This thesis describes thirteen published works which constitute an evolving programme of research into service user and carer participation in old age psychiatry. They share the common objective of extending knowledge and understanding of methodologies, benefits and challenges of service user and carer participation in old age psychiatry services. The publications contribute to knowledge in three areas. The copying of letters to users and carers, and requests for their feedback on the practice, was described as part of routine practice in old age psychiatry: this research addresses the area of „users and carers as recipients of communication‟. „Users and carers as subjects of consultation‟ is addressed by several publications: an evaluation of users‟ experience of electro-convulsive therapy and later development of a method of integrating feedback from users into practice; a similar method was applied regionally in service improvement in order to access users‟ and carers‟ views and use them to identify areas for improvement work, and nationally by a professional organisation to inform and develop its work programme. The third area of contribution is that of „users and carers as agents in control‟ and this is addressed in an initiative in higher education where users and carers were agents of control in designing, delivering and evaluating an MSc module on user and carer experience. The contribution of the publications is related to four overall objectives: ways in which users and carers participate in old age psychiatry services; the benefits and drawbacks of user and carer participation in old age psychiatry services; ways of conceptualising user and carer participation in old age psychiatry; and finally, potential areas for future research in user and carer participation in old age psychiatry.

Pain is multidimensional and self-management is advocated to manage the biopsychosocial impact of this on individuals’ lives. Thus, these individuals’ perspectives regarding self-management have been explored. This study aimed to firstly explore how self-management was understood in the context of low back pain through the experiences of people living with low back pain and physiotherapists’. This then led to informing the development of an education programme for physiotherapists to support self-management. The study used a mixed method approach, which involved three phases being carried out over a period of time with each informing the subsequent phase. Phase 1, a qualitative synthesis examined primary qualitative research focusing on people living with low back pain and physiotherapist experiences of self-management of low back pain. The synthesis informed phase 2, two qualitative studies addressing areas of paucity found within the literature. The final phase, a feasibility study involved the development of an education programme for physiotherapists who completed pre and post outcome measures. Focus groups were also used in evaluating the intervention. The qualitative synthesis revealed a limited amount of literature regarding physiotherapists’ views and experiences of self-management of low back pain. A large proportion of studies that related to physiotherapy focusing on people living with low back pain experiences of self-management concentrated on strategies, in particular exercise with limited relation of this to daily life. The primary qualitative studies highlighted some difficulties physiotherapists faced when supporting the management of the biopsychosocial impact of LBP. Further, at times self-management could be used as a last resort. In relation to this, half of the people interviewed living with low back pain found this to be restricting their daily activities and were fearful and concerned regarding worsening pain in the future. These findings suggested people were not managing the biopsychosocial impact of low back pain and physiotherapists at times viewed influences on the pain experience as separate rather than integrated. Pain neurophysiology education linked to clinical practice was used to demonstrate the integrated nature of the pain experience, be relevant to physiotherapists and ultimately facilitate biopsychosocial self-management through enhancing understanding of the multidimensional nature of pain. Collectively, this thesis has developed understanding of self-management from the physiotherapist perspective, illuminating the support required for physiotherapists and revealed physiotherapists value pain neurophysiology education linked to practice however further support is required to implement this in clinical practice.

