Dissertations / Theses: 'General surgery'

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Pockney, Peter Graham. "Aspects of minor surgery in general practice." Thesis, University of Southampton, 2004. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.403822.

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Symons, Nicholas. "Quality of care in emergency general surgery." Thesis, Imperial College London, 2014. http://hdl.handle.net/10044/1/18617.

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There are more than 600,000 emergency general surgery admissions per year in England. These patients comprise about 50 percent of general surgical workload but make up 80-90 percent of all general surgical deaths. In recent years surgical colleges and societies in the UK have warned of significant variability in the quality of care between hospitals but, to date, little formal evaluation of the quality of care in emergency general surgery exists. This thesis uses the Structure/Process/Outcome quality assessment framework, devised by Avedis Donabedian, to examine quality of care in emergency general surgery across all three of these domains. A study of high risk emergency general surgical admissions using the administrative Hospital Episode Statistics dataset demonstrated significant variability in 30-day in-hospital mortality between NHS Trusts. Investigation of NHS Trust structure was performed using data from the Department of Health. There were significant differences in the provision of intensive care beds and in the utilization of computed tomography and ultrasound scanning between low mortality and high mortality NHS Trusts. The process of care was assessed using an explicit checklist for the admission phase of care and using ethnographic field notes for patients’ subsequent hospital stay. Across 5 London hospitals, process reliability during admissions to hospital was poor, with nearly 20% of recommended processes omitted. Failures in the process of care were also common in subsequent ward based care. Failures were considered to be highly preventable and frequently caused harm to patients or delayed their discharge. Overall, this thesis has identified significant variability in the quality of care for emergency general surgical patients in structure, process and outcomes. While the thesis does not evaluate every single aspect of patient care it demonstrates the degree of improvement required in emergency surgical care and provides some recommendations for future quality improvement.

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Hauck, Robert. "Virtual surgery and orthopaedic surgery : towards training using haptic technology." Thesis, University of Nottingham, 2017. http://eprints.nottingham.ac.uk/38530/.

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Medical education and practical training in surgery is changing, by shifting from an on the job learning paradigm, which possesses problems such as that it is unpredictable, dependent on clinical needs and that patient safety may be jeopardised, to an evidence-based surgical skills training driven by curricular needs, and acquiring basic surgical skills prior to assisting in the operating theatre and thus reducing operation duration. Towards achieving this goal, virtual reality (VR) simulators are used in minimally invasive surgery for technical skills training at the beginning of the learning curve, but have not yet been adapted for open surgery due to its complexity for simulation. This thesis investigated the potential of using a VR simulator for training in orthopaedic hand surgery, with an emphasis on providing a meaningful, effective and motivating addition to current training methods for surgical procedures. A review of literature, preliminary research projects and currently available surgical systems revealed limited results on whether a VR simulation of orthopaedic hand surgery could be created, fulfilling the needs of medical experts. Therefore, a study investigating the current state of medical education and to understand the expectations on such a simulator was carried out, which resulted in the identification of promising medical scenarios for simulation (such as carpal tunnel release, distal radius fracture treatment or surgical incision) and in requirements for its development. Different software frameworks have been evaluated for their ability for use by analysing five developed demonstrators, with the result that a custom implementation of a six-degrees-of-freedom haptic algorithm was required. By following a human-centred design approach, a VR surgical simulator with inbuilt objective measures of assessment has been developed, allowing applying a plate, drilling holes, measuring their lengths, inserting screws and taking virtual X-rays, supported by haptic feedback for increased realism and teaching aspects not possible by common computer-based simulators, such as feeling the resistance when drilling through the cortical bone. By close collaboration with medical experts and following user interface design principles, a carried out medical evaluation of the simulator showed that the simulator was well-received by the targeted young doctors and medical students, that relevant aspects of the implemented medical scenario are taught and that the users’ performance can be assessed. The findings of this work showed that it is possible to create an interactive VR simulator aimed at early stages to learn basic orthopaedic principles of open surgery using the example of the treatment of distal radius fractures in a meaningful manner. It addresses issues in the current medical education and enables learning educational objectives repeatedly in reusable medical scenarios and in a safe and controlled environment, without the risk of harming patients, and thus contributing to improved quality and patient safety when proceeding to the operating theatre.

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DeGirolamo, Kristin. "Structure, process and outcomes in emergency general surgery." Thesis, University of British Columbia, 2017. http://hdl.handle.net/2429/61611.

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Background: Dedicated emergency general surgery (EGS) services have been established across North America as a means to bring focus and quality to a large, complex and vulnerable surgical population. The emergence of these services represents a great opportunity to understand and improve emergency surgical care. Methods: This research programs applies a health systems structure/process/outcomes framework to the study of EGS services in Canada: 1. OUTCOME: A systematic review of the effects of an EGS service on patient and non-patient related outcomes 2. STRUCTURE: A national cross sectional study of structure and case mix on 14 EGS services 3. PROCESS: Detailed process mapping of a complex EGS condition Results: 1. OUTCOMES: Studies found increased daytime and decreased after-hours operating, improved patient transit from ED to OR to home, and decreased length of stay after implementation of an EGS service. The overall trend was higher more diverse case volumes, which improved resident education. Lower complication rates were noticed in the appendicitis and cholecystitis groups. 2. STRUCTURE: Canadian EGS services demonstrated variability in service organization and access to operating rooms. However, a national cross sectional study of EGS patients revealed that all services see diverse case mix and high complexity, and routinely make complex judgments about operative and non-operative care. 3. PROCESS: The processes of care for small bowel obstruction (SBO) patients from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration. Data visualization strategies were used to identify substantial variability in terms of time to CT scan and time to OR. Conclusions: The EGS model has been implemented worldwide, and has demonstrated an improvement in timeliness of care, decreased administrative costs, and improved trainee learning. EGS services are well-established in Canada, and poised to identify new opportunities for improved patient care. Process mapping has been successfully integrated into surgical specialties and provides insight into potential areas of performance improvement in EGS.
Medicine, Faculty of
Surgery, Department of
Graduate

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Chana, Prem. "Identifying quality in the delivery of emergency general surgery." Thesis, Imperial College London, 2017. http://hdl.handle.net/10044/1/60838.

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The delivery of high-quality emergency general surgical care remains a concern for clinicians, healthcare providers and policy makers. Emergency admissions contribute to approximately half of a general surgeon’s workload, however the morbidity and mortality figures seen in this cohort are up-to ten times higher than those seen in elective practice. Despite considerable advances in surgical technology and peri/post-operative protocols over the past twenty years, there appears to be little improvement in outcome following emergency surgical admissions. It is therefore proposed that the delivery of emergency surgical services and hospital structure may significantly contribute to the poor outcomes seen in the acute setting and a greater understanding of the factors that contribute to high-quality care is required. An introduction to the factors that contribute to the delivery of emergency general surgery is presented along with the concepts of examining and identifying quality both in healthcare and other high-risk industries. A systematic review then examines the different models of care seen in the delivery of emergency general surgery across the world along with their effect on outcome and sets the scene for the areas of interest in this thesis. A series of inter-linked, mixed methods studies combining: quantitative analyses of an international dataset, ethnographic observation, a healthcare failure mode effects analysis and audit to identify structural factors that lead to improved outcomes in the delivery of emergency general surgery. The themes of high-quality care, hospital structure, international benchmarking and their association with outcome run throughout these studies in this thesis with outcome data from hospitals in Australia, the United Kingdom and the United States being compared. This thesis highlights a series of unit-level quality indicators whose introduction can be associated with high-quality care and be directly translated into clinical practice using quality improvement methodologies to ultimately improve patient care.

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Allison, Marion. "Surgery and me : the experience of surgery as a transition in young adults with inflammatory bowel disease." Thesis, Cardiff University, 2015. http://orca.cf.ac.uk/85751/.

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The peak incidence of Inflammatory Bowel Disease is between 15 – 25 years. A significant number of young people whose disease is not controlled by medication undergo surgery. However, the experiences of young adults with Inflammatory Bowel Disease have not been well researched. The aim of this two phase exploratory mixed methods sequential study was to investigate the process of transition in young adults aged 18 – 25 years with Inflammatory Bowel Disease who faced the prospect of, or had undergone, surgery. Schlossberg’s Transition Theory (Goodman et al, 2006) was used to identify the important factors that influenced their experience. Phase1 was qualitative and exploratory and obtained narratives from semi structured interviews with 24 young adults. Phase 2 was a survey. In order to establish whether findings from Phase 1 could be generalised a questionnaire developed from the Phase 1 findings was developed and sent to 158 young adults randomly sampled from seven NHS centres in England,. One hundred and twenty people responded (76%). Key findings from Phase 1 were that preoperatively most young people knew that their disease was out of control. Afterwards they perceived that surgery had improved their physical health and positively changed their lives. The key findings from Phase 2 were that 72 (60%) young people had a positive perception of their surgery. Participants also experienced an improvement in physical health and made a good psychological recovery. The majority of participants (n=106, 84%) received appropriate support and used positive coping strategies such as acceptance and positive reframing. Fear, worry, uncertainty, negative experiences of surgery and body image concerns hindered the process of transition. The specialist Inflammatory Bowel Disease or stoma nurse had a key role in facilitating a positive transition. The study findings will enable health care practitioners to provide appropriate information, care and support for young adult patients with Inflammatory Bowel Disease facing surgery.

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Gasiūnaitė, Diana. "Comparison of general and combined anesthesia during laparoscopic colorectal surgery." Doctoral thesis, Lithuanian Academic Libraries Network (LABT), 2013. http://vddb.laba.lt/obj/LT-eLABa-0001:E.02~2013~D_20130930_092313-13566.

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The doctoral dissertation analyses and compares general endotracheal and combined endotracheal epidural anesthesia’s impact on organ systems and describes the systems parameters in laparoscopic colorectal surgery. Comparing two perioperative analgesia techniques used in laparoscopic colorectal surgery the hemodynamic and respiratory parameters trends; the impact of anesthesia and postoperative analgesia methods on patients’ tracheal extubation time, intestinal motility recovery rate, duration of hospitalization and inflammatory response have been determined. Laparoscopic colorectal resection, even being a minimally invasive technique for laparoscopic surgery, stimulates the body's response to stress and pro-inflammatory mediator’s secretion. Perioperative pain management may also influence the immune response. The doctoral dissertation analyses the impact of epidural analgesia method on the body stress response, investigating variations of cortisol and interleukin-6 levels. The results showed that analgesia and patient satisfaction using epidural analgesia method for perioperative pain management were better. Tracheal extubation time was significantly shorter. Recovery of intestinal motility using epidural analgesia was significant and much prior than using intravenous analgesia. The use of epidural analgesia in laparoscopic colorectal surgery caused less stress response – less cortisol levels increase. It has not showed the increase in number of complications.
Disertacijoje analizuojama ir lyginama bendrosios endotrachėjinės ir kombinuotos endotrachėjinės epiduralinės anestezijos įtaka atskiroms organų sistemoms ir tas sistemas apibūdinantiems rodikliams laparoskopinių kolorektalinių operacijų metu. Darbe nagrinėjama dviejų perioperacinių skausmo malšinimo būdų įtaka hemodinamikos ir kvėpavimo sistemos parametrų kitimo tendencijoms, pacientų trachėjos ekstubacijos laikui, žarnyno motorikos atsinaujinimo greičiui, hospitalizacijos trukmei bei organizmo uždegiminiam atsakui. Laparoskopinės storosios žarnos rezekcinės operacijos, net ir būdamos minimaliai invazinės dėl laparoskopinės operacijos technikos, sužadina stresinį organizmo atsaką bei uždegimo mediatorių išskyrimą. Perioperacinis skausmo valdymas taip pat gali daryti įtaką imuniniam atsakui. Disertacijoje nagrinėjama epiduralinės analgezijos metodo įtaka organizmo stresiniam atsakui tiriant kortizolio kiekio kitimus ir interleukino-6, kaip vieno pagrindinių uždegimą skatinančių citokinų, koncentracijos kitimą taikant epiduralinę analgezijos metodiką. Gauti rezultatai parodė, kad analgezijai pasitelkiant epiduralinį skausmo malšinimo metodą, perioperacinis pacientų skausmo valdymas ir pasitenkinimas yra geresnis, trachėjos ekstubacijos laikas patikimai trumpesnis, žarnyno peristaltikos atsitaisymas ankstyvesnis, sukeliamas stresinis organizmo atsakas mažesnis (mažesnis kortizolio koncentracijos padidėjimas) ir nenustatyta komplikacijų padaugėjimo.

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Al, Hinai Alreem. "Predictors of outcomes in emergency general surgery patients : a scoping review." Thesis, University of British Columbia, 2015. http://hdl.handle.net/2429/54560.

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Background: Emergency General Surgery (EGS) patients have unique physiologic characteristics and are at a high risk of complications compared to elective general surgery patients. We aimed to perform a scoping review of the literature that examines predictors of outcomes in EGS patients. Methodology: A scoping review of published literature from 2004 to May 2015 was conducted in Medline, EMBASE, Cochrane library and PubMed. Keywords were chosen based on the three most common diagnoses in EGS; acute appendicitis, cholecystitis and small bowel obstruction, in addition to emergency general surgery, acute care surgery, outcomes & post-operative complications. Articles meeting inclusion criteria were summarized. Quantitative data regarding study characteristics were analyzed and expressed as descriptive statistics. Qualitative data from included studies were grouped intro predictors based on a framework derived from a grounded theory approach to content analysis. Primary outcomes of interest were post-operative morbidity and mortality. A predictor was included if it was significantly correlated with an outcome based on a minimum of bivariate analysis. Results: A total of 715 articles were identified during the primary search, of those 62 were found to be relevant to the search criteria. Almost all of the studies were retrospective. The median number of patients in these studies was 1000 (IQR 266,20896) with a mean of median/mean age reported of 53.2 years. Average length of follow up was 4.6 years. There were 54 predictors of outcome identified and these were grouped into patient related, process related and structure/system related predictors. The most frequently reported predictor of any adverse outcome was absence of an EGS system, followed by an ASA score of 3 or more. The most frequently reported predictor of post-operative morbidity was absence of EGS system. The most frequently reported predictor of mortality was age ≥ 65, emergency status and ASA ≥ 3. Conclusion: EGS patients are at a higher risk of post-operative adverse outcome as compared to elective surgical patients. System implementation significantly improves outcomes in this patient population. Identifying what predicts adverse outcomes can help in future risk assessment scores, planning future prospective trials and improving performance in emergency general surgery systems.
Surgery, Department of
Medicine, Faculty of
Graduate

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van, Hoving Daniël J. "An evidence-based algorithm for the rapid diagnosis of tuberculosis in HIV positive patients presenting to emergency centres." Doctoral thesis, Faculty of Health Sciences, 2021. http://hdl.handle.net/11427/33960.

