow calculation of Acute Physiology and Chronic Health Evaluation (APACHE) version II and III, Simplified Acute Physiology Score (SAPS) version II, Mortality Probability Model (MPM) version II (calculated on admission and at 24 hours). The models' Goodness of Fit (discrimination and calibration) and performances in subgroups (Uniformity of Fit) were evaluated using Receiver Operating Characteristic Curves, Hosmer-Lemeshow Goodness of Fit test, Chi Squared test and Confidence Intervals. Three of the Models (APACHE II, SAPS II, and MPM II) were customised with Scottish data using logistic regression techniques. Results: All models had good discrimination but poor calibration. However, the SAPS II and APACHE II models appeared to have better calibration than other models. All models, except the new APACHE II model, showed significant differences in important subgroups. Conclusions: Questions remain about the accuracy of these models even after customisation. Further research is needed to investigate variations in Intensive Care Units and the relationship to clinical effectiveness. However, where case mix adjustment is needed the new customised models remain the most accurate means of doing this in Scottish data.

The role of intestinal nematode infections in the aetiology of iron deficiency and anaemia in pregnant women was investigated in peri-urban and rural areas of Western Sierra Leone. A randomised placebo-controlled field trial was carried out to evaluate the efficacy of a single course of albendazole (400 mg) and daily iron-folate supplements (36 g iron and 5 mg folate), administered after the first trimester, as control interventions for intestinal nematode infections and anaemia during pregnancy. At baseline, in the first trimester of pregnancy, the prevalence (and geometric mean intensity) of intestinal nematodes was as follows: <I>Ascaris lumbricoides </I>21.1% (267 eggs per gram); <I>Necator americanus </I>66.5% (191 epg); and <I>Trichuris trichiura </I>71.9% (93 epg). Chronic undernutrition (height < 150 cm) and chronic energy deficiency (body mass index < 18.5 kg/m<SUP>2</SUP>) was found in 5.4% and 8.2% of women respectively. Anaemia (Hb < 110 g/l) was diagnosed in 58.7% of women and associated with iron deficiency (serum ferritin < 20 μg/l) in 21.2% of women. Iron deficiency is likely to have a dietary basis in these women. The dietary iron intake was predominantly non-haem, and was estimated to supply less than 1 g of absorbable iron daily. High fertility and closely spaced pregnancies placed additional stress on iron stores. The findings of this study indicate that anthelminthic treatment should be included in strategies to control maternal anaemia in Western Sierra Leone. It is recommended that pregnant women routinely receive a single course of anthelminthics after the first trimester, alongside daily iron-folate supplements, to minimise the decline in maternal Hb concentration during pregnancy. These interventions could be implemented through the existing primary health care system, although the use of traditional birth attendants should be investigated as a means of improving compliance and coverage. The implications of these findings for public health policy in other antenatal populations will depend on the local epidemiology of intestinal nematode infections and on the extent of underlying maternal iron deficiency and anaemia.

No description available.

This study was conceived against the backdrop of academic and medically based discussions about inappropriate use of General Practice, in the context of an overburdened and under resourced National Health Service. Both frequent and less frequent consulters prioritised dilemmas around functional ability, reporting attempts to control illness, and resist loss of normal life and familiar selves. Despite our attempts to sample frequent and less frequent users with similar levels of morbidity in the more detailed qualitative interviews the frequent consulters conveyed more severe illness, which limited their lives and challenged their coherent and moral identities. Cultural, structural and social factors combined to influence health actions; personal troubles were linked to public matters. The accounts revealed how the severity of condition combined with social position influenced the place of the GP consultation in overall management strategies. Women and men communicated common problems, but also discussed experiences which were related to their traditional family roles. Housing status was not revealed as significant, in the context of a complex combination of micro and macro influences on experience. In the frequent consulters’ accounts the role of the GP was magnified in lives diminished and disrupted by chronic illness, whereas the less frequent consulters’ accounts presented a more peripheral role for their GP. Using Bourdieu’s central concepts, the GP was conceptualised as a ‘dispenser of capital’. Throughout, all of the participants described the hard work of illness management, and they used the accounts to display their moral competence. The medical encounter was conveyed against a moral backdrop, and this may have had implications for frequency of consulting. Overall, the symbolic and physical burden of chronic illness was highlighted.