Assumptions are our taken for granted interpretation of the world. They are identified as important in reasoning, sense making, behaviour and action. Anecdotal evidence from users of neurological rehabilitation services suggest that assumptions influence how they are perceived and related to, impacting on their experiences of inclusion. This study investigates the assumptions held by service users and staff about neurological rehabilitation, examines their influence on inclusion and explores the conditions influencing change in assumptions. This doctoral study drew largely on data generated as part of a funded research project, which investigated perceptions of inclusion and inclusive practice in neurological rehabilitation. Both the funded research project and this study adopted a participatory action research approach, using photography, mapping, diaries, interviews and focus groups to generate data. Additional data was generated for this doctoral study through a workshop and reflective questionnaire which focussed specifically on assumptions. Data analysis and sense making used framework analysis and a thematic approach. Research participants and critical friends contributed to validation of findings. The findings identified that assumptions do form the basis for interactions and practices that influence whether neurological rehabilitation is inclusive and/or effective. Addressing assumptions requires that specific attention and scrutiny are given to situations where taken for granted thought has been disrupted, therefore, creating opportunities for critical dialogue and new understanding to be developed. Importantly, when service users and staff work collaboratively to ask the question “how do we do this together” assumptions of role, knowledge and expertise can be challenged and inclusion facilitated. The study recognises that addressing assumptions in practice requires a change in the way of working in neurological rehabilitation. A re-framing of practice is called for and a critical relational ontology proposed to replace the currently advocated person centred approach, with the acknowledgement that this is likely to radically challenge current principles and practices in neurological rehabilitation.

This thesis aimed to assess the feasibility of conducting a randomised controlled trial (RCT) into the use of Korean Hand Acupuncture (KHA) for pregnancy related pelvic girdle pain (PPGP). Despite PPGP developing in approximately 20% of all pregnant women, there are currently very few studies that have investigated interventional strategies, with a dearth of UK based studies. Of extant interventions investigated to date, acupuncture has shown some promising findings, although the effects of KHA on PPGP remain unclear. In line with the MRC framework for complex interventions, any potential treatment should be subjected to feasibility testing prior to a definitive RCT. This three phase feasibility study followed a mixed methods paradigm. Phase 1 was a comparative study of 20 non pregnant women, measuring the belief that there had been a needle inserted into the skin, between a penetrating KHA (pKHA) group and a non-penetrating KHA (npKHA) group. Between group analysis found that at initial assessment (p=0.07) and one week post intervention (p=0.643), believability was similar. Qualitative comments were analysed through content analysis, and provided insight into what factors influenced their belief score, such as ‘acupuncture noises’. The study findings helped to develop the intervention protocol in Phase 3. This study was the first to investigate the believability of a non penetrating form of KHA. Phase 2 recruited eight PPGP sufferers and adopted a qualitative approach, using semistructured interviews to gain an understanding of how PPGP affected them. Data was subjected to thematic analysis and produced four themes: The reality of PPGP; Support mechanisms most important in PPGP; Vulnerability and; Knowledge is power. Findings indicated PPGP is a problem that is biopsychosocial, and one which is represented via the Pelvic Girdle Questionnaire (PGQ). It demonstrated that information provision was considered as important to the participants within this study as it is to sufferers outside of the UK, and that they valued health care professional advice and support. This is the first UK based study to investigate women’s experience of PPGP, the first piece of qualitative work with the lead author and interviewer being male, the first to provide a level of validity to PGQ use within the UK and the first to adopt a pragmatic philosophy. Phase 3 was a mixed methods feasibility study, assessing the acceptability and practicality of conducting a definitive RCT on KHA for PPGP. A two armed study consisting of six sessions in either a standard physiotherapy plus pKHA or a standard physiotherapy plus npKHA group. The study recruited 59 women, 40 of whom completed all six sessions. Acceptability and practicality was confirmed through content analysis of the qualitative data produced by the participants, in particular those in the pKHA group who stated they would seek out the treatment again. Further acceptability was noted as all adverse events experienced were minor and transient, and that the retention of women to the study was greater than normally expected from the study population. In addition, trends noted in NRS at present (p=0.002) and PGQ (p=0.041) at the final data point indicated that pKHA may have additional benefits over npKHA for PPGP. The original contributions from Phase 3 are that it is the first study to be conducted using KHA for a pregnancy related condition in the English language and the first study to adopt a mixed methods approach within the UK for an acupuncture study within pregnancy. Finally, it is the first study written in English that has compared pKHA to npKHA for any condition.

No description available.