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Background Tuberculosis remains a prevalent and deadly global disease. Diagnostic delays are partly due to reduced diagnostic performance of tuberculosis tests in HIV-positive people. The use of reliable pointof-care and near-patient diagnostic tests (e.g. urine lipoarabinomannan and point-of-care ultrasound) are increasingly being used and would benefit patients presenting to emergency centres by rapidly diagnosing HIV-associated tuberculosis. Methods Two studies were done: i) A systematic (Cochrane) review was done to determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals, and ii) A cross-sectional diagnostic study to derive a multi-parameter clinical decision tree, incorporating clinical information, point-of-care ultrasound features, chest x-ray and urine lateral flow lipoarabinomannan. The cross-sectional study was performed at the emergency centre of Khayelitsha Hospital, a South African district-level hospital in a high HIV-prevalence community, and resulted in three different publications. Consecutive HIV-positive adults presenting with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period (June 2016 to October 2017). Demographic and clinical information was recorded on a standardized data collection form. Point-of-care ultrasound was performed according to a standardized protocol. Urine lipoarabinomannan assays were done at point-of-care by emergency physicians and repeated in the laboratory. Chest x-rays were reviewed by a single radiologist using a standardized assessment form. The reference standard was a positive tuberculosis culture or Xpert MTB/RIF test on sputum, or appropriate extra-pulmonary samples. We compared diagnostic accuracy and reproducibility of urine lipoarabinomannan between point-ofcare readers and laboratory readers. We determined the diagnostic accuracy of individual point-ofcare ultrasound features, performed an external validation of the focused assessment with sonography for HIV/TB (FASH) protocol, and determined independent point-of-care ultrasound predictors of HIV-associated tuberculosis. We derived the decision tree model from multivariable logistic regression models. Results Abdominal ultrasound had a pooled sensitivity of 63% (95%CI 43-79; 5 studies, 368 participants; very low-certainty evidence) and a pooled specificity of 68% (95%CI 42-87; 5 studies, 511 participants; very low-certainty evidence) for bacteriologically confirmed tuberculosis. We screened 556 patients in the cross-sectional study of whom 414 (74.5%) were enrolled. The prevalence of microbiologically confirmed tuberculosis was 41.5% (n=172). Point-of-care and laboratory-performed urine lipoarabinomannan had similar sensitivity (41.8% vs 42.0%, P=1.0) and specificity (90.5% vs 87.5%, P=0.23). Moderate agreement was found between point-of-care and laboratory testing (k=0.62), but there was strong agreement between point-of-care readers (k=0.95) and between laboratory readers (k=0.94). Sensitivity and specificity of ≥1 individual point-of-care ultrasound feature were 73% (95%CI 65-79) and 54% (95%CI 47-60), and of the FASH protocol 71% (95%CI 64-78) and 57% (95%CI 50-63). Independent point-of-care ultrasound predictors identified were intra-abdominal lymphadenopathy of any size (aDOR 3.7; 95%CI 2.0-6.7), ascites (aDOR 3.0; 95%CI 1.5-5.7), and pericardial effusion of any size (aDOR 1.9; 95%CI 1.2-3.0). Two or more independent point-of-care ultrasound predictors had 33% (95%CI 27–41) sensitivity and 91% (95%CI 86-94) specificity. The best performing model included WHO screening symptoms ≥2, antiretroviral therapy use, urinary lipoarabinomannan, independently predictive point-of-care ultrasound features (ascites, any size pericardial effusion, any size intra-abdominal lymphadenopathy), and chest x-ray (c-statistic 0.82; 95%CI 0.78–0.86). Adding CD4 cell count did not improve the performance of the model. Classification And Regression Tree (CART) analysis positioned urinary lipoarabinomannan as the optimal screening test after WHO symptoms (75% true positive rate, representing 17% of participants). Conclusion An evidence-based algorithm for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre was developed. Urinary lipoarabinomannan can be reliably performed at the point-of-care since there was no diagnostic accuracy advantage in laboratory-performed versus pointof-care–performed tests. The role of ultrasound in diagnosing HIV-associated tuberculosis had limitations. The low sensitivity of ultrasound (63% in the systematic review; 73% in the cross-sectional study) and the moderate discrimination (specificity 91%) of the presence of ≥2 independent point-ofcare ultrasound predictors indicate that point-of-care ultrasound results should be interpreted in combination with other diagnostic information. The derived decision tree can facilitate the immediate initiation of anti-tuberculosis treatment in about a quarter of patients among whom 75% would have a definitive diagnosis of tuberculosis regardless of CD4 cell count. The 30% false negative rate indicates that the algorithm should not be used to exclude tuberculosis. The performance of the decision tree needs to be further evaluated in settings with a different prevalence of HIV-associated tuberculosis.

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Chinyepi, Nkhabe. "Outcomes after thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injuries (TTAI) - a single center retrospective review." Master's thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/29270.

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Background: Blunt and penetrating traumatic thoracic aortic injuries constitute surgical emergencies that are attended with high mortality rates. Most patients do not survive long enough, post injury, to reach a hospital. On-site mortality rates may approach approximately 85%. Two main treatment options for blunt thoracic aortic injuries (BTAI) are open surgery and thoracic endovascular repair (TEVAR). Penetrating thoracic aortic injuries (PTAI) have a higher mortality than blunt trauma, with patients often only reaching the hospital in extremis. Most will require early intervention. Currently TEVAR is rapidly evolving as the standard of care for thoracic aortic injuries (TAI) at many centres, primarily due to the emerging evidence of lower mortality and morbidity trends in comparison to open surgery (1–4). Methods: From December 2006 to December 2016, 34 patients (30 blunt trauma, 4 penetrating trauma) with traumatic aortic injuries (grades I-IV) were treated with thoracic aortic stent-grafts in the Groote Schuur Hospital Vascular Unit, Cape Town. We assessed the technical and clinical outcomes following TEVAR in these patients. Results: The 30- day mortality rate was 5.8%, corresponding to 2 deaths both associated with the index trauma-related fatal strokes. The overall mortality rate was 11.8% (4/34): three deaths were due to major strokes and one death was related to pulmonary complications. Conclusion: TEVAR after TAI is associated with significantly lower procedural and postoperative mortality. The 30 day and overall mortality after TEVAR in our unit is comparable to international standards. Even though there is a paucity of literature on PTAI, TEVAR has low peri-procedural adverse events and is safe in selected patients.

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Pillay, Santhoshan Thiagaraj. "Pig mucus as an inhibitory agent of HIV-1." Doctoral thesis, University of Cape Town, 2017. http://hdl.handle.net/11427/26949.

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The Human Immunodeficiency Virus (HIV) epidemic still poses a problem with approximately 2 million new infections reported worldwide in 2014. New strategies are required to alleviate this burden. Our laboratory has previously shown that crude saliva and purified mucins from cervical plug mucin, saliva and breast milk inhibit HIV-1 infection in vitro. This project investigates purified mucins sourced from pig and horse mucus, as an alternative and abundant source of material for anti-HIV-1 research. Pig gastric and cervico-vaginal mucus was collected and stirred overnight in 6M guanidine hydrochloride with 10mM Na₂HPO4, 10mM EDTA, 1mM PMSF and 5mM NEM. Gastric and cervicovaginal mucus was purified by density gradient ultracentrifugations in CsCl at 105 000g for 48 hours, twice, and mucin rich fractions were separated by size exclusion column chromatography. Mucin-rich materials eluting in the void volume (V₀) were reduced with 10mM dithithreitol (DTT) or subjected to proteolysis with trypsin. Pig saliva was collected in 0.2M NaCl:0.02% sodium azide and horse saliva (due to its viscous nature) was collected and stirred overnight in 6M guanidine hydrochloride with 10mM Na₂HPO4, 10mM EDTA, 1mM PMSF and 5mM NEM. Pig and horse saliva samples underwent size exclusion column chromatography, where the V₀ fractions of both were purified with one density gradient ultracentrifugation and then dialysed and freeze dried, after which aliquots were treated with either DTT or trypsin. At every stage of purification, lyophilized aliquots of all mucin sources were tested on a luciferase based replication defective HIV neutralization assay on a CD4 expressing HeLa cell line. Luciferase expression quantified as relative light units by a luminometer was used to calculate percentage neutralization. Log dose response curves were constructed to extrapolate the half maximal inhibitory concentrations (IC₅₀) on GraphPad Prism. Samples were tested on an MTT cell toxicity assay. Pig gastric and cervicovaginal mucins were added to a simulated vaginal fluid to make gels (at a concentration of 30mg of mucin per ml of buffer). These gels were tested on the neutralization, MTT assays and the pig gastric mucin gel then underwent particle tracking and nanoparticle diffusion assays at varying pH. Pig gastric and cervicovaginal mucin showed good inhibition and low toxicity, with pig gastric mucin V₀ having the best IC₅₀ (1.668μg/ml). Pig and horse saliva showed inhibition but low cell viability. Pig gastric and cervicovaginal mucin gels exhibited good IC₅₀'s but pig gastric mucin had the best neutralization and lowest toxicity (PGM in Gel Solution 4 IC₅₀: 20.23μg/ml). HIV particle tracking and nanoparticle diffusion assays showed that the pig gastric mucin gel inhibited HIV-1 at low pH and existed as a soft gel. This project shows the efficacy of pig gastric mucin to possibly being a component of an anti-HIV-1 vaginal microbicide.

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Ngarande, Ellen. "Sustained hydrogel-based delivery of RNA interference nanocomplexes for gene knockdown." Doctoral thesis, Faculty of Health Sciences, 2019. https://hdl.handle.net/11427/31705.

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Scaffold based delivery of RNA interference (RNAi) molecules such as free small interfering RNA (siRNA) and microRNA has recently begun to be employed towards treatment of diseases such as cancer, bone regeneration, muscular dystrophy and cardiovascular disease. Effective translation from bench side to clinical use of RNAi has been limited in part because upon systemic delivery the RNAi molecules are degraded by RNases and flushed by excretory organs causing an inefficient duration of gene silencing effect at target tissues. These challenges can potentially be minimised by delivering RNAi molecules via non-viral nanoparticle carriers encapsulated in biocompatible, biodegradable and injectable scaffolds such as hydrogels. Various scaffolds have been shown to aid in sustained localised delivery of RNAi molecules and improve gene silencing. This research focused on optimising and establishing such an RNAi hydrogel-siRNA-nanoparticle (hydrogel-nanocomplex) system for targeted and sustained gene knockdown both in vitro and in vivo using dendrimer and lipid based nanoparticles in combination with synthetic polyethylene glycol (PEG) and natural fibrin hydrogel scaffolds. Four siRNA nanocarriers were investigated for siRNA delivery, that is, fourth generation dendrimer nanoparticles poly(amidoamine) (D) and its modified version (MD) with PEG and a lipid 1, 2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE) molecule, commercial lipid based Lipofectamine® RNAiMax and Invivofectamine® 3.0 nanoparticles. D and MD achieved better RNase protection compared to lipid nanocomplexes though Invivofectamine® 3.0 nanocomplexes protected a small percentage of siRNA over 10 days. The MD nanoparticle displayed improved siRNA release and transfection efficacy compared to D but efficacy of the dendrimers was lower than the lipid particles. Four hydrogels that have not been investigated for RNAi were assessed for sustainability. Namely, hydrolytically and proteolytically degradable PEG-acrylate (PEGAC), proteolytically degradable PEG - vinyl sulfone (PEG-VS) hydrogels, unmodified fibrin and PEGylated fibrin hydrogel. The nanocomplex release rate in vitro from the various hydrogels showed minimal release from PEGylated hydrogels, burst release from unmodified fibrin and sustained release from PEGylated fibrin. Invivofectamine® 3.0 nanocomplexes retained efficacy optimally after release from PEGylated fibrin hence this hydrogel was utilised for downstream analysis. For in vivo sustained delivery to be effective, determination of hydrogel persistence in vivo was required. After injection in the mouse tibialis anterior (TA) muscle PEG-AC and PEGylated fibrin gels degraded within 2 days. The efficacy of the various nanocomplexes was assayed in a 3D assay that more closely resembled delivery in soft tissue. PEGylated fibrin containing nanocomplexes with cell death siRNA sequences was polymerised around a preformed PEGylated fibrin cell containing droplet. Invivofectamine® 3.0 nanocomplex consistently achieved the highest gene knockdown effect with no evidence of cytotoxicity whilst Lipofectamine® RNAiMax was ineffective. MD showed signs of cytotoxicity when delivered in a sustained fashion. Thus Invivofectamine® 3.0 nanocomplexes in PEGylated fibrin hydrogel were found to be the optimal gel-nanocomplex system to proceed to in vivo assessment. BALB/c GFP transgenic injected in their TA muscle with Invivofectamine® 3.0 nanocomplexes made with siRNA targeting GFP or myostatin (siGFP/siMSTN) in the presence or absence of PEGylated fibrin gel were analysed 7 days post treatment for siRNA retention and GFP and Mstn gene knockdown. Increased retention of siRNA after encapsulation in PEGylated fibrin was observed at 7 days. A non-significant reduction in GFP protein was seen for limbs injected with siGFP- fibrin after 7 days. A substantial and significant reduction in Mstn mRNA levels was elicited by delivery of siMstn–fibrin. Furthermore, only siMstn-fibrin resulted in significant increase in muscle mass. In this study, dendrimer based nanoparticles were found to effectively protect siRNA against RNases however lipid based nanocomplexes were the most efficacious at gene knockdown. The combination of Invivofectamine® 3.0 and PEGylated fibrin was shown to be the most effective in 3D assays and as an injectable controlled release scaffold into soft tissue suggesting that this approach has therapeutic potential.

