It is well recognised that physical illness is associated with an increased risk of experiencing psychological problems and disorder and that there is considerable variation in the nature and severity of psychological reaction. This variance is not explained by physical disease characteristics alone. The meaning that is ascribed by patients to physical illness experiences has been examined as a potential explanatory variable. However the term 'meaning' has been used inconsistently and has been subject to semantic confusion within the literature. The term has been used to refer to discrete interpretations, the process of making sense of the occurrence of traumatic personal events and the outcome of this process of 'search for meaning'. Meaning can also be distinguished in term of whether it is focused on cross- situational and global themes (e.g. 'The world is unjust, cruel and unfair') from a focus on interactions between an individual and situation specific events, so called situational meaning (e.g. 'I blame myself for having cancer'). Cancer is known to be associated with a number of specific psychological challenges many of which have informed research in psychosocial oncology. Global and situational meaning have been examined across a range of clinical populations. The existence of a range of valid and reliable assessment measures of global meaning has contributed to this literature. Although studies are beginning to examine global meaning in cancer, further development in understanding situational meaning in cancer has been hampered by the lack of any validated measure for this purpose.

Stroke is a leading cause of death and disability worldwide and remains a largely unmet clinical need. Despite decades of pre-clinical stroke research there are only two licensed interventions: intravenous delivery of thrombolytic recombinant tissue plasminogen activator (rt-PA) within 4.5 hours of stroke or mechanical thrombectomy. However, the number of patients eligible to receive either treatment is limited. An alternative intervention is needed, one which directly address specific aspects of stroke pathophysiology. Through their ability to alter the expression of multiple genes involved in stroke pathophysiology microRNAs (miRNA or miR) offer a novel therapeutic intervention. miRNA expression is altered both in experimental stroke and in patients with stroke. It was initially hypothesised that modulation of specific dysregulated miRNAs would be therapeutically beneficial in pre-clinical experimental ischaemic stroke. Recently, active transport of miRNAs in extracellular vesicles (EV), such as exosomes, has been demonstrated pre-clinically between cells in atherosclerosis and cardiac hypertrophy disease settings. It was therefore hypothesised that miRNAs packaged in exosomes would differ between patients with stroke and patients without stroke, raising the potential for novel exosomal miRNAs to be used as biomarkers or therapeutic agents for modulation. In Chapter 3, investigations were carried out to test the hypotheses that modulation of either miR-494 or miR-21 would be therapeutically beneficial in pre-clinical in vitro models of stroke. While miR-494 expression was unchanged in brain tissue of spontaneously hypertensive stroke prone rats (SHRSP) harvested at either 24 or 72 hours following transient middle cerebral artery occlusion (tMCAO) its expression was successfully up-regulated in B50 neuronal and GPNT cerebral endothelial cell lines following delivery of miR-494 mimic in combination with siPORT, a lipid based transfection reagent. mRNA expression of putative miR-494 target genes (PTEN, MMP2 and MMP9) was investigated post-miR-494 modulation but there was no obvious change in their expression. Modulation of miR-494 expression did not appear to be therapeutically beneficial (or detrimental) when assessed by a cell survival assay (MTS). As the balance of evidence did not indicate that miR-494 would be a suitable target for modulation in experimental stroke subsequent similar experiments investigated the therapeutic potential of miR-21. Its expression was significantly increased in SHRSP brain tissue at 72 hours following ischaemic stroke. miR-21 expression was successfully increased in cerebral endothelial cells following delivery of miR-21 mimics (with siPORT). mRNA expression of putative target genes (PDCD4 and PTEN) was unchanged following miR-21 modulation and cell survival (assessed by MTS assay) was unaffected. Subsequent experiments looked at vessel reactivity of aortae taken from miR-21+/- and miR-21-/- mice in comparison to wild type (WT) mice. Treatment of