Heart failure in young adults

Heart failure (HF) is a major health concern affecting 15 million people in Europe and around 900 000 people in the U.K. HF predominantly affects the elderly, with the mean age of patients with a diagnosis of HF between 70 and 80 years. Most previous HF studies have accordingly focused on older patients. Although HF is less common in younger adults (<65 years), 15% to 20% of patients hospitalised with HF are younger than 60 years of age. Very few studies have described the characteristics of younger adults with HF and its outcome. The aims of this thesis are to describe the clinical characteristics of younger adults with HF, explore the epidemiology of HF in younger adults and determine their short- and long-term outcomes. This was made possible by access multiple databases consisting of large patient cohorts with HF. The first chapter is a systematic literature review of younger adults with HF. Gaps in the current literature were identified and the thesis focused on some of these. The CHARM study allows detail characterisations of younger adults with HF. It recorded characteristics of patients with HF, including symptoms and signs of HF, electrocardiographic changes, chest radiographic findings, and also left ventricular ejection fraction. HF hospitalisations and its precipitating factors were also recorded systematically. Younger adults were more likely to have a third heart sound and hepatomegaly, but less likely to have pulmonary crackles and peripheral oedema. Similarly, radiological findings in younger adults were less likely to show interstitial pulmonary oedema or pleural effusion. Interestingly, younger adults aged <40 years not only have similar HF hospitalisation rate to older patients, however during their presentation with decompensated HF, they were less likely to have clinical pulmonary oedema and radiological signs of HF. Physicians managing younger adults with HF need to be aware of this. Younger adults were also less compliant with medications and lifestyle restriction resulting in hospitalisation with decompensated HF. Fortunately, despite these challenges, mortality rates in younger adults with HF were lower compared to older patients. To further substantiate the findings from the CHARM study, the MAGGIC study, a meta-analysis consists of over 40 000 patients with HF from large observational studies and randomised controlled trials, was examined. In both databases, the commonest aetiology of HF in younger adults was dilated cardiomyopathy. The ejection fraction was the lowest in younger adults. Similar to the CHARM study, mortality rates in younger adults were lower compared to older patients. However, in the MAGGIC study, by stratifying mortality into patients with preserved ejection fraction and with reduced ejection fraction, younger patients with preserved ejection fraction have a much lower mortality rate compared to patients with reduced ejection fraction. Findings from clinical trials are not always reflective of the real life clinical practice. The U.K. Clinical Practice Research Datalink (CPRD), a large and well-validated primary care database with 654 practices contributing information into the database representing approximated 8% of the U.K. population, is a rich dataset offering a unique opportunity to examine the characteristics, treatments, and outcomes of younger adults with HF in the community. In contrast to the CHARM and MAGGIC studies, younger adults aged <40 years were stratified into 20-29 and 30-39 years in the CPRD analysis. This is possible due to the larger number of younger adults with HF. Further stratifying the younger age groups demonstrated heterogeneity among younger adults with HF. In contrast to previous data showing younger adults have lower co-morbidities, the proportions of depression, chronic kidney disease, asthma, and any connective tissue disease were high among patients aged 20-29 years in the analysis from the CPRD. Surprisingly, the treatment rates for angiotensin converting enzyme (ACE) inhibitor, and aldosterone antagonist were the lowest in patients aged 20-29 years. With the exception of patients aged ≥80 years, treatment rate with beta-blocker was also the lowest in patients aged 20-29 years. With over two decades of follow up, long-term mortality rates in younger adults with HF can be determined. The mortality rates continued to decline from 1988 to 2011. Physicians managing younger adults with HF can now use this contemporary data to provide prognostic information to patients and their family. A hospital administrative database is the logical next platform to explore younger adults with HF. The Alberta Ministry of Health database links an outpatient database to a hospitalisation database providing ample data to examine the relationship between outpatient clinic visits and hospital admissions in younger adults with HF. Following a diagnosis of HF in the outpatient setting, younger adults were admitted to the hospital with decompensated HF much sooner than older patients. Younger adults also presented to emergency department more frequently following their first hospitalisation for HF. In conclusion, this thesis presented the characteristics and outcomes of younger adults with HF, and helped to extend our current understanding on this important topic. I hope the data presented here will benefit not only physicians looking after younger adults with HF, but also patients and their family.