Previously cloned bacteriophage encoded HyIP 1 from the genome sequenced organism Streptococcus pyogenes SF370 was expressed in Escherichia coli and purified to homogeneity. The protein, previously assigned to glycoside hydrolase family 69 (GH69) was biochemically recharacterised as a polysaccharide lyase and reassigned to family 16 (PL16). The enzyme demonstrated a Km of 1.47 mg m1-1 and a kcat of 7.2 s-1. Biochemically the enzyme had an optimum pH of 6.5 and temperature of 37 °C. The enzyme required no additional divalent ions for catalysis. The enzyme demonstrated strict substrate specificity only degrading hyaluronate and with no activity against related substrates chondroitin 4 sulphate and chondroitin 6 sulphate. HPAEC indicated the HylP1 had an endo mechanism of cleavage producing a range of differently sized oligosaccharides with the smallest being a tetramer. Site directed mutagenesis revealed a role for residues D157 and Y169 with substitution of these residues with alanine resulted in a 88.5% and 91.9 % loss of activity respectively. The location of these residues within the solved structure of HylP1 falls within the triple stranded (3 helix formed by the trimerised protein. This region of the protein was cloned, expressed and characterised and demonstrated similar kinetics as the full length protein (Km of 0.53 mg m1-1 and keat of 11.1 s-1). The activity of the enzyme when compared to other hyaluronate lyases shows it to be relatively inefficient yet when compared to other bacteriophage encoded hyaluronate lyases, HylP 1 was very similar. The proposed role of these bacteriophage encoded hyaluronate lyases is one of degradation of the hyaluronate capsule surrounding the streptococcal cells to allow for penetration of the bacteriophage during infection. Using the sequence of HylP1 the recently completed genome of Streptococcus equi was searched using bioinformatics tool BLAST. This revealed the presence of a protein, SEQ2045, sharing 85 % identity with HylPl. The protein was cloned and expressed in E. colt and biochemically characterised as a hyaluronate lyase. The enzyme demonstrated a Km of 2.05 mg m1-1 and a kcat of 6.2 s-1 which when compared to those of Hy1P 1 is suggestive that the two enzymes are strongly related. The enzyme had an optimum pH of 6.5 and temperature of 37 °C and like Hy1P 1 demonstrated only activity against hyaluronate and had an endo mechanism of cleavage with the smallest product of digestion being a tetramer. Site directed mutagenesis of the same residues as in HylP1 again yielded reduced activity (91.3 % and 87.6 % respectively). Bioinformatic analysis of the genome of S. equi was performed by BLAST searching with the proposed gene sequences of S. equi flanking SEQ2045. This allowed for the production of a prophage map which shows distinct similarities to the prophage map of S. pyogenes suggesting both may be of the same origin. Purified SEQ2045 was used in western blot analysis with S. equi convalescent horse serum. A strong positive reaction demonstrated a possible role for SEQ2045 during an infection suggesting that the bacteria have acquired this enzyme as a potential virulence factor by horizontal gene transfer. This presents a useful opportunity for the study of both S. pyogenes and S. equi infection process and the role of bacteriophage by the use of S. equi as a model for S. pyogenes.

Anomalies noticed in midwifery practice prompted a review of literature around progress in labour after Loop Excision of the Transformation Zone (LETZ). The previous research was equivocal. This study investigates the pattern and progress of women's labours following LETZ, and the effect of the experience on women. It also explores the basis of clinical decisions made by midwives. It takes place in North East England and involves women giving birth in 2004-2005. The case study strategy brings together quantitative retrospective case control results, qualitative analysis of semi-structured interviews from women and midwives, and guidelines and protocols surrounding assessment and management of labour. The quantitative data is from 111 women after LETZ and 214 controls, reducing to 94 and 150 respectively after removal of cases with confounding variables. Interviews are from four women, three individual midwives caring for one of the women and a focus group of four midwives. In the interviews, women gave no thought to how their births may be affected by LETZ, as no one had discussed the possibility with them. Women having their second baby after LETZ take less time to reach full dilatation; a result related to grade of Cervical Intraepithelial Neoplasia. Women having their first baby after LETZ are 1.8 times more likely to be admitted later in their labours, an important emergent issue that needs further research. Women having their first or second baby after LETZ are 2.3 times more likely to have a premature birth, confirming indications in previous research. This study for the first time reveals important differences in pattern and progress of labour after LETZ. It adds to our knowledge of premature birth after LETZ. Midwives, obstetricians and colposcopists need to incorporate the study results into counselling of women before LETZ and during any pregnancy after LETZ.