vessels with L-NAME to block endogenous nitric oxide (NO) bioavailability resulted in unopposed contraction to U46619 in WT mice while there was no change in contraction in miR-21-/- mice aortae, consistent with reduced basal NO bioavailability, and a detrimental phenotype associated with the loss of miR-21 expression. As the data generated in this study were primarily neutral and gave no indication that either miR-494 or miR-21 would be therapeutically beneficial in the setting of ischaemic stroke, subsequent studies focussed on investigating exosomal miRNA in ischaemic stroke. In Chapter 4, exosomal miRNA expression was profiled in blood samples from stroke patients and subsequently in pre-clinical rodent stroke models. Patients with suspected stroke were recruited and a blood sample taken at 48 hours post-stroke. All participants gave full informed consent and the study was approved by the Scotland A Research Ethics Committee. Exosomes were isolated from 200 μL serum before RNA was extracted. A miRNA microarray was performed (OpenArray™ platform) on samples from 39 patients. Validation of results was performed by real-time quantitative polymerase chain reaction using samples from 173 patients to determine the expression levels of specific miRNAs. Microarray experiments identified 26 exosomal miRNAs that were significantly dysregulated between stroke and non-stroke patients or between specific TOAST subtypes and non-stroke controls. Of these, changes in 13 miRNAs were validated in the larger cohort and levels of 9 miRNAs (-27b, -93, -20b, -17, -199a, -30a, let-7e, -218 and -223) were found to be significantly increased in definitively diagnosed stroke patients as compared to non-stroke patients. Differences in exosomal miRNA expression were observed between TOAST subtypes with small vessel disease patients consistently having the highest levels of these miRNAs. miRNA expression did not correlate with baseline or day 7 NIHSS score, although there was a trend towards patients with better functional outcome post-stroke (as assessed by modified Rankin Score at 1 month) having a higher level of some exosomal miRNAs. Subsequently total and exosomal miR-17 family (miRNAs -17, -93 and -20b) expression was investigated in pre-clinical models of hypertension and stroke. Total circulating miR-17 expression was unchanged between the serum of normotensive WKY and hypertensive SHRSP rats, whilst exosomal miR-17 expression was significantly increased in SHRSP vs. WKY. miR-17 family expression was unchanged in peri-infarct brain tissue of SHRSP at both 24 and 72 hours post-tMCAO. Experiments profiling total and exosomal circulating miR-17 family expression in serum of SHRSP post tMCAO or permanent MCAO revealed that expression was variable and changes observed were not significant. Cellular expression of miR-17 family miRNAs was unchanged following hypoxic challenge in neuronal, glial and cerebral endothelial cell lines and exosomal miRNA expression was highly variable, with no changes detected as significant. This study both identified and validated (for the first time) changes in exosome packaged miRNA expression in patients with stroke across differing stroke subtypes. The pre-clinical experimental findings corroborate the human data and support a functional role for these findings. In Chapter 5 exosomal packaged miR-17 family miRNAs were delivered in pre-clinical models of ischaemic stroke (both in vivo and in vitro) to test the hypothesis that they would be therapeutically beneficial following in vitro hypoxic challenge or in vivo experimental stroke. Bioinformatics analysis highlighted a number of important target genes implicated in stroke pathophysiology for each miRNA including genes involved in the regulation of the cellular response to stress, apoptosis and angiogenesis. miRNAs were artificially loaded (by electroporation) into EVs harvested from SHRSP brain. While miRNA loaded EVs did not successfully modulate miRNA expression either in vivo or in vitro it is believed that this is a result of technical issues with the loading of the miRNAs into the EVs. This study should be repeated when miRNAs have been successfully loaded into EVs, as these experiments remain of interest. In summary, the findings presented in this thesis confirm that packaging of miRNAs into exosomes is significantly dysregulated in stroke patients and that as a result the circulating exosomal miRNA profile is altered. This will direct future studies looking into paracrine signalling in the setting of stroke and the modulation of specific miRNAs as a novel therapy in the setting of experimental stroke.