Gestural communication of music structure during solo classical piano performance

The production and perception of music is a multimodal activity involving auditory, visual and conceptual processing, integrating these with prior knowledge and environmental experience. Musicians utilise expressive physical nuances to highlight salient features of the score. The question arises within the literature as to whether performers’ non-technical, non-sound-producing movements may be communicatively meaningful and convey important structural information to audience members and co-performers. In the light of previous performance research (Vines et al., 2006, Wanderley, 2002, Davidson, 1993), and considering findings within co-speech gestural research and auditory and audio-visual neuroscience, this thesis examines the nature of those movements not directly necessary for the production of sound, and their particular influence on audience perception. Within the current research 3D performance analysis is conducted using the Vicon 12- camera system and Nexus data-processing software. Performance gestures are identified as repeated patterns of motion relating to music structure, which not only express phrasing and structural hierarchy but are consistently and accurately interpreted as such by a perceiving audience. Gestural characteristics are analysed across performers and performance style using two Chopin preludes selected for their diverse yet comparable structures (Opus 28:7 and 6). Effects on perceptual judgements of presentation modes (visual-only, auditory-only, audiovisual, full- and point-light) and viewing conditions are explored. This thesis argues that while performance style is highly idiosyncratic, piano performers reliably generate structural gestures through repeated patterns of upper-body movement. The shapes and locations of phrasing motions are identified particular to the sample of performers investigated. Findings demonstrate that despite the personalised nature of the gestures, performers use increased velocity of movements to emphasise musical structure and that observers accurately and consistently locate phrasing junctures where these patterns and variation in motion magnitude, shape and velocity occur. By viewing performance motions in polar (spherical) rather than cartesian coordinate space it is possible to get mathematically closer to the movement generated by each of the nine performers, revealing distinct patterns of motion relating to phrasing structures, regardless of intended performance style. These patterns are highly individualised both to each performer and performed piece. Instantaneous velocity analysis indicates a right-directed bias of performance motion variation at salient structural features within individual performances. Perceptual analyses demonstrate that audience members are able to accurately and effectively detect phrasing structure from performance motion alone. This ability persists even for degraded point-light performances, where all extraneous environmental information has been removed. The relative contributions of audio, visual and audiovisual judgements demonstrate that the visual component of a performance does positively impact on the over- all accuracy of phrasing judgements, indicating that receivers are most effective in their recognition of structural segmentations when they can both see and hear a performance. Observers appear to make use of a rapid online judgement heuristics, adjusting response processes quickly to adapt and perform accurately across multiple modes of presentation and performance style. In line with existent theories within the literature, it is proposed that this processing ability may be related to cognitive and perceptual interpretation of syntax within gestural communication during social interaction and speech. Findings of this research may have future impact on performance pedagogy, computational analysis and performance research, as well as potentially influencing future investigations of the cognitive aspects of musical and gestural understanding.

Managing university records and documents in the world of governance, audit and risk: Case studies from South Africa and Malawi

There are enormous benefits for any organisation from practising sound records management. In the context of a public university, the importance of good records management includes: facilitating the achievement the university’s mandate; enhancing efficiency of the university; maintaining a reliable institutional memory; promoting trust; responding to an audit culture; enhancing university competitiveness; supporting the university’s fiduciary duty; demonstrating transparency and accountability; and fighting corruption. Records scholars and commentators posit that effective recordkeeping is an essential underpinning of good governance. Although there is a portrayal of positive correlation, recordkeeping struggles to get the same attention as that given to the governance. Evidence abounds of cases of neglect of recordkeeping in universities and other institutions in Sub-Saharan Africa. The apparent absence of sound recordkeeping provided a rationale for revisiting some universities in South Africa and Malawi in order to critically explore the place of recordkeeping in an organisation’s strategy in order to develop an alternative framework for managing records and documents in an era where good governance is a global agenda. The research is a collective case study in which multiple cases are used to critically explore the relationship between recordkeeping and governance. As qualitative research that belongs in the interpretive tradition of enquiry, it is not meant to suggest prescriptive solutions to general recordkeeping problems but rather to provide an understanding of the challenges and opportunities that arise in managing records and documents in the world of governance, audit and risk. That is: what goes on in the workplace; what are the problems; and what alternative approaches might address any existing problem situations. Research findings show that some institutions are making good use of their governance structures and other drivers for recordkeeping to put in place sound recordkeeping systems. Key governance structures and other drivers for recordkeeping identified include: laws and regulations; governing bodies; audit; risk; technology; reforms; and workplace culture. Other institutions are not managing their records and documents well despite efforts to improve their governance systems. They lack recordkeeping capacity. Areas that determine recordkeeping capacity include: availability of records management policy; capacity for digital records; availability of a records management unit; senior management support; level of education and training of records management staff; and systems and procedures for storage, retrieval and dispositions of records. Although this research reveals that the overall recordkeeping in the selected countries has slightly improved compared with the situation other researchers found a decade ago, it remains unsatisfactory and disjointed from governance. The study therefore proposes governance recordkeeping as an approach to managing records and documents in the world of governance, audit and risk. The governance recordkeeping viewpoint considers recordkeeping as a governance function that should be treated in the same manner as other governance functions such as audit and risk management. Additionally, recordkeeping and governance should be considered as symbiotic elements of a strategy. A strategy that neglects recordkeeping may not fulfil the organisation’s objectives effectively.