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Coccia, Anna Claudia. "Surveillance colonoscopy for Lynch syndrome in the Northern Cape: Does direct contact improve compliance?" Master's thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/29299.

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Introduction The Annual Northern Cape Colonoscopy Outreach program provides surveillance colonoscopy to high–risk individuals known with Lynch Syndrome along the west coast and in the Northern Cape Province of South Africa. There are currently over 100 known mutation positive individuals. Surveillance colonoscopies are performed annually in August/September, and are preceded a by a preparation visit approximately 6-8 weeks prior. The aim of the preparation trip has been to directly impart information, regarding preparation and importance of attendance, to individuals required to attend annual surveillance. During the preparation trip an attempt is made to reach all individuals scheduled for surveillance but due to the vastness of the Northern Cape inevitably every year some areas are not visited. It has been noted that over the past few years fewer than 25 % of the total participants obtained 100 % adherence to surveillance. Objectives The primary objective of this study is to determine whether there is a need for a yearly colonoscopy preparation visit to high–risk individuals in the Northern Cape. The study determines if direct interaction with patients prior to surveillance colonoscopy will significantly impact attendance and adequacy of bowel preparation. Methods Seventy-eight individuals known with a genetic mutation for Lynch syndrome were enrolled in this randomised crossover trial spanning two years of surveillance. The control group (Group A) of individuals had bowel preparation and instructions forwarded to their local clinics and distributed to them via clinic or hospital staff. The test group (Group B) of individuals were personally visited and provided with instructions and bowel preparation by the research team. A measurement of attendance at surveillance colonoscopy as well as cleanliness of the colon was recorded. The study spanned two years of colonoscopy surveillance, July 2014 to September 2015, with a crossover of the control and test groups. Results The study cohort consisted of 28 (36%) male and 50 (64%) female participants with a median age of 39.5 years. Groups A and B consisted of 38 and 40 participants respectively. In September 2014 thirty-six (46.2%) participants presented for annual surveillance colonoscopy, 19 (50%) from the control group (Group A) and 17 (42.5%) from the intervention group (Group B). In 2015 there were 41 (53%) compliant individuals; this included 21 (55%) individuals receiving a preparatory direct contact visit (Group A), and 20 (50%) individuals from the 2015 control group B. Following exclusion of carry-over and period effect, the study intervention was found not to significantly impact attendance (p-value = 0.853). Superior attendance was noted in individuals with prior compliance to surveillance (p-value = 0.001). Conclusions Direct interaction with known Lynch syndrome individuals prior to annual surveillance colonoscopy has not shown to positively impact attendance. Interaction and counselling should focus on individuals identified to be defaulting surveillance.

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Hameed, Muhammad Fayyaz. "Immunohistochemical identification of mismatch repair gene deficit and its clinico-pathologic significance in young patients with colorectal cancer." Master's thesis, University of Cape Town, 2005. http://hdl.handle.net/11427/2880.

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Includes bibliographical references (leaves 43-52).
An immunohistochemical technique is used in this study to detect mismatch repair deficit in young patients with colorectal cancers. Ninety three patients who were 45 years of age or younger at the time of diagnosis of colorectal cancer were studied.

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Ferreira, Yolandi. "Hard hitting facts on childhood head trauma: an epidemiological analysis." Master's thesis, Faculty of Health Sciences, 2019. http://hdl.handle.net/11427/31339.

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Background: According to the World Health Organization (WHO), Traumatic Brain Injury (TBI) will become the third largest cause of global disease by the year 2020. Despite its astonishing numbers, TBI remains a silent or even forgotten epidemic with significant paucity in epidemiological data. TBI in developing countries represents a disproportionate burden of disease and data are lacking regarding the unique demographics in South Africa to design and implement focused prevention programmes. A valuable tool to assess the severity of TBI is the use of Computer tomography (CT). CT also is the main imaging modality to provide rapid identification and information for the management of children with TBI. CT scanning utilises ionising radiation and as an imaging modality poses risk to the patient. In order to guide decision protocol/algorithm, various Clinical Decision Rules (CDRs) have been established in High Income Countries. These protocols, including the need for CT scan might differ in a Medium/Low Income setting. Methodology: This is a prospective, single centre cohort study. Data were collected over an 18-month period (1 August 2015 - 31 January 2017). Children under the age of 13 years (n=3007) presenting to RCWCH after sustaining a head injury were included. Various epidemiological data were collected. A Road Safety Questionnaire was also used to evaluate safety knowledge of health care workers. Three different CDRs were compared to the standard of practice in RCWCH. A final analysis of demographics, mechanism of injury, radiology outcome, safety analysis and evaluation of a comparison of local protocol compared to the other CDRs was performed using descriptive statistics. Results: The mean age of paediatric patients presenting after a head injury was 4.6 years. There was a significant male predominance (66%) and almost two thirds of all children were of pre-school age. Falls (53%; n=1601) represented the most common mechanism of injury across all age groups, followed by road traffic related injuries (RTI) (29%; n=864), struck by or against an object (9%; n=279) and injuries as a result of interpersonal violence (8%; n=230). Within the subset of RTI (n=864) only 6 passengers were appropriately restrained, with 142 unrestrained and 56 passengers transported on the back of a goods vehicle. In the under 3-yearold age group, only 1 patient was appropriately transported in a car seat, with 51 unrestrained and 6 transported on the back of a goods vehicle. Pedestrian related injuries were by far the largest group of RTI (70%) with 50% of these under the age of 5 years. Intentional injuries inflicted by an adult were most common (34%) in the pre-verbal (under 2 years old) group. Interpersonal violence among minors (assault with a brick or stone) constituted 52% of intentional injuries. Eight firearm related injuries were recorded. Appliances and iron gates that were not correctly installed were additional causes of injury. CT scans were obtained according to the RCWCH protocol in 59% of cases and 34% showed an abnormal result. The sensitivity (98%) and specificity (93%) while using the standard of practice protocol was better than the 3 CDRs developed in High Income Countries. Analysing our Road Safety Questionnaire there appears great room for improvement regarding awareness of road safety guidelines and legislation. Conclusion: The performance of the current RCWCH CT scan protocol appears appropriate in our setting although there is some room for improvement using the strengths of the other CDRs. Valuable insight regarding the epidemiology of TBI in our setting has been highlighted. Of specific importance is the large proportion of very young children at risk of injury by all mechanisms of injury, particularly pedestrian-related injuries, unrestrained passengers and interpersonal violence among minors. Important gaps in knowledge about current recommendations for road safety were identified by the questionnaire. As long as these issues are not appropriately addressed through enhanced injury prevention programmes, children will continue to carry the heavy burden of TBI morbidity and mortality.

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Owusu, Kyei Michael. "Assessment of cataract blindness prevalence and factors associated with surgical coverage in Rwanda." Master's thesis, Faculty of Health Sciences, 2020. http://hdl.handle.net/11427/32320.

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Background: The Rapid Assessment of Avoidable Blindness (RAAB) survey methodology is a cost-effective tool for assessing the burden of blindness and cataract surgical services in a population. This study analyses the 2015 Rwanda National RAAB data to ascertain whether there are gender differences in access to cataract surgical services and also assess whether there is an association between measured distances travelled to access cataract surgical services and the cataract surgical coverage (CSC) in the country. Methods: Secondary data non automated analysis was performed on the 2015 Rwanda RAAB data, which had a sample of 5,275 persons who underwent ophthalmic examinations as per RAAB protocols to elicit the prevalence and causes of blindness and answered a standard questionnaire on barriers to cataract surgery. Cataract blindness prevalence and cataract surgical coverage were estimated for males and females and assessed for significant differences. Distances from clustered patients' locations to the nearest eye surgical facility ere calculated using Google Maps and analyses performed to identify if a relationship exists between distances travelled and the CSC for the area. Results: The prevalence of bilateral cataract blindness for males was 0.4% (n=8; 95% CI=0.1-0.7) and females 0.5% (n=17; 95% CI=0.3-0.8) and the CSC for males and females were 69.2% and 68.5% respectively. The difference in CSC was not statistically significant. Females aged ≥70 years reported more barriers to cataract surgical services compared to men. At a VA <3/60 in the better eye, 1km increase in the distance to the nearest eye surgicalcentre was associated with a reduction in the CSC for the area of 4.8% (Linear regression: F (1,95) = 16.06, p = 0.0001, R-Squared = 0.1446, Adjusted R-Squared = 0.1356). Conclusions: Older women (≥70 years) were the most vulnerable to untreated cataract blindness in Rwanda and therefore special programs need to target them for cataract surgical services. Distance to surgical facilities with ophthalmologists is related to the cataract surgical coverage even in a small country like Rwanda.

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Bryce, Gavin John. "Preoperative cardiac risk assessment in vascular surgery : risk stratification, novel cardiac biomarkers, and their importance in abdominal aortic aneurysm surgery." Thesis, University of Glasgow, 2011. http://theses.gla.ac.uk/2628/.

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Major vascular surgery is associated with a substantial risk of cardiovascular events and death. This risk is of increased importance in prophylactic elective open Abdominal Aortic Aneurysm (AAA) repair, where a balance of risk of rupture and postoperative outcome is assessed prior to management decisions. Further, the UK Small Aneurysm Trial has shown that prophylactic repair of an AAA has no survival benefit for the first three years due to the major adverse cardiac event (MACE) rate of 5-15%. There is however no ideal method of predicting this risk. Cardiac Troponin I (cTnI) is a contractile protein that is a highly sensitive and specific marker of myocardial necrosis. A few case reports have commented on the finding of preoperative asymptomatic elevated cTnI levels and poor outcome in a small number of patients undergoing major vascular surgery. There are however no studies looking at its incidence in the vascular surgical population or its utility as a preoperative marker. Several studies have noted that B-type natriuretic peptide (BNP), a diagnostic and prognostic marker of heart failure, may have a role in predicting MACE in settings including major vascular surgery. There are no studies that have investigated this role in AAA repair alone. The aim of this thesis is to investigate the incidence of, and to determine a possible role for, preoperative elevated cTnI in major vascular surgery. The further aim is to determine if a single preoperative BNP level correlated with MACE and all-cause mortality in elective open AAA repair in both the short and long-term. Comparisons to current accepted risk indices in AAA, and a possible role for BNP in EndoVascular Aneurysm Repair (EVAR) will also be investigated. Patients were recruited in two cohorts: Firstly, a prospective, 2 year observational single centre cohort study of all patients undergoing a vascular procedure, with an expected cardiac event rate >5%, recruited patients who had no clinical or ECG evidence of myocardial ischaemia. Preoperative cTnI was performed in all and postoperative screening (clinical assessment, ECG and cTnI) for cardiac events was performed at days 2, 5 and 30. 213 patient were recruited, of whom 11 (5.2%) had an asymptomatic elevated preoperative cTnI (>0.02 ng/ml). Eight of these patients proceeded directly to theatre, and 2 were delayed but later underwent surgery with a persistently elevated cTnI. Of these 10 patients, 5 (50%) died and 4 (40%) suffered MACE. The remaining patient was delayed due to the poor outcome of the preceding patients, and later underwent an uncomplicated aortic bifurcation graft with a normal cTnI level which had been preceded by coronary intervention. Secondly, a prospective, 2 year observational multi-centre cohort study in the 3 largest vascular units in Glasgow (Gartnavel General Hospital, Glasgow Royal Infirmary and Southern General Hospital) was performed between August 2005 and August 2007, recruiting all patients who were admitted for both elective open AAA repair and EVAR. Preoperative BNP levels were performed and batch analysed at the end of the study. Postoperative screening for cardiac events was performed as described above. Data was collected to allow calculation of risk indices associated with outcome in AAA repair (Glasgow Aneurysm Score [GAS], Vascular physiology only Physiological and Operative Severity Score for enUmeration of Mortality [V{p}-POSSUM], Vascular Biochemical and Haematological Outcome Model [VBHOM], Revised Cardiac Risk Index [RCRI] and Preoperative Risk Score of the Estimation of Physiological Ability and Surgical Stress Score [PRS of E-PASS]). Follow-up was continued to a minimum of 3 years, where possible, with cause of death recorded. 106 of 111 patients were recruited. The median [interquartile range] BNP concentrations in the 16 patients (15%) who suffered immediate postoperative MACE was 206 [118-454] vs 35 [17-61] pg/ml in the remainder (p=0.001). ROC analysis indicated a BNP concentration of 99.5 pg/ml best predicted MACE (area under the curve 0.927), with sensitivity of 88% and specificity of 89%. The BNP in patients who suffered cardiac death was significantly higher than in those that did not (median BNP 496 [280-881] vs 38 [18-84] pg/ml, p=0.043). ROC analysis revealed a cut-off of 448 pg/ml (AUC 0.963), with sensitivity 80%, specificity 100%, positive predictive value 100% and negative predictive value 99%. Not only did higher values of BNP predict MACE, but it was also found to predict all-cause mortality in the immediate (median BNP 100 [84-521] vs 35 [17-81], p=0.028), intermediate (median BNP 201 [97-496] vs 35 [17-73], p<0.001) and long-term (median BNP 98.5 [58-285] vs 32 [17-71.5], p<0.001) postoperative periods. ROC analysis revealed decreasing BNP levels to predict outcome over time, with a BNP of >60.5 pg/ml (AUC 0.761) found to best predict death at 3 years. Whilst BNP was found to predict outcome, most risk indices performed poorly. The GAS, VBHOM and RCRI performed poorly and did not predict any outcome measure. V(p)-POSSUM was, however, found to predict all outcome measures (p=0.028, p=0.030, p=0.038 for MACE, cardiac death and all-cause mortality respectively). The PRS component of E-PASS was found to predict MACE (p=0.019) and cardiac death (p=0.017). BNP performed better than any risk index. During the study period only 40 of 42 patients admitted for elective EVAR were recruited. Of these 40, only 3 suffered a non-fatal MI and 1 died of respiratory failure. BNP was not found to predict MACE or death in this cohort, and due to the small number of patients, and events, no strong conclusions could be drawn. Whilst preoperative elevated cTnI was found to identify patients that were at an increased risk of both postoperative MACE and death following their major vascular surgical procedure, its use in elective open AAA repair is limited due to infrequent occurrence. Preoperative serum BNP concentration, however, predicted postoperative MACE, cardiac death and all-cause mortality in patients undergoing elective open AAA repair on immediate, intermediate and long term follow-up. Further, BNP performed better than any current risk index for elective open AAA surgery. This simple blood test, therefore, offers valuable information regarding risk stratification of prospective surgical patients and should be considered a part of routine preoperative assessment in this prophylactic procedure.