Background: Professionalism is contextual and varies with culture. It has multiple dimensions including individual, inter-personal, organizational, and societal components. The aim of this study was to add some new perspectives to understand professionalism. Professionalism was explored in the context of two different cultures, Scotland and Pakistan, to identify similarities and differences in perceptions of clinical faculty members and medical students. Methodology: The method used was qualitative multiple case studies in a constructivist approach. Cultural Historical Activity Theory (CHAT) was used as a theoretical framework to enhance understanding of the study. Faculty members from three Scottish and three Pakistani medical schools were interviewed. Focus group discussions were arranged with groups of 7-10 medical students from each of the six medical schools. The data was analysed using a thematic analysis to identify reasons for cultural similarities and differences across two countries. Results: The results were divided into nine themes, that is, the nature of the healthcare system, models and process of professionalism, attributes of professional doctors, approach of doctors towards their patients and other healthcare professionals, working in teams, self-regulation, the role of doctors in society and within families, dealing with ethical dilemmas and legally difficult situations, and resolving conflict situations in the work place. Discussion The variance of professionalism found in this study was mainly due to the health professionals working in two different healthcare systems. The cultural differences between the two countries were reflected in these systems and the activity of professionalism included conflicts and dilemmas, self-regulation, and professional attributes. Medical professionals were found to adopt different institutional models of professionalism when they perform their daily activities. Conclusions: This study showed that doctors and medical students from both countries have mostly similar perceptions about professionalism with some dissimilarities resulting from differences in the culture, history, institutional ethos, daily activities and the role of religion. There is a lack of training in professionalism and a need to include it in the formal curriculum in Pakistan. A training programme could be organized and incorporated into the curriculum using the themes, models and process of professionalism with attention to culturally sensitive situations to prepare medical students for their early professional years in both countries. A focus needs to be on the preparation of communication skills in different contexts and the improvement of the internal environment, which is within the control of every individual. A faculty development programme, with similar objectives, needs to be introduced for medical staff to enhance their understanding of professionalism.

Mathematical models of physiological processes can be used in critical care and anaesthesia to improve the understanding of disease processes and to guide treatment. This thesis provides a detailed description of two studies that are related through their shared aim of modelling different aspects of brain physiology. The Relationship Between Transcranial Bioimpedance and Invasive Intracranial Pressure Measurement in Traumatic Brain Injury Patients (BioTBI) Study describes an attempt to model intracranial pressure (ICP) in patients admitted with severe traumatic brain injury (TBI). It is introduced with a detailed discussion of the monitoring and modelling of ICP in patients with TBI alongside the rationale for considering transcranial bioimpedance (TCB) as a non-invasive approach to estimating ICP. The BioTBI Study confirmed a significant relationship between TCB and invasively measured ICP in ten patients admitted to the neurological intensive care unit (NICU) with severe TBI. Even when using an adjusted linear modelling technique to account for patient covariates, the magnitude of the relationship was small (r-squared = 0.32) and on the basis of the study, TCB is not seen as a realistic technique to monitor ICP in TBI. Target controlled infusion (TCI) of anaesthetic drugs exploit known pharmacokinetic pharmacodynamic (PKPD) models to achieve set concentrations in the plasma or an effect site. Following a discussion of PKPD model development for the anaesthetic drug propofol, the Validation Study of the Covariates Model (VaSCoM) describes a joint PKPD study of the Covariates Model. Pharmacokinetic validation of plasma concentrations predicted by the model in forty patients undergoing general anaesthesia confirmed a favourable overall bias (3%) and inaccuracy (25%) compared to established PKPD models. The first description of the pharmacodynamic behaviour of the Covariates Model is provided with an estimated rate constant for elimination from the effect site compartment (ke0) of 0.21 to 0.27 min-1.

Craniofacial development requires progressive morphologic change, proliferation, differentiation and organization of chondrocytes preceding osteogenesis. The Wnt signalling pathway has been involved in regulating bone development and maintenance. As they are fated to become bone, chondrocytes require Wnt to polarize and orientate appropriately to initiate the endochondral ossification program. Although the canonical Wnt signalling has been studied in the context of bone development, the effects of non-canonical Wnt signalling in regulating the timing of cartilage maturation and subsequent bone formation in shaping ventral craniofacial structure is not well understood. In this thesis, I examined the role of the non-canonical Wnt signalling pathway (through the study of the role of wls, gpc4, wnt5b and wnt9a) in regulating zebrafish Meckel’s cartilage maturation to the onset of osteogenic differentiation. First, I show that disruption of wls resulted in a significant loss of craniofacial bone, whereas lack of gpc4, wnt5b and wnt9a resulted in severely delayed endochondral ossification. This demonstrates the importance of the non-canonical Wnt pathway in regulating coordinated ventral cartilage morphogenesis by directing chondrocyte polarity. Second, I found distinct cellular requirements within the body and midzone of the mandible. Without non-canonical Wnt signalling, chondrocytes within the midzone appear to remain in their prehypertrophic state and fail to elongate and stack. This may suggest the importance of Wnt signalling in determining jaw length and size. Third, I generated a double transgenic zebrabow line to allow cellular studies on dynamic cell behaviour during development. Finally, to further interrogate the role of Wnt signalling during chondrocyte maturation, I studied the role of intracellular Wnt trafficking. More recently, there has been increasing evidence that Wnt activity is not only regulated in the receiving cells but also on the level of its secretion (Gross and Boutros, 2013). By studying wntless (wls), a multi-transmembrane protein that shuttles Wnts from the Golgi to the plasma membrane, I found that wls trafficking through coat protein vesicles (COP) is key in neural crest specification and differentiation. These works provide important insights into the non-canonical Wnt signalling during endochondral bone formation and craniofacial lower jaw development.