Innovations in cancer care requiring intensive support, and improved cancer patient survival in and out of critical care, have led to greater numbers of cancer patients than ever accessing critical care. Of these, however, a fair proportion will die. Current research points to around one in six patients dying in general critical care units and even higher numbers for cancer patients. End-of-life care (EOLC) for critically ill patients is problematic and rarely addressed beyond satisfaction or chart review studies, while palliative care is an established domain in cancer. It is not known whether dying, critically ill cancer patients experience good EOLC. In the context of a cancer critical care unit, this thesis explores the provision of EOLC for cancer patients in a critical care unit. Exploring measures for comfort care and palliative principles of care helped identify what is important for patients and families, and what those measures meant for all participants. The diagnosis of cancer and how it impacts on EOLC provision for critically ill cancer patients was also explored from the perspective of patients, families, doctors and nurses. A Heideggerian phenomenological interview approach was undertaken, in order to gain personal experiences. Families of those patients who died after decisions to forgo life-sustaining treatment (DFLSTs) were interviewed. Patients who have experienced critical care were also interviewed, since patients‘ views about EOL care provision are very rarely explored. Doctors and nurses also contribute their vision for, and experiences of, EOL care in a cancer critical care unit. Thirty one interviews with 37 participants were carried out. Cancer prognosis together with critical illness prognosis contributed to difficulties in deciding to move to, and enact EOLC. The nursing voice in DFLSTs was minimal and their role in EOLC depended on experience and confidence. Achieving a good death was possible through caring activities that made best use of technology to prevent prolonged dying. EOLC was an emotive experience. Decision-making and EOLC could be difficult to separate out which, in turn, affects prospects for EOLC. A continuum of dying in cancer critical illness is presented with different participants‘ experiences along that continuum. Three main themes included: Dual Prognostication; The Meaning of Decision-Making; and Care Practices at EOL: Choreographing a Good Death with two organising themes: Thinking the Unthinkable and Involvement in Care. These themes outlined the essence of moving along a continuum toward patients‘ deaths and the impact that had on opportunities for care and a good death. Nurses could use the care of patients dying in critical care as an opportunity to develop specialist knowledge and lead in care, but this requires mastery and reconciliation of both technology and EOLC. This work builds on Seymour‘s (2001) theory of a negotiated and natural death related to achieving a good death in critical care. Trajectories of dying, part of Seymour‘s (2001) theory, are extrapolated on with reference to Glaser and Strauss (1965) and Lofland (1978)‘s theories on dying trajectories. Nursing theory is developed through examination of Falk Rafael‘s (1996) and Locsin‘s (1998) theories of empowered caring. Implications and propositions are presented for nursing and wider practice around EOL care for critically ill cancer patients.