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McGlade, Kieran John. "A study of general practitioners awareness of psychological morbidity among surgery attenders." Thesis, Queen's University Belfast, 1989. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.335971.

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Lewis, Joanne. "A Video Intervention Targeting Opioid Disposal After General Surgery: A Feasibility Study." eScholarship@UMMS, 2020. https://escholarship.umassmed.edu/gsn_diss/60.

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PURPOSE: The purpose of this feasibility study was to explore the use of an online video intervention to prepare surgical patients to properly dispose of unused opioids. SPECIFIC AIMS: Describe the feasibility of recruiting, enrolling, randomizing and retaining participants who recently had a general surgery into the study. Describe the differences in opioid disposal by age, sex, education, and type of surgery for the entire sample and by treatment assignment. Describe the preliminary change in knowledge, behavioral beliefs, normative beliefs and disposal of opioids from baseline to post-intervention by group. Describe the relationship between social desirability and behavioral beliefs, normative beliefs and disposal of opioids. FRAMEWORK: The Theory of Reasoned Action was used to guide both the intervention and the measures. DESIGN: This study used a randomized controlled feasibility study to explore a novel video intervention to teach safe storage and disposal of unused opioids after general surgery. RESULTS: A total of 40 participants were enrolled in the study, average age was 44.7 (range 21-75 years), most were White, educated and employed. Recruitment took 11 weeks and the retention rate was excellent at 85%. Differences in opioid disposal was not significantly different by age, sex, education or type of surgery. The video intervention was positively received, but the majority (80%) still stored their pills unsecured. CONCLUSION: The results demonstrate that a video intervention addressing safe storage and disposal practices of unused opioids is feasible and more research is needed to determine efficacy in increasing rates of secure storage and disposal of unused opioid pills KEYWORDS: Opioids, opioid disposal, general surgery, video education

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Kahn, Miriam. "A retrospective audit of the outcomes of the Fellow Of College Of Surgeons (FCS) (General Surgery) Final Examinations." Master's thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/29799.

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Background and aim: An audit of the Fellowship of the College of Surgeons FCS (SA) Final Examination results has not been previously performed. The purpose of this study was to review and determine any predictors of outcome. Methods: The results of the FCS (SA) Final Examinations from October 2005, to and including, October 2014, were retrieved from the College of Medicine of South Africa database. The current format of the examinations consists of: two written essay question papers, an OSCE, two clinical cases and two vivas. These were retrospectively reviewed and analyzed. Predictors of failure or success were determined. Analysis was performed using IPython for scientific computing. Assumptions for the normal distribution of numerical values were made based on the Kolmogorov-Smirnov test and quantile-quantile plots. Normally distributed variables were analyzed by parametric tests. In all other cases nonparametric tests were employed. An alpha value of 0.05 was chosen to indicate statistical significance, using a confidence level of 95%. Results: During the 10-year study period, 472 candidates attempted the examinations. A total of 388 (82,2%) candidates were successful in the written component of the examination and were subsequently invited to participate in the oral/clinical component of the examinations. 9 Overall, 296 (62,7%) of candidates passed and 176 (37,3%) failed. A total of 19 candidates achieved less than 50% for both papers, yet still managed an average of more than 45%. A total of 15 (79%) of these candidates went on to fail the examination. There were 51 candidates who were invited to the oral examinations despite an average of less than 50% in the two papers, and 34 (67%) failed the overall examination. Similarly, 126 candidates were invited having failed one of the two papers of which 81 (64.3%) ultimately failed. A total of 49 candidates failed the OSCE, 82% of these candidates failed overall. There was strong correlation between paper one and paper two (r = 0.56, p-value < 0.01), oral one and oral two (r = 0.41, p-value < 0.01) and case one and case two (r = 0.38, p-value < 0.01). Similar correlations were seen between the averages of the papers versus the orals (r = 0.52, p-value < 0.01), the papers versus the cases (r = 0.5, p-value < 0.01) and the papers versus the OSCE (r = 0.54, p-vale < 0.01). Conclusion: The written papers are the main determinant of invitation to the second part of the examination. Candidates with marginal scores in the written component had an overall failure rate of 67%. Failing one paper and passing the other, resulted in an overall failure rate 64,3%. Failing the OSCE resulted in an overall 82% failure rate. With the high failure rate of candidates with marginal scores and with the inter-examination variability of the papers, it might be prudent to revisit both the process of invitation selection and the decision to continue with the long-form for the written component.

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Hickman, Carrie J. L. "Weight Loss Surgery Maintenance and Psychosocial Development| A Narrative Perspective." Thesis, Walden University, 2014. http://pqdtopen.proquest.com/#viewpdf?dispub=3601345.

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Bariatric surgery is not the panacea it was once thought to be for weight loss. Due to patient noncompliance issues, many weight loss surgery patients are relapsing and regaining the significant amounts of weight that bariatric surgery had initially helped them to lose. This failure is costly monetarily, psychologically, and medically to both the patient and to society. Using the narratives of 32 post-weight loss surgery patients, this narrative study explored: (a) whether Erikson's psychosocial stages of development occur after weight loss surgery, (b) whether successful patients (defined as those who are able to maintain their weight loss long term) have successfully navigated Erikson's stages, and (c) whether these patients formed new identities in the process. Recursive analysis and text analysis revealed noticeable trends toward developmental progress among participants after weight loss surgery, with regard to all stages in Erikson's psychosocial developmental theory. This trend suggests that participants are experiencing developmental changes after surgery and that participants who have successfully navigated psychosocial stages are at least beginning to build new identities. These findings may indicate the need for social changes in the way clinicians guide patients through the weight loss surgery process; these findings may also inspire the creation of programs that address developmental milestones, which may increase successes after weight loss surgery.

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Kearns, Rachel Joyce. "Anaesthesia for emergency and elective hip surgery : improving patient outcomes." Thesis, University of Glasgow, 2015. http://theses.gla.ac.uk/6757/.

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This thesis is presented in two parts. The first is concerned with the management of patients undergoing repair of hip fracture while the second part describes a randomised controlled trial examining analgesic options after total hip replacement. Musculoskeletal disease has the fourth greatest impact on the health of the world’s population (when both death and disability are considered) and is the second most common cause of disability globally. Disability due to musculoskeletal disease has risen by 45% over the last 20 years compared to the 33% average increase seen across other disease groups. This is likely to increase unless action is taken to resolve some of the problems. This has been recognised by The European Parliament Leading Committee on the Horizon 2020 Programme (the European Union Research Framework Programme) resulting in the identification of rheumatic and musculoskeletal conditions as a priority for research over the next 7 years. Glasgow Royal Infirmary is a tertiary referral centre for orthopaedic and trauma surgery undertaking a high volume of both elective and emergency procedures each year. I wished to investigate current standards of care relating to patients undergoing emergency surgery and to establish whether by benchmarking our practice against national data, we could identify areas for improvement. Hip fracture repair was chosen for analysis as it is a common, serious and costly condition that occurs in an increasingly elderly, frail and dependent patient population. Hip fracture is a worldwide concern and a significant public health challenge. Important patient outcomes such as time to theatre, 30 day mortality and length of stay were analysed and compared against national audit data. These data compared favourably. Prior to commencing this work, staff members were asked to communicate any opportunities they saw for care to be improved. Certain sub-populations were identified by staff as meriting particular attention. These were patients admitted to ICU and patients taking warfarin. The sub-population of patients who were taking warfarin and required admission for repair of hip fracture were particularly frail and resulted in a number of management challenges for staff. A quality improvement endeavour was employed in order to standardise management, reduce confusion, expedite time to theatre and ensure adequate thromboprophylaxis throughout the peri-operative period. This work resulted in the production of a protocol to guide management and is subject to ongoing review and audit. The role of anaesthesia in the performance of elective total hip replacement surgery was also investigated. Total hip replacement is one of the most commonly performed surgical procedures in the United Kingdom, can result in improved quality of life, and is considered to be cost effective. In Glasgow Royal Infirmary, anaesthesia is most commonly performed using spinal anaesthetic with the addition of an opioid. Spinal opioids, whilst effective, are associated with side-effects of which the most serious is respiratory depression. Other adverse effects such as pruritus and nausea and vomiting may delay recovery and impact upon a patient’s satisfaction with their experience. I carried out a randomised controlled, double blinded trial to assess whether a regional anaesthetic technique (ultrasound guided fascia iliaca block) could be used as an alternative to spinal morphine. This technique has not yet been assessed clinically in the published literature, though it has shown promise as being more reliable when compared to the landmark based technique. A non-inferiority design was employed in order to compare these two techniques. The primary outcome was 24 hour intravenous morphine consumption. After obtaining the necessary approvals from the West of Scotland Research and Ethics Committee and the West of Scotland Research and Development Department, recruitment was commenced in May 2011. Peer review was received from a journal of trial methodology and the protocol was published. Further peer review and funding was received from the European Society for Anaesthesia and Pain Therapy as well as a local peri-operative research fund. This study shows that ultrasound guided fascia iliaca block is not non-inferior to spinal morphine, or in other words, that ultrasound guided fascia iliaca block is unacceptably worse than spinal morphine in the provision of analgesia after hip replacement. Adverse effects were not statistically significantly different between groups and reassuringly, there were no episodes of respiratory depression or sedation in either group. This study has clear implications for practice and would suggest that spinal morphine remains an effective anaesthetic and analgesic agent in this patient group.

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Roodt, Liana. "Female general surgeons: current status, perceptions and challenges in South Africa. A pilot study at a single academic complex." Master's thesis, University of Cape Town, 2016. http://hdl.handle.net/11427/23661.

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Background: Today, the majority of medical graduates in South Africa and internationally, are female. Current literature suggests that the surgical workforce does not reflect this gender integration. This trend, as well as a decrease in the popularity of general surgery as career choice, has been investigated internationally. It is postulated that gender plays a significant role in specialty choice. In the midst of the gender debate, there are also generational shifts in preferences around work and lifestyle that need to be considered. Paucity of data about these trends from the African continent exists. Aim: The aim of this study was to determine the gender, generational and discipline-specific factors that are currently impacting on general surgery as a career and specialty choice by administering questionnaires to undergraduate students, surgical trainees and consultant surgeons. The questionnaires were designed to determine the: 1. "Status" of female general surgeons as opposed to male general surgeons. 2. "Perceptions" about female general surgeons opposed to male general surgeons. 3. "Challenges" faced by general surgeons, both male and female. Methods: An institutionally validated, self-administered questionnaire was used to gather data on the current status, perceptions and challenges pertaining to general surgeons, male and female, at the University of Cape Town. The questionnaires were distributed to a group of final-year medical students, and to current surgical registrars and surgical consultants in the department of surgery, and were analysed with a particular focus on gender. Results: The response rate from the surgical department was 67.8%: 29 (51%) respondents were consultant surgeons (six female and 23 male), and 28 were surgical registrars (11 female and 17 male). Of the 114 students invited, 59 (51.7%) completed the survey: 18 male and 41 female. Status: The small numbers made it difficult to comment on the status of female surgeons within the discipline. However, the average age of female surgical consultants were six years younger than male consultants (39 vs. 45). Two female consultants were the head of a firm, none has been on the editorial board of a peer-reviewed journal, nor has acted as postgraduate research supervisors, but their average number of publications is almost equivalent to those of the male consultants. Perceptions: A statistically significant proportion of registrars (p = 0.03; six [35%] female and 16 [40%] male) felt that women had an advantage when applying for a surgical training post. A total of 19 (33%) felt that there are too many female surgical registrars; only two (3.5%) felt there are too few. Nine (32%) registrars felt that more female surgeons complicate the departmental routine - male participants were statically more likely to consider a female presence disruptive (p = 0.02). Fourteen (50%) registrars, 13 (45%) consultants and 36 (61%) students think men are better suited for a career in general surgery, but the majority across all groups considers female surgeons just as technically competent as male surgeons. A minority of registrars (5/28: 18%) and consultants (4/29: 13.7%) perceive female surgeons to portray a lot of masculine qualities, while 24 (40.6%) students think female surgeons are more assertive, aggressive and decisive than women in other specialties. Challenges: Poor work-life balance, the effect their surgical career has on their family and personal relationships, together with meeting research and academic demands, were identified as major challenges across both genders in the consultant and registrar groups. The majority of students, both male - 13 (72%), and female - 28 (68%), indicated that perceived lifestyle during training will deter them from choosing a career in general surgery. Nineteen (46.3%) female and six (33%) male students are deterred by the influence a surgical career may have on their personal relationships. Conclusion: This pilot study moves the gender conversation in surgery beyond balancing numbers. More women in surgery does not necessarily translate into better integration - in our survey, men are still considered better suited for a career in general surgery. Women are considered disruptive to the discipline and are perceived to face more challenges in carving out a successful career in general V surgery. There are, however, challenges that increasingly affect both genders. As the number of women in the surgical workforce rise, it will be imperative to distinguish what challenges are discipline rather than gender-related. Addressing gender as well as generational challenges may enable the discipline to draw the best candidates and restore general surgery to its position as a popular career choice.

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Roche, Dominic. "A realist evaluation of patient involvement in a safer surgery initiative." Thesis, Cardiff University, 2016. http://orca.cf.ac.uk/97033/.