Background: Within the routine practice, specific screening for autism spectrum disorder (ASD) has been recommended, in order to facilitate early intervention and improve outcomes. Despite the substantial advantages of this process, it has also presented a variety of challenges, across clinical settings, which have not yet been explored sufficiently. There is little information available to support the introduction of ASD screening in Oman. Research is required to identify the potential facilitators of and barriers to ASD screening in Oman, prior to the implementation of a screening programme, to ensure its successful introduction. Method: An exploratory mixed-methods design was adopted, in two sequential phases. Phase 1 involved two focus group discussions, with seven nurses and six GPs, from primary health care (PHC) settings in Oman. The participants were recruited using a purposive and snowballing technique. The discussions were audio-taped and transcribed verbatim. Framework Analysis was used to identify recurrent themes within and across groups. Data from the focus groups was then used to inform the development of a questionnaire, which was piloted on a sub-sample of volunteers from both groups. Phase two (quantitative phase) comprised of sending the final draft of the questionnaire to a random sample of primary health care providers (PHPs) (n=571) across Oman. The returned data was analysed statistically with the software program SPSS (Statistical Package for Social Sciences version 22.0). The Social Ecological Model (SEM) was then applied to interpret the final data from both phases and to draw conclusions. Results: Qualitative data analysis revealed five themes, which voiced the major challenges facing ASD screening in Oman, as well as highlighting a few facilitators. The findings revealed that both nurses and GPs believed that introducing screening for ASD would be a positive step. However, they felt overwhelmed by their responsibilities and believed that their workplaces lacked the necessary infrastructure. Practitioners’ awareness of ASD services was identified as poor, as were the essential skills required for undertaking screening. Additionally, limited public awareness of ASD and a strong interest in traditional medicine, as well as the social stigma attributed to ASD, were thought to create barriers to screening. The groups also discussed their preference for a clear, simple, paper-based questionnaire, supported with guidance and researcher availability to reward their willingness to participate. The findings from the focus group informed the development of a 38-item questionnaire to explore the potential barriers to and facilitators of the introduction of ASD screening in Oman. The questionnaire was short so that it could be completed within 15 minutes. Five hundred and seventy-one questionnaires were sent to a random sample of PHP providers across Oman. Of those, five hundred and sixteen questionnaires were returned, in phase 2 (response rate 90.37%). The quantitative results of this phase were congruent with the qualitative findings, in that they suggested a deficit in the knowledge of professionals, among both older respondents and nurse respondents. In addition, a lack of resources, time constraints, workload issues and staff shortages were highlighted. The respondents also emphasised the ambiguity surrounding their role and the lack of guidance on protocols to identify or refer suspected cases. This was compounded by a lack of public awareness and knowledge of ASD identification and its potential causes, as well as the attributed social stigma. Conclusions: The root challenges and potential facilitators for screening for ASD were examined, through the SEM. Challenges were addressed and resolved across three levels (intrapersonal, organisational, and community). At the intrapersonal level, more training and knowledge regarding ASD is required. Organisations need to implement a clear protocol, to guide the process, with greater coordination and collaboration among services. A country-wide awareness campaign, targeting social issues, may reduce the stigma and improve the uptake of screening.