Introduction. Trace element status may be important in acutely-inflamed patients. Plasma concentrations of trace elements are known to alter during the evolution of the acute phase response, however, erythrocyte trace element concentrations do not. It is not known whether either erythrocyte or plasma concentrations reflect the status of the tissues where trace elements are utilised. Therefore trace element concentrations were examined in tissues and blood from non-inflamed patients, with plasma and erythrocyte concentration changes studied during the evolution of the acute phase response. Methods: 31 patients undergoing liver resection had liver, rectus muscle, and blood samples obtained pre-operatively, and blood sampling for 3 days post-operatively. Se, Cu and Zn concentrations were obtained by inductively coupled mass spectrometry after nitric acid digestion. Erythrocyte glutathione peroxidase (GPx) was measured by spectrophotometry. C-reactive protein and albumin concentration were measured on each day. Results: C-reactive protein increased and albumin concentration decreased over the 3 days postoperatively. Plasma Zn and Se concentration changed in the 3 days post-operatively (p<0.001); erythrocyte Cu, Zn and Se concentration, GPx activity and plasma Cu concentration did not change. Preoperatively, liver Cu concentration was associated with erythrocyte Cu concentration (r2 15.9%; p=0.036) but not plasma Cu concentration (r2 4.3%; p=0.264); plasma Zn concentration was associated with liver Zn concentration (r2 14.4%; p=0.046) but erythrocyte Zn concentration was not (r2 0.1%; p=0.896); and liver Se concentration was associated with erythrocyte Se concentration (r2 17.1%; p=0.023), erythrocyte glutathione peroxidase (r2 22.6%; 0.008) and plasma Se concentration (r2 43.1%; p<0.001). Conclusions: Erythrocyte Cu and Se concentration, and GPx activity are associated with liver Cu and Se concentration respectively, and do not change during the evolution of the acute phase response. They should be considered as potential markers of Cu and Se status. Plasma Zn is associated with liver Zn concentration but the concentration changes during the acute phase response; caution should be taken interpreting results in patients with inflammation, and further work is required to find a suitable alternative marker of Zn status.

This thesis presents men’s discussions and experiences of health and illness and its relation to, and implications for, the practices of masculinity amongst a diversity of men. Fifty five men participated in fourteen semi-structured focus group interviews. Diversity in men’s experiences of health and illness and in their constructions of masculinity was sought within the sample by age (range 15-72 years), occupational status, socio-economic background and current health status. Groups of men were recruited who had had ‘everyday’ or unremarkable experiences of masculinity and health and groups of men with health experiences that could have prompted reflection on masculinity and health. This included groups with men who had prostate cancer, coronary heart disease, mental health problems, and Myalgic Encephalomyelitis (ME). All of the men that participated in the study lived in central Scotland (Glasgow, Edinburgh, Dundee, Lanarkshire and Perthshire) and just one group was conducted with men of Asian origin, which reflects the limited ethnic diversity in this part of Britain. The first data chapter examines participants’ descriptions of their masculinity and their health-related beliefs and behaviours. The data capture both the experiences of men who felt pressured to engage in behaviours that may be harmful to their health in order to appear masculine and the accounts of those who regarded themselves as freer to embrace salutogenic health practices as they perceived there to be fewer consequences for their masculinities. These considerations are then followed by an examination of how participants re-negotiated male identity in the light of illness. The final data chapter presents participants’ discussions and experiences of help seeking and its relation to the practice of masculinity. The data suggests a widespread endorsement of a ‘hegemonic’ view that men ‘should’ be reluctant to seek help, particularly amongst younger men.