Recent literature suggests that 84% of lower extremity amputations (LEAs) are due to peripheral arterial occlusive disease (PAOD), and half of those will have diabetes. Only 40% will go on to rehabilitate with a prosthetic limb and the remainder will be wheelchair dependent. Until now, the majority of research has focused on the short-term clinical outcomes in this population e.g. prosthetic fitting, morbidity and mortality rates. There is a dearth of research into the long-term impact of a LEA on the individual’s quality of life (QoL), especially in those with PAOD with or without diabetes. Aim This thesis aims to determine which factors influence QoL after an LEA due to PAOD in the presence or absence of diabetes. Methods A prospective review of medical case notes and other relevant documentation was conducted on all patients who underwent a major lower extremity amputation for PAOD in NHS Greater Glasgow and Clyde in Scotland, between 1st March 2014 and 28th February 2015. Patients who consented to follow-up completed the EQ-5D-5L QoL measure, Reintegration into Normal Living (RNLI) and the Prosthetic Limb Users Survey of Mobility (PLUS-M), 6 and 12 months after LEA. Semi-structured interviews were conducted on 15 participants who completed follow up questionnaires to explore their views and experiences of living with a LEA and to understand which factors influence their QoL. Results There were 171 participants with a LEA in one year and their mean age was 66.2 years, 75% were males and 53% had diabetes. Over two thirds of the cohort lived in the two most deprived areas in Glasgow. From the follow up questionnaires (n=101) participation, measured by the RNLI had the greatest influence on QoL six and twelve months after LEA. Limb fitting positively influenced QoL, however, level of mobility was poor for all levels of LEA and there was a positive association between mobility (PLUS-M) and QoL. Mortality was seven times greater in those who were not limb fitted. Face-to-face interviews identified five broad themes that influenced QoL: the prosthesis; experience of pain; social support/isolation; sense of self/identity and interactions with others with an amputation. Conclusion Quality of Life was influenced by several factors, primarily participation, which was improved if limb-fitted. Those of male gender, younger age and diagnosed with diabetes were more likely to have a prosthesis fitted. While having a prosthesis did not determine QoL per se, those with greater levels of mobility were more likely to be able to participate, feel less isolated and require less social support which afforded them greater levels of QoL. Conversely, those who were wheelchair dependent or had poorer levels of prosthetic mobility reported lower levels of QoL; which was associated with dependence on social support, feelings of isolation and changes in the way they felt about themselves.

This project is largely creative in nature offering the first half of a now published novel entitled Stranger Than Kindness and a textual and critical analysis of that novel that explores the experience of traumatized or ‘bruised' nurses. The novel, half set in 1989 and half set in 2013, follows the clinical and personal traumatization of two nurses and their tentative steps towards restoration. It reveals a backdrop of a sometimes subtle institutionalized brutality and a culture that lends itself to the individual collection or absorption of difficulty. It uses gentle magical realism to counterpoint the gritty backdrop of the pre-community care asylum of the 1980s and the neoliberal, free market setting of the modern world of healthcare in the second half of the book. It's dénouement is a celebration of whimsy in the face of hard industrialized science. The novel reveals the capacity of the nurse to collect emotional residue, trauma or bruising and be both changed and hurt by the experience of care to the point of being damaged. It essentially resorts to poetics to explore the ‘felt' world of the nurse or carer. In tone and in theme the book is a novel of the emotions. Valuing an emotional literacy over medical rationalism, it seeks to gently reclaim the idea that caring for others is a pursuit or enactment of embodied wisdom rather than just the exercising of scientific knowledge. The critical discussion uses the text of the novel to make three observations in relation to the research question. The first is that the question is political. It is strikingly unaddressed in policy responses to ‘The Francis Report' (2013) and perhaps in terms of mainstream research it is unaskable because it addresses the felt world. In the same way that the novel explores a hierarchy of values in the caring profession, the ensuing critical discussion reveals a hierarchy of knowledge. The second observation is that it is our tacit understanding of what reason is and how we make sense of the world we have constructed that helps make questions about bruised or damaged nurses somehow beyond convention. Iain McGilchrist's The Master And His Emissary (2009) offers a way of making sense of that by exploring the contemporary imbalance between the logical and linear thinking of the left hemisphere and the integrative and imaginative right hemisphere. We have come to prize the measurable over the experiential or contextual and reflective to such an extent that we organize the world accordingly. The third observation, which emerges from the first two and the novel, is the suggestion that nursing is assuming an ill-fitting Cartesian epistemology that cannot do justice to its breadth or holistic need. I suggest that a philosophy that took clearer account of the body, the senses and the felt world would more comfortably accommodate and legislate for the needs of the nurse and the profession of nursing. An embodied realism (Lakoff and Johnson, 1999) that emerges from Damasio (2000, 2012) and Merleau-Ponty (2005) offers the potential to restore a more balanced and less reductionist philosophy that might enable a fuller and more person-centred response to the nursing crises. A further more general observation the thesis makes is that fiction can inform social science and offers a way in which it can do that. Thus it finds itself in a tradition of narrative inquiry (Clandinin and Connelly, 2000). However, it also notices the potential paradox in valuing art as a sociological resource: something that offers us knowledge, meaning and even moral review while turning to cognitive neuroscience to legitimize that methodology.