Progressive Multiple Sclerosis (MS) is a degenerative neurological disease with no known cure. The overall aim of the research within this thesis was to investigate physiotherapy, an important part of the care, for people with progressive MS. This was done in three studies. A systematic review of the current literature for the effectiveness of physiotherapy for the rehabilitation of people with progressive MS; an online survey of people with progressive MS assessing levels of access to, and use of, clinical services across the United Kingdom; and a feasibility study of High Intensity Interval Training (HIIT) for people with progressive MS. The systematic search returned 15 studies, 482 participants in total, which investigated eight different interventions: exercise therapy, multi-disciplinary rehabilitation, functional electrical stimulation, botulinum toxin type A injections and manual stretches, inspiratory muscle training, therapeutic standing, acupuncture and body weight supported treadmill training. All studies, apart from one, produced a positive result, however, only one study was adequately powered. In conclusion, the review found that the evidence was positive for using physiotherapy for rehabilitation in people with progressive MS, but further adequately powered research, is required to strengthen this. In total 1298 people with progressive MS from across the United Kingdom completed the online survey in August to October 2015. Participants were asked regarding access and use of clinical services, delivery and opinion of physiotherapy, and use of complementary and alternative therapies. Access to MS Specialists was high (95%), as was access to a physiotherapist (87%). Seventy seven percent of physiotherapy was delivered by the National Health Service and 32% were currently receiving physiotherapy for their MS. Physiotherapy was very well perceived by people with progressive MS and the most common interventions received were independent (83%) and supervised exercise (71%). Five percent of respondents were currently using disease modifying therapies and 23% had previously taken them. Almost three quarters (74%) received a regular review but 37% received this review less than annually. It was recommended that service providers make steps to address this gap in service provision. Finally, eight weeks of twice weekly HIIT sessions were compared to twice weekly sessions of continuous moderate intensity training. Ten out of twelve participants completed the trial. The HIIT intervention was well tolerated with 93% adherence, 100% compliance with protocol and no adverse events. There were three adverse events in the continuous training group and compliance was 79%. In addition, those who received HIIT improved their maximal heart rate and mental processing speed while no changes were found in the continuous training group. A larger, fully powered trial is required to confirm these results. Overall the studies within this thesis demonstrate that physiotherapy has the potential to be beneficial in the rehabilitation of people with progressive MS, that people with progressive MS are engaging with physiotherapy, and that interventions such as HIIT may provide new avenues for eliciting health benefits from this patient group. However, despite these positive findings, more work is required to strengthen the evidence base and gaps in service provision should be addressed.

Background: Changes in therapeutic radiography have promoted the development of a consultant practitioner role in clinical practice. Clinical duties that were once performed by the clinical oncologist are now being shared in some trusts by Consultant Therapeutic Radiographer (CTRs) who are experts in their scope of practice. The first CTR was appointed in 2003, yet an evaluation of the role has remained limited. Aims: The thesis examines the CTR role, through the perspectives of medical, nursing, therapeutic staff and key stakeholders by means of a qualitative inquiry, with the intention to explore professional and organisational impact. Methods: A collective case study approach was adopted to facilitate the examination of the CTR role, using the Dimensions of Impact Framework (Gerrish et al., 2011). A three-phased research design was employed. Phase one of the study utilised a focus group with CTRs (n=4) as a scoping exercise to understand the current state of the CTR role in clinical practice. Phase two consisted of six case studies and utilised individual semi-structured interviews with CTRs (n=6) and interviews with medical, nursing and therapeutic staff (n=18) to gain a thorough view of the CTR role from their perspectives. Document analysis was also conducted using the CTR job descriptions to discern similarities or differences and examine whether the job descriptions provided the opportunity to demonstrate professional and organisational impact. In the analysis of the Phase two, data were mapped against the Dimensions of Framework to identify the perceived professional and organisational impact of the CTR role. Finally, Phase three utilised semi-structured interviews with key stakeholders (Society and College of Radiographers, NHS England and Health Education England) (n=6), to explore their views on the CTR role and on the themes derived from the six case studies Results: The themes identified under perceived professional impact were: professional outcomes, working relationships and identity. The themes identified under perceived organisational impact were: service targets, perceived patient experience and power. In addition, two further themes were identified: challenges of the role and future prospects of the role were also indicated. The main challenges noted were: lack of medical knowledge; lack of time for research; increased workload; meeting the expectations of the role; medico-legal implications and financial implications. The future prospects for the role were: more engagement with the consultant practice domains (such as the research domain); increase the CTR numbers and specialities; and develop CTR’s medical knowledge; further promote the CTR role, and have a responsibility for prescribing the radiotherapy treatment. Conclusions and recommendations This original piece of research has provided a detailed examination of the perceived organisational and professional impact of the CTR role. It has also identified a number of challenges and considerations for the future. Recommendations for clinical practice and policy include: conduct a national evaluation to capture the impact of the CTR role, further promote the role, develop a detailed job plan, undertake a review of educational and training of the CTR; and ensure adequate clinical support and mentoring. The addition of the concepts of power of and identity to the Gerrish et al., (2011) Dimensions of Impact Framework within this research needs testing in different professional and organisational contexts. Overall the knowledge generated from the participants’ perceptions of the CTR role presented in this thesis contributes to the literature on capturing perceived impact and provides new perspective on, and representations of, power and identity.