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Background Research has shown that healthcare organisations can cause harm to patients, much of which is avoidable, and there is reliable evidence to suggest that this harm is a widespread and recurring phenomena (Institute of Medicine 1999; Department of Health 2000; Leape et al 2002; de Vries et al 2008; Longtin et al 2009; Jha et al 2010). Encouraging patients to take an active role in their own healthcare was identified in the landmark patient safety publication ‘To Err is Human’ (Institute of Medicine 2000) as a vital factor in the quest to improve patient safety. It has since been contended that if patients were involved in their healthcare they could help to further reduce opportunities for accidents and errors during the course of their care (Vincent and Coulter 2002; Koutantji et al 2005; Weingart et al 2005; Unruh and Pratt 2006; Davis et al 2007). More recently, there has been growing interest in the development and use of interventions to promote and support patients’ roles in securing their own safety in healthcare contexts (Hall et al 2010; Longtin et al 2010; Peat et al 2010; Doherty and Stavropoulou 2012; Vaismoradi et al 2014). Aims The broad aim of this study is to explore the extent to which patients are involved in attempts to improve their own healthcare safety through enrolment in an enhanced recovery after surgery (ERAS) programme. Recognising that patient safety is just one aspect of the ERAS programme theory, this research evaluates those elements of the programme that see patients taking a role in their own healthcare safety. This is achieved by considering in realist terms the mechanisms of effect by which patients might contribute to their healthcare safety and investigating the conditions and circumstances (contexts) that are required to enable this involvement. The overall aim of this research is to seek out regularities in the patterns of these contexts and mechanisms which result in patient involvement in patient safety. The emerging theory will explain implementation variations, and the experiences of the programme participants in the different cases will provide an opportunity to make comparisons with initial programme theories, the objective being to better understand when and why patient involvement in patient safety works in an ERAS programme. Methods The underpinning methodological framework for this research is realist evaluation (Pawson and Tilley 1997), which is a technique concerned with exploring the interaction among context, mechanism and outcome, based on the realist principle of generative causation. This study uses an in-depth multiple case study approach, with each of the three surgical units under study purposively selected to represent involvement in the ERAS programme. To capture the complex and dynamic nature of the programme under investigation, the study draws on a wide range of empirical data sources, methods and materials, including ethnographic observations, semi-structured interviews and document analysis. Taking ‘early mobilisation’ as a tracer outcome, the study examines the mechanisms and contexts involved in programme outcomes in relation to patient involvement in patient safety. The first stage of the enquiry involves eliciting and formalising the programme theories relating to patient involvement in patient safety in an ERAS programme which are then articulated in conjectured context-mechanism-outcome configurations (CMO) terms. The next stage involves collecting data that will allow interrogation of these hypotheses, comparing the programme’s intentions with case study data of actual practice that occurred and the views and experiences of key stakeholders, including patients and nursing staff. This is followed by cross case comparisons which attempt to determine how the same mechanisms played out in different contexts. Key findings Overall, the findings show that there are many contextual factors relating to the successful outcomes of the programme theories postulated. The key findings of this study demonstrate that successful patient involvement in patient safety related elements of an ERAS programme requires that: ward staffs are aligned with the programme objectives; that patients’ expectations for their post-operative recovery are managed prior to surgery and the underlying rationale for their care is understood and; in the post-operative period patients’ enrolment in the programme is sustained and reinforced by ward based staff. The study also demonstrates how differences in the implementation of ERAS across the study sites, support for early mobilisation and individual patient differences (for example emotional status and operation type) were consequential for the outcomes of the programme theory. Conclusion This thesis sits at the interface of a number of health policy and quality improvement trends including patient involvement, patient safety, standardisation, patient centred care, co-production and the growing interest in healthcare with the implementation and embedding of interventions. The aspirations of policy and programme documentation to ‘empower’ patients to take a more active role in their care also proved more complex in reality. The study highlights the tensions between achieving a quality standard and patient centred care and how the approach to postoperative care in the three different case study sites shaped nurses’ willingness to adapt the programme and support patient involvement. The main areas for consideration from this study include the importance of the role of healthcare staff in attempts to involve patients in patient safety, along with the tensions between standardisation of care versus the aspirations of providing person-centred, individual care for patients. This is considered in relation to the ongoing standardisation of healthcare through an increasing reliance on protocols and pathways, such as the ERAS programme.

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Husson, Malinda. "Evaluating Dental Surgery Post-operative Pain in Children Following Treatment Under General Anesthesia." VCU Scholars Compass, 2011. http://scholarscompass.vcu.edu/etd/2481.

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Purpose: The purpose of this pilot study was to determine if there is a difference in post-operative pain experience for children following dental restorations and/or extractions under general anesthesia (GA), with and without local anesthetic (LA). The alternative hypothesis is that children will experience less post-operative discomfort and soft tissue trauma when using intra-ligamental local anesthetic during the intra-operative time period. Methods: Patients were recruited for this single blind, randomized, prospective cohort study with the following inclusion criteria, children age 2-6 years requiring general anesthesia for dental treatment. Patients were randomized into categories of either receiving a standardized local anesthetic or no local anesthetic for the dental procedure. A Wong-Baker Faces Pain Scale (Figure 1) was utilized to evaluate pre-operative and post-operative pain. Data were compared using a pooled t-test and two way mixed model ANOVA controlling for sex, ethnicity, and intra-op meds given. Results: Currently, 33 patients have been enrolled in the study. No difference was found in the LA versus the no LA groups, and significantly more pain was reported in the extraction versus non-extraction groups. With the limited sample size, current trends indicate that pain scores do depend on whether or not treatment included the extraction of a tooth. Conclusion: When adequately powered (n=100), this study could assist clinicians providing dental surgeries under general anesthesia care by providing evidence based criteria for the provision of local anesthetic during general anesthesia to reduce need for intra-operative pain medication to relieve post-operative pain.

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Mokgwathi, Gaorutwe Thomas. "An Audit of preoperative evaluation of general surgery patients at Dr George Mukhari Hospital (DGMH), Ga-Rankuwa." Thesis, University of Limpopo (Medunsa Campus), 2010. http://hdl.handle.net/10386/800.

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Thesis (Anaesthesiology)) -- University of Limpopo, 2010.
ABSTRACT INTRODUCTION: Preoperative evaluation of a patient is the fundamental component of anaesthetic practice. Poor documentation and record keeping on the preoperative evaluation (PEF) form is a big obstacle in attaining good practice and hence improving patient outcome following operative procedures. The aim of the study was to conduct an audit of the anaesthetic preoperative evaluation of general surgery patients at Dr George Mukhari hospital (DGMH), Garankuwa. METHODS: A sample size of 88 record files of general surgery patients who underwent elective surgery during 2008 at DGMH was analysed. The proportion of completeness of information recorded on the PEF used at DGMH was compared with a standardized PEF which uses the global quality index (GQI). RESULTS: Only 75 out of88 patients had PEF in their files. The Modified GQI scores for the sample of75 patients ranged between 33.3% and 100%. The mean Modified GQI score was 72.2 +/- SD 13.9%. The median was 73.3 %, while the lower quartile was 60% and the upper quartile was 80%. The GQI scores were low for the following criteria; 'preoperative diagnostic procedure' (46.7%), 'medications prescribed by surgeons' (46.7%), 'preoperative fasting status' (32%), and deficiency in 'patient's weight' (34.7%) and 'allergies' (34.7%) during the preoperative assessment. Only in 1.3% was the PEF filled completely in accordance with the Modified GQI score. CONCLUSION: The overall quality of the preoperative assessment was inadequate in a number of the ModifiedGQI scores criteria suggesting the need for improvement in preoperative assessment of patients by anaesthetists at this hospital to improve patient outcome.

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Wake, Deven Francis. "The effect of a physical exercise and education prehabilitation program in general surgery patients." Thesis, Wake, Deven Francis (2020) The effect of a physical exercise and education prehabilitation program in general surgery patients. Masters by Research thesis, Murdoch University, 2020. https://researchrepository.murdoch.edu.au/id/eprint/57365/.

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Background: Patients undergoing general surgery can often experience complication rates of 30-40% after surgery and can include post-surgical bleeding, pain, nausea, infection, and sepsis which can all significantly delay recovery. Prehabilitation enhances the physical function of patients prior to surgery to improve surgical outcomes and facilitate recovery. Previous research has explored the benefits of aerobic-based prehabilitation in improving recovery after surgery, however research into appropriately prescribed resistance focussed interventions is lacking. Resistance based exercise has the benefit of increasing muscle mass, muscle strength and physical function prior to surgery, enhancing recovery and return to pre-surgery function. This study explored the effects of a resistance-based prehabilitation program on overall patient recovery when compared to usual care. Methods: Seventeen participants (8 males and 9 females) were recruited via inpatient admissions and randomly assigned to an intervention group (n=9) receiving a pre-surgery resistance-based exercise program or usual care group (n=8) receiving standard patient education. The exercise program consisted of 6 resistance exercises targeting large major muscle groups with the focus of building muscle mass. Primary outcomes were length of stay (days) and post-operative complications. Secondary measures included; whole body resistance, isometric muscle strength, physical function, aerobic fitness, self-reported physical function and quality of life (QoL) and limb disability (upper and lower limb) Results: No differences were observed in length of stay between the prehabilitation and control groups (p=0.655). The control displayed a significant within group loss of 8.4kg in grip strength between pre and post-surgery (p=0.001), compared to the intervention group who only lost 0.8kg (p=0.776). Mental health summary score reported a significant difference between groups at six-week post-surgery (p=0.006) displaying increased quality of life as a result of the intervention. Conclusion: The preliminary results of this study indicate that resistance-based exercise training in the peri-operative period are associated with reported increases in patient mental health and isometric muscular strength.

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Russell, Stuart J. "Temporary biventricular pacing after cardiac surgery in patients with severe left ventricular dysfunction." Thesis, Cardiff University, 2013. http://orca.cf.ac.uk/60107/.

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Left ventricular (LV) function is an important predictor of outcome after cardiac surgery. Severely impaired LV function (EF<20%) carries a 4-fold increase in the risk of in-hospital mortality compared to patients with EF >40%. Optimising LV function in the peri-operative setting may improve outcomes. Haemodynamic studies of permanent BiV pacing have reported a relative 25% increase in EF compared to dual-chamber right ventricular pacing. Methods: 38 patients in sinus rhythm, ejection fraction ≤35%, undergoing on-pump cardiac surgery were enrolled into the main study. All patients received temporary pacing wires attached to the right atrium, right ventricular outflow tract and left ventricle. Patients were randomly assigned to post-operative biventricular pacing or atrial-inhibited/dual-chamber right ventricular pacing. The primary endpoint was the transition from level 3 to level 2 care. The cardiac output measurements obtained using the PA catheters were compared to simultaneous measurements obtained from a FloTrac device (Edwards Lifesciences, arterial pulse-wave analysis). The measurements were compared using a Bland-Altman analysis. Results: The median duration of level 3 care was 22.0 (IQR: 16.0-66.5) hours and 37.5 (IQR: 16.3-55.0) hours in the BiV and standard pacing groups respectively (log-rank p=0.58, 95% CI: 0.43-1.61). At 18 hours, cardiac output with biventricular pacing (5.8 L/min) was 9% higher than dual chamber right ventricular pacing (5.3 L/min), ( p=0.001). Optimisation of the VV interval produced a further 4% increase in cardiac output (p=0.005). Analysis of the cardiac output measurements taken simultaneously from the PA catheter and FloTrac system yielded a bias -0.33L/min±2.2 L/min and a percentage error of 42%. Conclusions: Patients who require post-operative pacing or a prolonged haemodynamic support after surgery may benefit from optimised BiV pacing. However, for the majority of patients BiV pacing does not alter the clinical outcome compared to atrial-inhibited or dual chamber RV pacing. Although the FloTrac system is easy to use and rapidly reports changes in cardiac output, its precision requires refinement before it can be used instead of a PA catheter.

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Percy, Charles L. "Predicting excess bleeding due to haemostatic failure following cardiac surgery requiring cardiopulmonary bypass." Thesis, Cardiff University, 2015. http://orca.cf.ac.uk/76453/.

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Bleeding following cardiac surgery requiring cardiopulmonary bypass (CPB) is associated with increased morbidity. Identification of patients at increased risk of bleeding might allow intervention to prevent bleeding developing. In this thesis, clotting factors, anticoagulants and calibrated automated thrombin generation were investigated as potential methods for identifying such patients. Post-CPB FXIII, fibrinogen and platelet count were significantly lower in those who bleed more than 2 mL/kg/hr for two consecutive hours and in those who bleed in excess of 1 litre at 24 hours. ROC analysis demonstrated these had modest predictive value. Calibrated automated thrombography was unable to identify patients at risk of bleeding. Calibrated automated thrombography was also used to investigate the effects of haemostatic treatment (FFP, rFVIIa, PCC and TFPI inhibition) on thrombin generation in vitro. Blocking the effect of TFPI produced the greatest improvement in thrombin generation. The effect of CPB on platelet phospholipids was investigated using mass spectrometry. Post-CPB the ability to externalise phosphatidylethanolamine and phosphatidylserine was impaired. The ability to externalise and synthesise 12-HETE-PC and 12-HETE-PE in response to both thrombin and collagen post-CPB was also reduced. The effect of these phospholipids on thrombin generation and the ability to identify patients at risk of bleeding was then investigated. Thrombin generation using liposomes containing 12-HETE-PC or 12-HETE was lower in patients who required haemostatic treatment for post-CPB bleeding compared to those who did not. This suggests there are variations between individuals in the way their coagulation factors interact with oxidised phospholipids and that this may influence bleeding. Finally a cell based model of thrombin generation was developed using monocytes as a source of tissue factor and incorporating the observed changes in phospholipids, clotting factors and anticoagulants. This model provides a basis to further investigate the influence of different TF expressing cells on thrombin generation which may affect bleeding.

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Bailey, Melissa D. "The assessment of postoperative refractive surgery patients in clinical research." Connect to this title online, 2004. http://rave.ohiolink.edu/etdc/view?acc%5Fnum=osu1086104689.

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Thesis (Ph. D.)--Ohio State University, 2004.
Document formatted into pages; contains 137 p. Includes bibliographical references. Abstract available online via OhioLINK's ETD Center; full text release delayed at author's request until 2005 June 1.

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Coleman, David John. "An evaluation of the delivery of pharmaceutical care from a general practice surgery based pharmacy." Thesis, University of Portsmouth, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.311077.