Missing Pieces is a novel about mental health nursing and the difficulties faced by a challenging profession, as Ron seeks an understanding of his personal and professional world. The novel challenges traditional stereotypes, offering a greater range of character depictions. The critical discussion asks why mental health nursing is represented in fiction like it is. By first contextualising the argument within the sphere of fictional representations of other health professions, it then examines the stereotypes of mental health nursing in fiction, and argues that, while literary shortfalls are in part supported by clinical evidence, existing novels fail to accurately depict the experience of the profession. By reference to the nursing theory of Peplau and others, we not only see the failures of fiction writers, but realise that mental health nursing must assume some culpability, by failing to disseminate its identity with sufficient clarity. Looking at the work of Freya Barrington and Monica Starkman in other health disciplines, it asks how fictionalised accounts of mental health practitioner/writers can integrate into health education programmes, and looks at the professional benefits of writing fiction including continuing professional development. Finally, it points to potential areas for further investigation.

The aim of this thesis is to evaluate the expression of both TSG101 tumor susceptibility gene and ret oncogene in human thyroid carcinoma specimens. Functional inactivation of TSG101 in mouse fibroblast leads to cellular transformation and the ability to form metastatic tumors in nude mice. No genomic deletion of TSG101 gene has been reported in human cancer, casting a doubt on the role of TSG101 as a classical tumor suppressor. Subsequent studies reveal that TSG101 is a frequent target of spilicing defects, which is correlated with cellular stress and p53 status, and might reflect the cellular environment during the cancer development. Furthermore, recent reports demonstrate TSG101 as a part of the MDM2/p53 regulatory circuitry, a well recognized circuitry that upon deregulation results in tumorigenesis. In this study we have analyzed TSG101 gene expression in 85 specimens of thyroid carcinomas. The results indicated that 100% of papillary carcinomas (48/48), 85% of follicular carcinomas (18/21), 91% of medullary carcinomas (10/11) and 60% of undifferentiated carcinomas (3/5) showed strong to moderate cytoplasmic staining, whereas the staining was completely negative, or cytoplasmic dot-staining in the adjacent non-neoplastic follicular cells. Occasionally, the staining could be found in the nucleus. Subsequently, sequence analysis of 17 papillary carcinoma specimens revealed no mutation in steadiness box region, indicating that it might not be the cause of TSG101 protein overexpression. In summary, our results indicate strong correlation of TSG101 overexpression and thyroid carcinomas. Further experiments are urged to clarify the relationship of TSG101 overexpression and thyroid tumorigenesis. Rearrangement of ret proto-oncogene is unique to papillary thyroid carcinoma (PTC). These rearrangements consist of the fusion of ret tyrosine kinase domain to a variety of heterologous genes, thus generating chimeric transforming oncogenes termed, ret/PTC. The frequency of ret/PTC activation in non-radiation exposured adult populations has been reported to vary from 0-55% depending on the geographic distribution. To detect ret rearrangement and to identify candidate of novel ret/PTC in 62 specimens of PTC collected from southern Taiwan, a RT-multiplex PCR method was used to reveal the possible specimens that harbor ret rearrangements. Type specific-PCR amplification and subsequent sequence analysis of PCR product were performed to identify the known types of ret/PTC. We have identified two cases of ret/PTC1, two cases of ret/PTC3 and one case of ELKS-RET. Excitingly, four cases of unknown ret/PTC type were identified. Hence, 5¡¦-RACE strategy will be employed to identify novel ret/PTC in these four specimens.