The overall aim of this thesis is to develop prediction models to identify key predictors of poor outcome in people with osteoarthritis (OA) and examine the cost effectiveness of two approaches to delivering primary care interventions for OA compared to current primary care. This thesis is comprised of two parts – the first part concerns the development of prediction models to identify the combination of factors that predicts poor outcome of OA in relation to pain and functional limitation at three year follow up for participants aged 50 years or more. The strongest baseline predictors of pain and functional disability were having pain in the previous year and poor physical function at baseline respectively. The models developed showed good internal validity and hence may be further tested for external validity in community-based adults with similar characteristics as those in this study. The second part involves a summary of evidence on the effectiveness of four primary care interventions (information and advice, simple analgesia, topical NSAIDs and exercise) in reducing pain and improving function at one or more joint sites among osteoarthritis patients in primary care. The results showed significant small to moderate improvements in pain and functional disability for advice/information, topical NSAIDs and exercise interventions compared to their controls, whilst simple analgesia failed to demonstrate significant improvements in either measures. This evidence was used to populate the economic (decision) model developed in this thesis. The decision model examined the cost effectiveness of two approaches to delivering primary care interventions for OA - stepped care and one-stop-shop care were compared with current primary care. The primary results were robust to changes in the input v variables with stepped care emerging as the most cost-effective option ahead of one-stop-shop care and current care in that order. These findings need to be confirmed in samples of primary care consulters.

The most common clinical treatments for large bone deficiencies resulting from trauma, disease or infection are autograft, allograft or bone graft substitutes (BGS). However, these treatments still have limitations for clinical applications. Thus, this project aims to fabricate an optimal scaffold design for enhanced bone formation. Human bone is not solely hydroxyapatite (HA) but consists of multi-ionic substitutions in the HA lattice. Here, we have developed multi-substituted HA (SiCHA) nanopowders as bone substitute materials. SiCHA-2 was found to closely mirror the composition of the bone mineral content associated with the most enhanced proliferation and osteogenic activity. An innovative coating materials assembly was then established using SiCHA-2 nanopowders in combination with hyaluronan and collagen type I by the Polyelectrolyte Multilayers (PEMs) technique. Increasing the number of deposition cycles resulted in linear increases of surface properties and cell activities up to 5-bilayers. One common problem in scaffold-based tissue engineering (TE) is the rapid formation of tissue on the outer edge of the scaffolds whereas inner regions of the scaffold undergo necrosis. In this study, we incorporated aligned channels on the structure of three-dimensional (3D) scaffolds by Rapid Prototyping (RP) technique using Poly (lactic acid) (PLA) followed by PEMs. We investigated the fate of human mesenchymal stem cells (hMSCs) on these scaffolds in a rotary bioreactor compared to static conditions using osteogenic and proliferation media. We demonstrate that the combination of appropriate substrates with aligned channels, biochemical cues from the osteogenic media and better mass transport provided by rotary bioreactor enhances bone formation. In order to create pre-vascularized 3DP hybrid scaffolds, proof of concept work introduces the co-culture model of human umbilical vein endothelial cells (HUVECs) and hMSCs into the best scaffold design. Co-culture shows enhanced expression of both proangiogenic markers, which is an early indication of an ability supporting vessel formation in vitro.