Although parents’ involvement has been identified as important for interventions for their children and young people, little research is conducted to explore parental management strategies for anxiety in children and young people with mild to moderate learning disabilities (LD) and autism. Given that children and young people with LD and autism are more vulnerable to experience anxiety, the overall purpose of this thesis was to identify the prevalence rates of anxiety and explore management strategies for anxiety in children and young people with LD and autism. Three studies were conducted to identify prevalence of anxiety and develop and implement a parental programme of management strategies for anxiety in children and young people with LD and autism. In the first study of this research “Screening study”, 150 children and young people with LD and autism were screened for anxiety using Reiss Scale and Glasgow Anxiety Scale. Results from the screening indicated that children and young people with LD and autism have high prevalence rates of anxiety (32.6%). The second study of this research “Developing a programme” was to develop a programme of management strategies for anxiety from parents’, carer’s, teachers’ and health professionals’ views. In this study parents and teachers were interviewed regarding the management strategies they use to manage their children’s / young people’s anxiety. Results from 34 interviews revealed that sixteen different management strategies were identified by parents and teachers of children and young people with LD and autism. Following this, the management strategies identified by parents, carers and teachers were discussed with an expert panel of health professionals to develop a parental programme “Calm Child Programme” of the most useful and appropriate strategies for those children and young people. The Calm Child Programme was developed using Delphi method to identify a consensus approach with professionals. This consisted of ten useful management strategies for parents to manage their children’s and young people’s anxiety. Finally, the third study of this research “Implementing the calm child programme” was a pilot study of the implementation for the Calm Child Programme. This programme of parental management strategies for anxiety was piloted with seven parents of children and young people with LD and autism. The results from the pilot study indicate reduction in the children’s and young people’s anxiety after its use by parents. Parents reported that the developed strategies were useful in managing their children’s and young people’s anxiety. This research has two key contributions to knowledge. Firstly, this research highlighted the theme of anxiety of children and young people with LD and autism. The identification of high prevalence of anxiety in this population indicates the need for management strategies. Secondly, this research aimed to improve the paucity of autism specific research as it relates to anxiety management strategies in children and young people with autism. This research explored a new programme of parental management strategies for anxiety in children and young people with LD and autism. This research has contributed to our understanding of using systematic and evidence based management approaches in supporting and involving parents.

Complementary and Alternative Medicine (CAM) has long been used in the Far East to aid in the recovery and prevention of illness. Ginseng, an over-the-counter herbal product in the UK, is amongst these herbal CAMs currently available to the general public. Ginseng is renowned for its rejuvenating properties and its purported ability to aid cognitive function and well-being. Despite the huge global market for ginseng there is little in the way of human research, utilising standardised ginseng extracts and well controlled methodology to support many of these claims. Additionally, ginseng's underlying mechanisms of action are poorly understood. The present thesis documents 5 double-blind, placebo-controlled, cross-over trials investigating the effects of Panax ginseng, following acute and chronic ingestion, on behaviour, mood and indices of glucose regulation in young healthy volunteers. The results of the five studies making this thesis suggest that both acute and chronic dosing with Panax ginseng is capable of modulating mood and cognitive performance in healthy young volunteers. Chapters 2 and 3 also demonstrate, for the first time, Panax ginseng's ability to modulate blood glucose levels following a single acute dose in overnight fasted healthy volunteers. In chapters 2 and 3, significant reductions in blood glucose levels and concomitant improvements in mental arithmetic (working memory) performance were reported. Chapter 4 revealed for the first time Panax ginseng's positive effects on traditional measures of working memory, thus posing the suggestion that previous failures to report working memory effects (using traditional working memory tasks) may have been due to poor task selection. Chapter 5 revealed an unexpected superimposed relationship between chronic and acute ingestion of Panax ginseng. The pattern of results suggests that following chronic dosing, an acute dose can further modulate cognition and mood (suggestive of a psychological dependence). The final chapter documents a different profile of cognitive and mood effects following a non-standardised Panax ginseng extract, thus highlighting the need for caution when generalising results across ginseng types and beyond the specific parameters of the methodologies utilised in any given study. Methodological differences between studies may go some way in explaining the inconsistent data patterns reported between studies, research groups and ginseng extracts. These data further highlight the need for well-controlled studies utilising standardised ginseng extracts and the need for the integration of 'theory driven' research in order to fractionate any behavioural effect. Such methodologies will inevitably lead to greater consistency between behavioural studies, at least in the first instance within the restricted population of volunteers utilised in the present thesis.