Syfte och frågeställningar: Syftet med denna studie av de globala mediekanalerna CNN och Russia Today är att tydliggöra vilka ståndpunkter som framförs i de undersökta medierna ochatt försöka kartlägga hur Ukrainakonflikten mer övergripande förmedlas. Frågeställningarna är: vilka är skillnaderna och likheterna i kanalernas nyhetsförmedling av händelserna? Vilketbudskap förmedlas av respektive nyhetskanal gällande konflikten? Hur förmedlas budskapen genom ordval? Hur förmedlas budskapen genom källor? Metod och material: Metoden som studien använder sig av är innehållsanalys på ett materialsom är kodad enligt Krippendorff-modellen. Huvudresultat: Skillnader och likheter existerar mellan mediekanalerna CNN och RT i deras nyhetsförmedling och hur budskapen förmedlas. Skillnaderna består i ordval och källor, likheterna består i användningen av källor som uteslutande stödjer påståenden. Budskapensom förmedlas är pro-ukrainskt (CNN) och anti-ukrainskt (RT) och budskapen förmedlas genom laddade ordval och kontextuellt relevanta källor.

The research reported in this thesis investigates the self-efficacy construct in the context of (real world) diabetes self-management programmes. Self-efficacy interventions, although widely implemented in diabetes care, lack basic information on what exactly was delivered. More importantly, there has been no assessment tool which would enable researchers to externally evaluate the use of self-efficacy-based techniques in interventions and provide accurate report information about the process of intervention delivery. To address this gap, the present PhD aimed to develop a reliable and valid coding tool to assess the use of self-efficacy-based techniques among nurses delivering education for people with diabetes and test its clinical utility by delivering a self-efficacy-based intervention to diabetes nurses. The four sources of self-efficacy: mastery experience, role modelling, verbal persuasion and physiological and affective states formed the conceptual basis of the coding tool. The findings of the literature review and observation of three educational programmes provided an operationalisation of the four sources of self-efficacy and resulted in 11 verbal behavioural techniques. Four coders rated diabetes programmes to establish reliability of the coding tool. Cross-sectional and longitudinal data from 52 patients, based on self-report and objective measures, as well as demographic information about five nurses were related to nurse-led self-efficacy based techniques to establish the validity of ASSET. In a single pre-post design, the feasibility and effectiveness of ASSET-based interventions delivered to five nurses were evaluated. The key findings were that ASSET could be a useful tool to identify the use of self-efficacy in interventions. The use of self-efficacy-based techniques reflected nurses’ work-related experience gained prior to the study, and to some extent predicted patientrelated outcomes including intention and behaviour regarding diabetes management. The use of self-efficacy based techniques by nurses, however, did not predict patients’ selfefficacy beliefs. ASSET-based training guided nurses in reflecting on their practice. As a result of that, nurses started using more self-efficacy-based techniques when delivering group-based education. The effect was, however, not maintained over time. Nurses who were less experienced prior to the intervention increased their use of self-efficacy-based techniques to a greater extent than those with prior experience. One of the major limitations of the thesis was that only the author of the thesis coded all nurse-led speech utterances. The other three coders rated a selection of utterances. Therefore, there is no sufficient evidence to conclude on the reliability or validity of ASSET.

Multiple sclerosis (MS) creates numerous ongoing challenges which, for some, result in negative outcomes such as depression, poor quality of life, and impaired functioning. This thesis aimed to investigate the nature of psychological adjustment to MS and elucidate factors that interventions could address in order to promote successful adjustment. A review of the theoretical literature on chronic illness and a systematic review of the empirical MS literature suggested that various theoretical approaches are useful for explaining aspects of adjustment to MS but no single existing theory offered a comprehensive framework. An integrative cognitive behavioural model of adjustment to MS was proposed and elements of this were examined in the empirical chapters. In an initial qualitative study, people with MS (n=30) were interviewed about their experiences of living with the disease. Inductively-derived themes characterised the context and process of adjustment and the resources, actions, thoughts and feelings that have a bearing on it. Findings supported and elaborated on the model, and new insights were used to revise it. The quantitative studies were nested within a trial of interventions for adjustment to MS (n=94). A cross-sectional study using pre-therapy data found that cognitive and behavioural variables explained substantial variance in distress and functional impairment. Unhelpful beliefs and behaviours relating to MS itself (illness perceptions and responses to symptoms) appeared most relevant for explaining functional impairment. Beliefs about the self and about experiencing and sharing emotions were important correlates of distress. In an analysis of change within the treatment trial, reductions in unhelpful cognitions and behaviours mediated the improvements observed within interventions. Cognitive and behavioural variables also moderated the effects of the interventions on outcomes. A final qualitative study (n=30) explored participants‘ experiences of the adjustment interventions. The set of interlinked themes provided insights into the broad range of positive outcomes of interventions, perceived therapeutic processes and factors that appear to promote engagement in interventions in this patient group. Overall, the suggested cognitive behavioural model appears to be a useful means of understanding adjustment. This thesis pinpointed a number of potential cognitions and behaviours which may be important targets for adjustment interventions. Continued research efforts to understand factors that determine a range of adjustment outcomes and to determine what people with MS find helpful and appropriate is necessary for a more complete understanding of successful adjustment to MS and how it can be promoted