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A longitudinal study was carried out on a population of 4,922 patients served by a general practice surgery with three doctors. The purpose was to investigate the opportunity which domiciliary care of elderly and infirm patients offers to UK pharmacists working in primary care. The aims of the study were: - 1) To identify indicators that could be used to identify patients in the community who might benefit from domiciliary pharmaceutical care, and which do not leave patients excluded. 2) To identify specific issues that would lead to better pharmaceutical care 3) To deliver a package of pharmaceutical care to these most "at risk" patients in the population over approximately a year. 4) To evaluate the interventions made considering the viewpoints of all parties found to be stakeholders. 5) To measure the scale of the challenge of domiciliary managed pharmaceutical care in relation to the population in the study. 6) To provide indicators for the development of pharmaceutical care including cost/ benefit and potential training requirements. A simple qualitative study design was pursued, based upon semi-structured interviews and field notes. A cohort of patients (n=149) identified as candidates for domiciliary visiting, represented 3% of the surgery population. After de-selection of unsuitable candidates, visits were made to 100 patients. Three concepts for the organisation of information and three clusters of criteria were identified and developed which would identify 94 out of 100 patients visited. A large number of indicators for pharmaceutical care were identified and described qualitatively under 14 headings. Though typical, these were not claimed as a comprehensive set of issues which could have been encountered. It was generally perceived that more of the pharmacist's interventions produced positive effects than those that were neutral or actually did harm. Some of the interventions were accepted by the GPs as very important, and developing the extended role to include for instance a cardiovascular review clinic; "in house" medication reviews was discussed. Domiciliary visits were deemed useful though the GPs pointed out that making visits was time consuming and, by implication, expensive. Patients reported a high level of satisfaction with the visiting programme. Satisfaction was explored in an attempt to differentiate sociometric issues from professional ones. Rating satisfaction with a domiciliary pharmaceutical service required that specific issues were identified and dealt with which reflected the main concerns of patients about their medicines. Most of the patients' concerns appeared to be centred around multiple medication, widely perceived (in this cohort) to have potential to cause harm. The author recommends that PCGs consider allocating part of the prescribing budget to fund a domiciliary pharmaceutical care service to a small targeted population through community pharmacies. This could be a first step in offering new professional opportunities through community pharmacies and might revitalise some which are currently in decline.

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Barker, Jill Patricia. "The metabolic and hormonal response to cataract surgery : a comparison between general and local anaesthesia." Thesis, University College London (University of London), 1996. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.244215.

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Touarti, Christina M. "Representations of cosmetic surgery in women's magazines." [Kent, Ohio] : Kent State University, 2007. http://rave.ohiolink.edu/etdc/view?acc%5Fnum=kent1185417036.

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Browne, Jonathan Sebastian. "Contested care : medicine and surgery during the Spanish Civil War, 1936-1939." Thesis, University of Kent, 2017. https://kar.kent.ac.uk/61266/.

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This thesis traces the important role played by Spanish medical personnel, particularly surgeons, in the development and organisation of their own medical services during the Spanish Civil War. This study, therefore, is not strictly a history of medicine during the conflict, nor does it seek to further explore international efforts in this regard; rather it analyses through an examination of the medical personnel involved on both sides, the causes, treatments and long term consequences of injury and trauma, including that of exile, on the wounded of the Spanish Civil War. This thesis, by picking over the bones of a wide body of literature and by engaging with a variety of different sources, forms an interlocking part of a new historiographical strand examining the origins and evolution of a traumatic conflict whose repercussions continue to be felt throughout Spain. Through its engagement with a diversity of sources, its analysis of the relationship between medicine and propaganda, and through an inclusive examination of the contribution made by Spanish medical professionals across Spain during the Spanish Civil War and its aftermath, this thesis provides its own unique historical perspective of a conflict whose living legacy of trauma and of wounds unhealed is still alive in Spain today.

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Ward, Michael. "Mechanical and structural performance of melt-processable bioresorbable engineering nanocomposites." Thesis, University of Nottingham, 2018. http://eprints.nottingham.ac.uk/52015/.

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The design of materials for medical implants is continuously evolving to improve their performance to address clinical needs. The development of a fully bioresorbable material with properties similar to bone is desirable for the replacement of existing metallic implants. This thesis forms part of a recent interdisciplinary effort to develop a scalable manufacturing route for the next generation of melt-processable bioresorbable polymer nanocomposites based on poly (lactic acid) (PLA) and nanohydroxyapatite (nHA). Recent progress in nanoparticle synthesis has enabled large scale production of nHA with different morphologies, forming either nanorods or nanoplatelets. The nanoplatelets can also be surface-modified during production, allowing for different surface coatings to be added to aid the dispersion process. PLA has been selected as the matrix material as it is already a popular choice for commercialised bioresorbable medical implants like small screws and pins. The focus of this work is on the structural and mechanical properties of melt-compounded nHA/PLA nanocomposites from the point of production through to the end of useful implant life, and on the understanding of the degradation mechanism of the PLA and the influence of the nHA on material performance. The accelerated hydrolytic response in phosphate buffer solution (PBS) of three commercial Evonik Resomer® PLA grades, LR 704s, LR 706s, and LR 708, was investigated. It was found that the presence of acidic chain ends in LR 708 increased the rate of hydrolysis relative to ester chain ends in LR 704s and LR 706s, and as a result induced autocatalysis much faster; autocatalysis was visible after 14 d for LR 708 and after 21 d for LR 706s. The presence of low molecular weight species within the distribution was also identified as a factor leading to faster degradation, and grade LR 706s was selected for compounding with nanoparticles. The rate of diffusion of water into PLA was measured in LR 706s and shown to obey Fickian diffusion with an activation energy of 48.6 ± 2.3 kJ mol-1. Creep compliance was measured in bending and was shown to plateau after one day of hydrolytic saturation, but increased again after 10 d due to autocatalysis leading to localised degradation. The use of a pH sensitive dye and microCT imaging provided further insight into the phenomenon. It was also shown that the rate of molecular weight loss increased by 20 times when raising the temperature of the degradation medium from 37 to 50 °C, increased due to the increased energy to break the ester bond alongside the increased autocatalysis due to the chain scission occurring at a much faster rate than diffusion of the breakdown products. Nanocomposites were produced by melt-compounding LR 706s with 2.5, 5 and 10 wt. % of uncoated nHA nanorods, nanoplates and dispersant-coated nanoplates. The presence of water during extrusion caused significant molecular weight loss to the polymer as a result of the increased energy that extrusion at 210 °C would provide to the water to enable hydrolysis of the ester bonds to occur. The molecular weight in the polymer was shown to fall from 422.4 kDa to (187.8 ± 18.0) kDa after extrusion in an air atmosphere. Nitrogen fed through a cold trap was used to prevent this. A pre-drying stage applied to the uncoated nanoparticles also helped to reduce degradation during the extrusion, and polymer processed with dried nHA retained a higher molecular weight (378.6 ± 11.4) kDa than a polymer without the pre-drying stage (327.7 ± 3.1) kDa. Dry nanorod-filled materials exhibited a modulus of up to (5.1 ± 0.2) GPa (at 10 wt. %) compared with (3.8 ± 0.5) GPa for the unfilled polymer, but only moderate increases in strength, from (106 ± 3) MPa to (108.1 ± 2.2) MPa (at 2.5 wt. %), were observed in the nanofilled materials. Both nanorods and nanoplatelets offered a degree of control over the rate of degradation, with a rate of change of molecular weight almost 2.5 times faster possible with 10 wt. % addition of particles. This could be helpful in tuning the implants to transfer loads back to the healing bones in shorter times. The strength of the nanocomposites during degradation was shown to correlate with the molecular weight, remaining constant at ca (44.9 ± 0.7) MPa until the molecular weight dropped to below 58 kDa, when it reduced approximately linearly with molecular weight. In conclusion, the addition of nHA compounded with suitable care offers unique opportunities for the design of materials with some increases in dry mechanical properties, and controllable degradation timescales.

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Clasper, Jonathan C. "Mortality and orthopaedic injury following military trauma." Thesis, University of Glasgow, 2017. http://theses.gla.ac.uk/8964/.

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This thesis details my contribution to the literature on military surgery, based on both front-line surgical experiences as well as research carried out on causes of death and disability, particularly in relation to limb injuries, the most common site of wounding in conflict. Injury analysis (6 papers). Injury prevention/mitigation (5 papers). Management (8 papers). Outcome (13 papers). Education (9 papers).

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Hamilton, George. "Prostacyclin activity in portal hypertension." Thesis, University of Glasgow, 2002. http://theses.gla.ac.uk/30845/.

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This work was performed between 1979 and 1985 when there was great interest in the role of the recently identified prostacyclin in vascular function and disorders. The discovery of this substance with its powerful vasodilatory and platelet anti-aggregatory powers raised the hypothesis that prostacyclin might be involved in the pathogenesis of portal hypertension, its associated hyperdynamic circulation and typically catastrophic haemorrhage from bleeding oesophageal varices. Partial portal vein ligation in a rat model of portal hypertension was used because of its simplicity and absence of hepato-cellular dysfunction. This model was found to result in short lived hypertension with return to normal pressure by two weeks. Anatomical studies (using venography and corrosion casting) of the changes to the portal venous circulation after partial portal vein ligation, revealed the development of a dominant portosystemic collateral draining into the left renal vein via the left anterior lumbar vein. Ligation of this collateral at the same time as partial portal vein ligation gave a reliable model of permanent portal hypertension. Accurate measurement of prostacyclin proved to be difficult. Initially a bioassay of prostacyclin-like activity was used with success. The rat was found to produce high levels of prostacyclin well within the range of accurate measurement of this assay. Prostacyclin production was shown to increase directly with pressure increase in the portal vein. This direct relationship was confirmed in the acute model where prostacyclin production fell as the portal pressure returned to normal; in the model of chronic portal hypertension, prostacyclin production remained permanently elevated. A radioimmunoassay for 6 ketoPGFIα, the stable breakdown product of prostacyclin, was developed to allow measurement of prostacyclin in human tissue and serum samples (at this time there were no commercially available RIA kits). Initially the Wellcome antiserum was used with accurate measurement in incubated human tissue samples. These studies confirmed greater intrinsic prostacyclin activity in normal mesenteric and portal vein compared to peripheral venous tissues but failed to show any difference in tissue or plasma levels of portal hypertensive compared to normal patients. A second antiserum, the Cardeza antiserum, was then used in the radioimmunoassay. Unlike the Wellcome assay, this antiserum did not require a prostanoid extraction process. Comparison of the two assays in identical samples revealed major differences with large quantities of 6 ketoPGFIα being measured using the Wellcome antiserum with its extraction step compared to virtually none detected using the Cardeza antiserum. The extraction step was resulting in production of cross-reacting prostanoid substances giving falsely high readings. Both radioimmunoassays were abandoned at this stage because of the inaccuracy of the first, and the inability of the second to detect the low levels of 6 ketoPGFIα in human plasma. The human studies were continued using a highly specific and sensitive assay of 6 ketoPGFIα, namely gas chromatography/negative ion chemical ionisation mass spectroscopy (GC/NICIMS). At the time of this work, this methodology was complex, cumbersome, with limited access and the numbers studied were small. Very low levels of 6 ketoPGFIα were found in peripheral blood of normal and portal hypertensive patients who were not bleeding from oesophageal varices, in patients without portal hypertension, portal blood levels of prostacyclin were higher compared to peripheral levels, confirming the finding in the rat and pig that prostacyclin activity is higher in the normal portal circulation compared to peripheral vein. Significantly elevated prostacyclin production was found in both the peripheral and portal blood of portal hypertensive patients who were actively bleeding from oesophageal varices. Portal prostacyclin production was found to be significantly higher in patients with portal hypertension who were actively bleeding compared to normal patients undergoing laparotomy for other conditions. These findings in bleeding patients support the hypothesis that prostacyclin activity is increased in portal hypertension and may play a role in the severity of haemorrhage. In both the animal and human studies a clear effect of surgical intervention on increased prostacyclin production was found. These studies demonstrated for the first time increased prostacyclin production in both developing, and established portal hypertension in both the experimental animal situation and in man. High levels of prostacyclin production were found in the portal circulation of portal hypertensive patients undergoing surgery for uncontrolled variceal bleeding.

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Watt, David G. "An investigation into the role of the innate immune system in patients undergoing surgery for colorectal cancer." Thesis, University of Glasgow, 2018. http://theses.gla.ac.uk/8915/.