Health and social care professionals at are risk of developing symptoms of trauma as a result of supporting traumatised individuals. This is termed secondary traumatic stress (STS; Figley, 1995). This paper reviews the predictors of STS in health and social care professionals followed by a study of the predictors of STS and burnout in paediatric nurses specifically. The literature review aimed to obtain an overview of the main risk and protective factors associated with STS. A systematic search of the literature was carried out, 68 studies met the inclusion criteria and a narrative synthesis was then conducted. The most consistent evidence suggested that increased empathy predicted STS whilst social support appeared protective. Current life stress was also associated with STS but the evidence was limited by methodological issues. Tentative evidence was found for the role of coping styles and compassion satisfaction, whilst evidence for exposure to workrelated trauma, a personal trauma history and emotional detachment was inconclusive. These are discussed in relation to clinical implications and directions for future research. The majority of research regarding predictors of STS and burnout has taken place in professionals working with adult populations and there is a lack of research regarding paediatric nurses specifically. The empirical study’s purpose was therefore to identify the predictors of these conditions in this specialist group and to clarify whether paediatric nurses working in high-mortality risk departments 3 were at greater risk. A cross-sectional survey was conducted and 84 members of nursing staff participated. Emotional empathy and current life stress significantly predicted STS, whilst both predicted burnout in addition to a lack of support and behavioural disengagement. No differences in STS or burnout levels were found between departments. Clinical implications are discussed and it is concluded that hospitals would benefit from implementing additional training to support their staff.

Debate surrounding the issue of pain management in neonates has mushroomed over the last ten years. Previously held beliefs that neonates do not feel pain because their anatomical make up is different from that of an adult, and that they do not remember pain therefore there is no need to relieve it have been demonstrated as erroneous. Studies such as Volpe (1981), Gilles, Shankle and Dooling (1983) and Beyer and Wells (1989) refuted previously held physiological misconceptions. Anand and Hickeys' 1987 study did much to raise our awareness of the deleterious effects of unrelieved pain in neonates. The impetus for the present study was the wish to improve analgesic techniques in one such group of infants - postoperative neonates. Valid assessment is foundational to improving analgesia and measuring the efficacy of interventions thus broadening our knowledge of safe, effective methods of preventing undue pain in newborns. The research presented here follows four distinct phases. The primary aim of the research was to develop a pain assessment tool. This was initially developed by use of an observational research technique, watching and cataloguing the behaviour of newborns (n=25) over a number of hours in their home environment. Video recordings of normal neonatal behaviour and development were also viewed and empirical evidence from neonatal behaviour experts such as Wolff (1966), Brazelton (1977) and Trevarthan (1977) was drawn upon to provide a detailed overview of neonatal behaviour. Observations were then made on a surgical group of babies (n=34) around normal caregiving episodes. Each observation lasted a number of hours. Some of these episodes were videod for later viewing by 3 clinical psychologists. The qualitative data collected from the observations of these babies (n = 59) was transcribed. The unstructured observations of both real life and video recordings collected by pen and paper provided rich, descriptive information to be analysed qualitatively. Glaser & Strauss (1967) term these "field notes". The field notes were then reduced in order to summarise the information by teasing out themes around which behaviours were clustered (Miles and Huberman 1984). These categories were organised into a detailed scoring system. This was called the Liverpool Infant Distress Score (LIDS). Following initial development the scale was subjected to rigorous reliability and validity tests. After piloting the scale on a further 10 babies undergoing surgery, adjustments were made to the initial scale. The scale was then applied to 31 babies in the peri operative period and a control group of 10 non surgical babies. Validity of LIDS was demonstrated. The value of an assessment tool such as LIDS also lies in its ability to be reproduced consistently and accurately by differing carers. (Melzack 1984). The next part of the study addressed this issue. By teaching the scale to a group of 4 nurses and testing their scores over a number of assessments, inter rater reliability was demonstrated. The final phase of the study compared the subjective scores of two groups of nurses – one experienced neonatal nurses, one paediatric nurses- to the more objective LIDS scores. The results from this final phase of the study suggest that despite an increase generally in nurse awareness regarding pain cues in neonates, pain assessment is still open to subjectivity.

No description available.