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Colorectal cancer is the 4th most common cancer in the UK and the second commonest cause of cancer death. Whilst mortality rates from colorectal cancer haven fallen over the last 2 decades, around 40% of those diagnosed with colorectal cancer will die from their disease. Surgery currently remains the only chance of cure. Around 10% of patients present as an emergency with perforation, obstruction or bleeding. Outcomes from these emergency operations are substantially worse than from elective procedures. The presence of a systemic inflammatory response pre-operatively is now widely recognised as a predictor of disease progression and poor outcomes, both long and short term, regardless of tumour stage in those with colorectal cancer. Numerous scoring systems that measure various components of the systemic inflammatory response have been documented, the most commonly used are the modified Glasgow Prognostic Score (mGPS) and the Neutrophil-Lymphocyte Ratio (NLR). The NLR has the advantage of using 2 components of the differential white cell count, which is routinely measured in surgical and oncological practice, whereas CRP is less commonly routinely measured. However, studies utilising the NLR have used a variety of thresholds, making comparison of the results from study to study difficult. Whether one of the components of the NLR is more important than the other remains to be seen and indeed whether there is a more optimal score that utilises the white cell count is not clear. To date no work has examined similar scoring systems in the post-operative period. The present thesis aims to examine the impact of the innate immune response, through such systemic inflammation based scoring systems, on patients undergoing surgery for colorectal cancer. Furthermore, it analyses the nature of the inflammatory response in the post-operative period in order to ascertain whether similar scoring systems may be of clinical utility. Chapter 1 provides an overview of colorectal cancer, its presentation and treatment and its known determinants of outcomes. Furthermore, the immune response to injury and post-operative inflammatory response are discussed. Chapter 2 documents a survey of clinicians who have an interest in systemic inflammation. The survey asks the participants whether they routinely measure systemic inflammation, to what purpose and which scoring system they prefer. Unsurprisingly, the majority of participants use these scoring systems for research purposes only with an even split in terms of which scoring system they prefer to use. Their use in clinical practice remains small but their use in some oncological studies may signify a step towards their incorporation into clinical practice in the future. Chapter 3 presents data from a cohort of patients whom have undergone surgery for colorectal cancer with pre-operative differential white cell counts in order to determine whether any of the white cell count components are important in determining long term outcomes. Only the neutrophil count was independently associated with poor long term survival in patients undergoing surgery for colorectal cancer. These results highlight the importance of both the neutrophil count and the innate immune system in outcomes in patients with colorectal cancer. In chapter 4, a cohort of colorectal cancer patients and a cohort of patients with cancer were utilised in order to determine whether a pre-operative systemic inflammation based score using the neutrophil and platelet count was capable of predicting survival in these patients. This was based on the fact that recent in-vitro work had suggested that a critical checkpoint early in the inflammatory process involved the interaction between neutrophils and activated platelets. The subsequent score – the neutrophil platelet score (NPS)- was shown to be capable of predicting survival, independent of TNM stage, in patients with colorectal cancer and had prognostic value in patients with a variety of other tumours. Chapter 5 describes a systematic review of studies analysing the effect of various surgical procedures on markers of the systemic inflammatory response. Only CRP and IL-6 were found to represent the degree of surgical trauma and invasiveness of the procedure. This work provides a framework for analysing the post-operative SIR and how it is affected by surgery and peri-operative programmes such as ERAS that are reported to improve length of stay and sort term outcomes following surgery for colorectal cancer. It was of interest in the previous chapter that white cell count did not reflect the degree of surgical trauma. Whether individual white cell components act differently and represent the degree of surgical trauma was unclear. Chapter 6 sought to clarify this by analysing, in a cohort of patients undergoing surgery for colorectal cancer, the differential white cell count and whether it reflected the magnitude of injury and short term outcomes. Only the neutrophil count reflected the magnitude of trauma and development of infective complications. However, it remains inferior to other well established markers such as CRP. Whilst the pre-operative systemic inflammatory response is a well-recognised determinant of both long term outcomes and short term outcomes such as infective complications, little work has focussed on the post-operative systemic inflammatory response. In chapter 7, the possibility of the post-operative systemic inflammatory response also being capable of predicting both short and long term outcomes was explored in a cohort of patients whom had undergone surgery for colorectal cancer. A score using the combination of post-operative CRP and albumin was created and called the post-operative Glasgow Prognostic Score (poGPS). In this cohort of patients, this score predicted the development of infective complications and also long term survival. Given that these results would indicate that a reduction in the post-operative systemic inflammatory response would improve outcomes, the clinicopathological factors that may alter this post-operative systemic inflammatory response should be investigated as some of these may be modifiable and may therefore improve outcomes following surgery for colorectal cancer. ERAS programmes have changed perioperative management and are reported to be beneficial in reducing length of hospital stay and post-operative complications. It is purposed that this is due to the reduction on the surgical stress response. However it is unclear which of the components of an ERAS programme are responsible for this reduction in the systemic inflammatory response. Chapter 8 describes a systematic review analysing studies of the various ERAS components and whether there is objective evidence of a reduction in the SIR, evidenced by a reduction in either CRP or IL-6. Only laparoscopic surgery was reported to reduce the SIR in these studies, all the remaining components had either little or no evidence of a reduction in the SIR. Further work is required to ascertain whether any of the other components also reduce the SIR. This will hopefully allow streamlining of the ERAS process in order to improve outcomes. Specific clinicopathological factors that may alter the post-operative systemic inflammatory response are examined in chapter 9. Common clinicopathological factors were examined using the poGPS to ascertain which factors resulted in increased poGPS scores. In those patients undergoing elective surgery, year of operation, ASA grade, pre-operative systemic inflammation, and tumour site were associated with increased poGPS scores. These findings may have important clinical consequences as whilst factors such as ASA grade and BMI are not readily modifiable in the short time frame between diagnosis and surgery, pre-operative inflammation could potentially be targeted with anti-inflammatory medication.
However, more work is required to identify the specific agent and the timing of its delivery. In chapter 10, a cohort of patients undergoing surgery for colorectal cancer in whom there was prescription information available. Patients prescribed aspirin or statin were identified and their post-operative inflammatory response and short term outcomes were compared to those not prescribed aspirin or statins. In 446 patients, neither aspirin nor statin prescription was associated with a reduction in the post-operative systemic inflammatory response. Therefore, it would appear that these medications will not be useful in moderating the systemic inflammatory response following surgery. However, further work is required to identify which medications will be of benefit and should take the format of a randomised controlled trial. Chapter 11 provides a summary of the main findings of this thesis, discussed their implications and provides some discussion surrounding future work in this field.

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Rahman, Ishtiaq Ali. "Application of remote ischaemic preconditioning to human coronary artery bypass surgery." Thesis, University of Birmingham, 2010. http://etheses.bham.ac.uk//id/eprint/843/.

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This thesis reports a clinical study designed to assess myocardial, renal and lung outcomes following cardiac surgery. In a single centre, prospective randomized, placebo intervention-controlled trial the effects of intermittent upper limb ischaemia (remote ischaemic preconditioning (RIPC)) were compared in non-diabetic adult patients undergoing on-pump multi-vessel coronary artery surgery. Patients, investigators, anaesthetists, surgeons and critical care teams were all blind to group allocation. Subjects were randomized(1:1) to RIPC(or placebo) stimuli (3x upper limb (or dummy arm) 5 minute cycles of 200mmHg cuff inflation/deflation) during sternotomy and conduit procurement. Anaesthesia, perfusion, cardioplegia and surgical techniques were standardized. Groups were well matched on demographic and operative variables. In contrast to prior smaller studies, RIPC did not reduce troponin T (48 hour area under the curve (AUC); 6hour and peak) release, improve post-operative haemodynamics (cardiac indices; low cardiac output episodes incidence; IABP usage; inotrope and vasoconstrictor use; M mode, 2D contrastenhanced echocardiography and tissue Doppler imaging) or offer antiarrhythmic benefit (de novo left bundle branch block or Q waves; ventricular tachyarrhythmia incidence). RIPC did not afford renal (peak creatinine, AUC urinary albumin-creatinine ratios, dialysis requirement) or lung protection (intubation times, 6hour and 12 hour pO2/FiO2 ratios). Case urgency did not influence RIPC effect.

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Fuzzell, Lindsay Nicole. "Cosmetic Surgery Pictures: Does Type of Picture Affect Acceptance of Cosmetic Surgery and/or Body Image?" UNF Digital Commons, 2010. http://digitalcommons.unf.edu/etd/424.

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The researcher investigates the effect of viewing positive and negative cosmetic surgery images, with short descriptive scenarios, on acceptance of cosmetic surgery. Two hundred ninety-nine participants were assigned to view one of three conditions: positive before/after cosmetic surgery pictures and an accompanying scenario, negative pictures and scenario, or no pictures or scenario (control), followed by the Acceptance of Cosmetic Surgery Scale (ACSS, Henderson-King & Henderson-King, 2005), the Body Parts Satisfaction Scale (Berscheid, Walster, & Bohrstedt, 1973), and the Physical Self Description Questionnaire (Marsh, Richards, Johnson, Roche, & Tremayne, 1994). There was a significant relationship between ACSS Intrapersonal subscale and picture/scenario type, specifically that the positive picture/scenario type participants had a higher Intrapersonal Acceptance of Cosmetic Surgery score. There was also a significant relationship between picture/scenario type & physicality, with four of the 11 subscales, physical activity, sport competence, strength, and endurance, being significantly related to acceptance of cosmetic surgery. Results show significant bivariate correlations between cosmetic surgery acceptance and the physicality aspect of body image as measured by the PSDQ, and total body image as measured by the BPSS. Ethnicity and gender were also significant indicators of cosmetic surgery acceptance. The researcher expects that these results could generalize to society as a whole because of the many people that view cosmetic surgery makeover shows on television. Viewing cosmetic surgery images in the media could possibly decrease body image and alter intrapersonal beliefs toward cosmetic surgery.

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Hübner, Claudia, Sabrina Baldofski, Markus Zenger, Wolfgang Tigges, Beate Herbig, Christian Jurowich, Stefan Kaiser, Arne Dietrich, and Anja Hilbert. "Influences of general self-efficacy and weight bias internalization on physical activity in bariatric surgery candidates." Universitätsbibliothek Leipzig, 2016. http://nbn-resolving.de/urn:nbn:de:bsz:15-qucosa-203442.

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Background: Physical activity (PA) seems to be important for long-term weight loss following bariatric surgery, however, studies provide evidence for insufficient PA levels in bariatric patients. Research found self-efficacy to be associated with PA and weight bias internalization, whose influence on mental and physical health has been shown in recent studies. Objectives: The purpose of the present study was to investigate the influence of general self-efficacy on PA, mediated by weight bias internalization. Setting: Consecutive multicenter registry study conducted in six German bariatric surgery centers. Methods: In N = 179 bariatric surgery candidates, general self-efficacy, weight bias internalization, and different intensities of PA were assessed by self-report questionnaires. Structural equation modeling was used to analyze the assumed mediational relationship. Results: After controlling for sociodemographic variables, weight bias internalization fully mediated the association between general self-efficacy and moderate-intense as well as vigorous-intense PA. Lower general self-efficacy predicted greater weight bias internalization, which in turn predicted lower levels of moderate-intense and vigorous-intense PA. Conclusions: The results suggest an influence of weight bias internalization on preoperative PA in bariatric surgery candidates. Subsequently, implementation of interventions addressing weight bias internalization in the usual treatment of bariatric surgery candidates might enhance patients’ preoperative PA, while longitudinal analyses are needed in order to further examine its predictive value on PA following bariatric surgery.

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Hübner, Claudia, Sabrina Baldofski, Markus Zenger, Wolfgang Tigges, Beate Herbig, Christian Jurowich, Stefan Kaiser, Arne Dietrich, and Anja Hilbert. "Influences of general self-efficacy and weight bias internalization on physical activity in bariatric surgery candidates." Surgery for Obesity and Related Diseases (2014) 11, 6, S. 1371-1376, 2015. https://ul.qucosa.de/id/qucosa%3A14726.

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Background: Physical activity (PA) seems to be important for long-term weight loss following bariatric surgery, however, studies provide evidence for insufficient PA levels in bariatric patients. Research found self-efficacy to be associated with PA and weight bias internalization, whose influence on mental and physical health has been shown in recent studies. Objectives: The purpose of the present study was to investigate the influence of general self-efficacy on PA, mediated by weight bias internalization. Setting: Consecutive multicenter registry study conducted in six German bariatric surgery centers. Methods: In N = 179 bariatric surgery candidates, general self-efficacy, weight bias internalization, and different intensities of PA were assessed by self-report questionnaires. Structural equation modeling was used to analyze the assumed mediational relationship. Results: After controlling for sociodemographic variables, weight bias internalization fully mediated the association between general self-efficacy and moderate-intense as well as vigorous-intense PA. Lower general self-efficacy predicted greater weight bias internalization, which in turn predicted lower levels of moderate-intense and vigorous-intense PA. Conclusions: The results suggest an influence of weight bias internalization on preoperative PA in bariatric surgery candidates. Subsequently, implementation of interventions addressing weight bias internalization in the usual treatment of bariatric surgery candidates might enhance patients’ preoperative PA, while longitudinal analyses are needed in order to further examine its predictive value on PA following bariatric surgery.

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Kenealy, Timothy William. "Systematic opportunistic screening for type 2 diabetes in general practice." Thesis, University of Auckland, 2004. http://wwwlib.umi.com/dissertations/fullcit/3155372.

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Some 70,000 people in New Zealand may have undiagnosed diabetes. This study aims to develop ‘systematic opportunistic screening’ for diabetes, testing people attending a general practitioner (GP) for some other reason, and to trial this process with Auckland GPs. The literature on how to change doctor behaviour is reviewed for both theoretical perspectives and empirical evidence. Two of the most promising strategies are computer reminders within a medical consultation and having patients influence doctors. Literature reviews cover GP attitudes to diabetes, guidelines and preventive care and the role of a computer in a GP consultation. The Mail Survey (response rate 154/212, 72.6%) reports GP attitudes to guidelines and preventive care. Factor analysis showed five ‘guidelines’ factors and two ‘preventive care’ factors that might indicate differential motivations to screening for diabetes. The Focus Group Study, of 35 GPs in 5 groups, discussed guidelines, diabetes and computer reminders in a consultation. The analysis suggested that GPs would respond to a patient reminder and may respond to a computer reminder to screen for diabetes. The Screening Reminder Trial involved 107 GPs randomly allocated across four interventions: Computer reminders, Patient reminders, Both and Usual care. The main outcome measures were whether a patient who was eligible for diabetes screening and who visited a GP during the trial had a glucose test done within the trial. The trial ran for two months. Analysis was by intention-to-treat and allowed for clustering by GP. Compared with the Usual care group (screening rate 15.5%), the Odds Ratio of eligible patients being screened were; Computer group OR 2.55 (1.68-3.88), Patient group OR 1.72 (1.21-2.43) and Both group OR 1.69 (1.11-2.59). The Computer reminders were more acceptable to GPs than were the Patient intervention. The findings suggest that a simple computer reminder can implement systematic opportunistic screening for diabetes in New Zealand. If all GPs in New Zealand used the computer reminders for one year, some 8000 patients might benefit from having their diabetes treated for five years longer than they would have under ‘usual care’.
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Meredith, James O. "Biocomposites for bone tissue engineering : innovation report." Thesis, University of Warwick, 2009. http://wrap.warwick.ac.uk/36741/.

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Historically, bone defects resulting from trauma, disease or infection are treated with autograft or allograft. Autograft is bone transplanted from a non-critical area of the skeleton and allograft is bone donated from another member of the same species. The drawbacks with these treatments such as limited availability, donor site morbidity, high cost and disease transmission have driven increasing use of bone graft substitute (BGS) materials. These represent 15% of the £1.6 billion global orthobiologics market. BGS materials available to date are not suitable for use in grafts that are intrinsic to the stability of the skeleton. Thus, the aim for this project was to fabricate an off the shelf and economically viable BGS that will support the skeletal structure whilst healing occurs. This project employed an empirical approach utilising both rapid prototyping (RP) and conventional manufacturing processes to produce novel BGSs. A range of RP techniques were attempted and discovered to be unsuitable as a result of their long build and postprocessing times, poor availability of suitable materials, and undesirable surface finish. Experiments with injection moulding and laser drilling of polylactic acid (PLA) successfully produced 10 mm blocks with a compressive strength of 67 – 80 MPa and compressive modulus of 1.5 – 2.2 GPa. This line of research led to the hypothesis that ceramic extrusion, a process hitherto untested for use in bone tissue engineering (BTE), may be feasible for production of a novel and high strength BGS. In collaboration with an international expert in the manufacture of ceramic monoliths it was possible, for the first time, to manufacture hydroxyapatite (HA) monoliths by adapting the process used for manufacture of automotive exhaust catalysts. These HA monoliths exhibited a compressive strength of 142 – 265 MPa and compressive modulus of 3.2 – 4.4 GPa. The exceptional strength of these monoliths match the properties of cortical bone whilst retaining the high levels of porosity (> 60 %) found in cancellous bone. This combination of strength and porosity will enable treatment of large structural bone defects where the high strength will withstand typical skeletal forces whilst the high porosity allows blood vessels to infiltrate the monolith and begin the healing process. Furthermore, these HA monoliths support the proliferation and differentiation of human osteoblast-like MG63 cells and compare very favourably with a market leading BGS material in terms of their biological performance. It is suggested that this work will result in the development of a new family of high strength and high porosity BGSs for use in challenging clinical situations. The International Preliminary Examination Report for the patent issued to the author (WO 2007/125323) decreed that all 45 claims contained novelty and an inventive step. Two successful applications for research funding have raised nearly £50,000 that helped fund this research effort. Warwick ventures are currently involved in negotiating with medical partners to licence this technology for clinical use.

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Siddiq, Abdur Rahman. "A novel method for the fabrication of porous Poly-Ether-Ether-Ketone using sodium chloride as a porogen." Thesis, University of Nottingham, 2016. http://eprints.nottingham.ac.uk/34614/.

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A novel technique to manufacture porous Poly-Ether-Ether-Ketone (PEEK) scaffolds via a tapped-packing route of fabrication incorporating rounded salt beads had been investigated. The conventional salt leaching technique has been improved via the tapping-route in manufacturing porous PEEK structure that possesses adequate structural and mechanical properties. Three types of PEEK, Vicote, LT3 and LT1 were used as main material and rounded salt as a porogen. PEEK powder and the rounded salt were mixed in 6:1 mass ratio by applying tapping to 22 mm cylindrical die. 5 g of PEEK/salt beads mixture was packed through 8000 taps. Alternative mixing techniques also involved wet (using sprayed water) and dry mixing routes prior to the compaction. To solidify the PEEK and to obtain free-salt PEEK scaffolds, then sintering, dissolving and drying were applied. The results show that only a combination of the tapping route and the LT1 PEEK could secure porous PEEK scaffolds with acceptable and required characteristics in associated with the pore size range (main pores of (560 + 180) µm and windows of (204 + 41) µm) and shape, good interconnectivity, and homogenous and high porosity > 80%. It was also successfully integrated into a viable spinal PEEK cage implant via injection moulding.

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Mehrez, Loujaine. "The application of probabilistic methods for the assessment of hip implant performance." Thesis, University of Southampton, 2007. https://eprints.soton.ac.uk/64798/.

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Sinnett-Jones, Polly. "Micromechanical aspects of fatigue failure in conventional and carbon nanotube-reinforced acrylic bone cement." Thesis, University of Southampton, 2007. https://eprints.soton.ac.uk/64769/.

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Bone cement is required for the majority of implant procedures. The mechanical integrity of cemented implants may be compromised by fatigue failure of the bone cement, mainly due to internal defects or debonding at the implant interfaces; improvements in the mechanical properties of bone cement may therefore be valuable if the implant lifetime of cemented arthroplasties are to be increased and revision rates decreased. The present study investigated the use of synchrotron X-ray microtomography for the observation of internal defects and failure processes that occur during fatigue loading. Initial assessments of fatigue damage processes in in-vitro fatigue test specimens demonstrated the uncertain nature of locating fatigue cracks and other defects, identifying the need for a synthesis of high resolution tomographic imaging with complementary prior damage monitoring methods. This was achieved via a novel amalgamation of acoustic emission, ultrasound and/or microfocus computed tomography scans prior to testing. Location of cracks/defects prior to high resolution tomographic imaging increased the probability of capturing crack initiation, furthering the underlying understanding of crack formation and propagation. Experiments performed at the European Synchrotron Research Facility have shown that the microstructural features of a commercial bone cement are readily imaged using microtomography of short exposure times. Furthermore, interactions (for example crack deflection and ligament formation) have been clearly identified between failure processes and both the cement defect population and internal microstructure. Early stages of crack initiation have also been captured: a new mechanism of crack initiation is proposed where porosity and local BaSO4 distribution are seen to act together to cause resultant crack initiation in the cement matrix rather than directly from pore surfaces. An opportunity for cement enhancement has been identified in the use of carbon nanotubes (CNTs); improved mechanical and physical properties of acrylic bone cement reinforced with CNTs are reported in the literature, although current methods utilised for CNT dispersion in polymers do not immediately lend themselves to surgical deployment. Adding CNTs to bone cement may further provide bio-active and sensing capabilities, beyond the conventional fixation and load-bearing rôle. The present study confirms that CNT-reinforcement (using shear mixing techniques) enhances the fatigue performance of a PMMA matrix and additional acoustic emission parameter based analyses confirm that the presence of CNTs alters the associated failure mechanisms. An insight into the potential capabilities of CNT reinforced cements, using relatively simple preparation techniques suitable for surgical deployment, is provided. These results suggest that enhanced fatigue performance may be achieved by means of CNT reinforcement of the matrix leading to crack shielding mechanisms such as crack bridging. Biologically, the presence of CNTs may reduce local thermal necrosis in the tissue surrounding the cemented construct through a reduction of the peak exothermic polymerisation temperature.

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Stuart, Bryan W. "Deposition and characterisation of RF magnetron sputtered phosphate based glasses." Thesis, University of Nottingham, 2017. http://eprints.nottingham.ac.uk/40609/.

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Phosphate based glasses are emerging in the field of biomaterials for their potential to resorb in biological environments, fulfilling applications from the fibre reinforcement of resorbable polymeric matrices to carriers for therapeutic drug delivery. Here we show the optimisation and characterisation of thin film glasses deposited by RF magnetron sputtering onto medical implant materials such as Ti6Al4V to function as ion leaching coatings to promote osseointegration or inhibit bacterial attachment. Vaporisation of the target preform occurred by momentum exchange interactions leading to non stoichiometric transfer to the condensed coating, sputtering in the order Na > Mg > Ca > Fe > P. Structural analyses revealed short range variation between compositionally equivalent glasses such that coatings with 32.5, 34 and 37 mol% P2O5 showed bulk polymerisation increasing in Q2 species by (23% to 45%) versus (9% to 32%) in quenched glasses. P O P bridging oxygens on the surface of coatings formed (PO3) metaphosphates (Q2), compared to (PO4)3 orthophosphates (Q0) and (P2O7)4 pyrophosphates (Q1) in quenched glasses. Quinternary coatings of up to 2.67 μm, containing Fe3+ and Ti4+ intermediate and cross linking elements were degraded in distilled water and phosphate buffered saline. Fe2O3 was increased from 4 to 8 mol% to stabilise dissolution, however an observed increase was attributed to variable condensation energies leading to inequivalent enthalpy and internal stress states. A comparison of a compositionally equivalent condensed and quenched glass suggested that the surface ratios of P O P to (P=O and PO ) were 34.2% to 65.8% versus 20.5% to 79.5% respectively leading to more soluble coating surfaces, exhibiting an exponential degradation dependence in the first 2 h in distilled water, followed by a linear profile. Post deposition heat treatments at 500, 550 and 610 °C were employed to stabilise dissolution and to tailor mechanical properties. All phosphate glass coatings showed interfacial tensile adhesion in excess of 73.6 MPa; surpassing ISO and FDA requirements for HA coatings. The initial exponential degradation from 0 2 h was stabilised via heat treatment. From 2 24 h coatings exhibited linear ion release rates ordering P > Na > Mg > Ca > Fe whilst dissolution rates reduced by factors of 2.44 to 4.55, attributed the formation of crystals and the depletion of hydrophilic P O P bonds within the surface layer. Vapour deposition has shown its ability to condense tailorable compositions of glasses, maintaining their amorphous tetrahedral structures whilst demonstrating exceptional adhesion to Ti6Al4V substrates. Coatings have demonstrated linear ion release capabilities and the ability to accommodate a vast array of potentially therapeutic ions to promote osteogenic or antimicrobial capabilities.

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Torabi, Kachousangi Ehsanollah. "Edge loading effect on total hip replacement." Thesis, University of Warwick, 2016. http://wrap.warwick.ac.uk/90967/.

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The most important hip post-surgery problem is named Edge Loading (EL). This phenomenon significantly increases the contact pressure on the ball and the socket of the hip prosthesis hence decreasing the lifetime of the hip prosthesis drastically. Nowadays millions of patients cannot go under total hip replacement surgery due to the short lifetime of the hip prostheses. This research mainly focuses on finding solution for reducing the effect of this phenomenon. In this research, reasons of EL are investigated and important factors in designing of the prosthesis are studied. Furthermore, a novel hip prosthesis is proposed. The model has been successfully patented with PCT number: PCT/GB2015/052933 and published with International Publication Number: “WO2016/055783Al”. In this study the proposed design is analysed using three methods and the results are compared with the best available hip prosthesis in the market. The key results of the proposed design are outlined below: -Comparison of the features of the proposed design with those of the available hip prosthesis suggests a promising outcome. This is mostly due to eliminating of the EL causes, in the new design. -According to Hertzian Contact Theory, the proposed design reduces contact pressure during EL by 99.7% in comparison with the best available prosthesis in the market. This represents an upper limit. -Finite element method simulation demonstrates up to 63% reduction (lower limit) of contact pressure during EL and also Neck-Rim/Ring impingement by the proposed design in comparison with the best available prosthesis in the market. Although reduction of contact pressure by the novel design is noticeable, aforementioned methods show different results. This is due to the limitation of every method in this study. In this regard the novel design expecting to reduce contact pressure during EL / Microseparation more than 63% but less than 99.7%. The novel design may open a new path for the total hip replacement surgery, and solve the EL problem forever.

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Guthrie, Graeme J. K. "An investigation into the role of interleukin-6 in linking systemic and local inflammatory responses in patients with colorectal cancer." Thesis, University of Glasgow, 2016. http://theses.gla.ac.uk/7409/.

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Colorectal cancer is the second most common cause of cancer death in the UK. It is accepted that both tumour and host factors are important determinants of disease progression and survival. While systemic and local inflammatory responses are increasingly recognized to be of particular importance the understanding of the mechanisms linking these important inflammatory processes remains unclear. This thesis examines the prognostic importance of measures of systemic and local inflammation and proposes a hypothesis for a link between tumour necrosis, systemic and local inflammatory responses in patients with colorectal cancer. Chapter 3 reports the comparison of the prognostic value of longitudinal measurements of systemic inflammation in patients undergoing curative resection of colorectal cancer. In Chapter 3 the results demonstrate that there was no significant overall change in either mGPS or NLR from pre- to post- operatively. This study highlighted the associations between pre- and post- operative mGPS and NLR and T-stage (p<0.001), TNM stage (p<0.005) and cancer-specific survival. The relationships between pre-operative measurements were examined using multivariate analysis. For pre-operative measurement both mGPS and NLR were associated with cancer-specific survival while when post-operative measures were examined only mGPS was specifically associated with cancer-specific survival (HR 4.81, CI 2.13-10.83, P<0.001). Chapter 4 examines the prognostic value of the Klintrup-Makinen scoring method and the existing limitations with regard to its clinical utility. An automated scoring method using commercially available image analysis software was developed and compared with manual scoring of tumour inflammatory infiltrates. This study demonstrated that both manual K-M scoring (p<0.001) and automated K-M scoring (p<0.05) had prognostic value in patients who had undergone potentially curative resection of colorectal cancer, and that the novel automated method may provide an objective method of assessment of tumour inflammatory infiltrates using routinely stained haematoxylin and eosin sections of tumour samples. In chapter 5 a hypothesis was proposed that Interleukin-6 may link tumour necrosis and systemic and local inflammatory responses in patients with colorectal cancer. This chapter examined the basis for this hypothesis, which is presented in figure 5.1. In addition, in chapter 5 the importance of this potential link is examined. In chapter 6, the hypothesis outlined in chapter 5 was examined in a cohort of patients who had undergone attempted curative resection of colorectal cancer. This study examined the inter-relationships between circulating mediators, in particular IL-6, tumour necrosis and systemic and local inflammatory responses. This results of this study demonstrated that IL-6 was associated with tumour necrosis (<0.001) and mGPS (<0.001) independent of T-stage. Thus adding weight to the hypothesis that elevated circulating concentrations of IL-6 may play a role in modulating both the systemic and local inflammatory responses in patients with cancer. Chapter 7 further develops the hypothesis that IL-6 signalling may be important in modulating systemic and local inflammatory responses in patients with colorectal cancer. Further, in chapter 7 the basis for the role of trans-signalling in this signaling pathway was examined. In this study, we reported that neither expression of the soluble IL-6 receptor or soluble gp130 were associated with systemic or local inflammatory responses. As a result the possible reasons for these findings were explored and future work suggested. A prospective database of patients undergoing attempted curative resection of colorectal cancer in Glasgow Royal Infirmary was used throughout this thesis. This database was created and is maintained regularly by successive research fellows at the Royal Infirmary. The work presented in this thesis highlights the importance of the host response in the form of systemic and local inflammation in patients with colorectal cancer and proposes a link between these responses and tumour necrosis. In addition, this work adds weight to the body of evidence suggesting that assessment of these host responses may improve stratification to treatment for patients with colorectal cancer. Further, this work proposes a mechanistic link, between tumour necrosis, systemic and local inflammatory responses through Interleukin-6, that merits further investigation.

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Dissertations / Theses on the topic 'General surgery'

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