The Scottish Parliament in the 15th and 16th centuries

Earlier histories of the Scottish parliament have been somewhat constitutional in emphasis and have been exceedingly critical of what was understood to be parliament's subservience to the crown. Estimates by constitutional historians of the extreme weakness of parliament rested on an assessment of the constitutional system. The argument was that many of its features were not consistent with a reasonably strong parliament. Because the 'constitution' is apparently fragmented, with active roles played by bodies such as the lords of articles, the general council and the convention of estates, each apparently suggesting that parliament was inadequate, historians have sometimes failed to appreciate the positive role played by the estates in the conduct of national affairs. The thesis begins with a discussion of the reliability of the printed text of APS and proceeds to an examination of selected aspects of the work of parliament in a period from c 1424-c 1625. The belief of constitutional historians such as Rait that conditions In Scotland proved unfavourable to the interests and. effectiveness of parliament in the fifteenth and sixteenth centuries, is also examined. Chapter 1 concludes that APS is a less than reliable text, particularly for the reign of James I. Numerous statutes were excluded from the printed text and they are offered below for the first time. These statutes have been a useful addition to our understanding of the reign of James I. Chapter 2 analyses the motives behind the schemes for shire representation and concludes that neither constitutional theory nor political opportunism explains the support which James I and James VI gave to these measures. Both these monarchs were motivated by the realisation that their particular ambitions were dependent on winning the support of the estates whose ranks should include representatives from the shires. Chapter 3 examines the method of electing the lords of articles, the composition of this committee, and some aspects of its operation. The conclusion is that in the main the estates were the deciding force in the choice of the lords of articles. The committee's composition was more a reflection of a desire for a balance between representatives from north and south of the Forth and for the most important burghs and clergy to be selected than an attempt at electing government favourites. The articles did exercise a significant control over the items which came before parliament but this control was not absolute and applied to government as well as private legislation. Chapter 4 questions the traditional view that the general council and convention of estates were the same body. It is argued that they were two different institutions with different powers, but that they nevertheless worked within certain limits and were careful not to usurp the authority of parliament. Chapter 5 concedes that taxation was sometimes decided outside parliament; that the irregularity of taxation certainly weakened the bargaining power of the estates and that the latter did not appear to capitalise on these occasions when taxation was an issue. But the tendency was to ensure that, whether in or out of parliament, the decision to impose taxation was taken by a large number of each estate. The infrequency of taxation was a direct consequence of an unwillingness among the estates to agree to a regular taxation and their preference to ensure for the crown an alternative source of income. Moreover taxation was one issue, which more than any other, would be subject to contentious opposition by the estates, and could lead to the crown's defeat. Chapter 6 is concerned with ecclesiastical representation after the Reformation and the church's attitudes to the possibility of ministerial representation. Some ministers had doctrinal misgivings but the majority came to believe that the church's absence from parliament bad severely reduced. the influence of the church. That no agreement was forthcoming on a system of ministerial representation, particularly after 1597, is attributable to the estates' unwillingness to compromise and, not to the strength of opposition in the church. Chapter 7 examines the institutions which are sometime seen as 'rivals' of parliament and concludes that institutions such as the privy council were generally very careful in matters which needed the approval of parliament, and seemed aware of the greater authority of parliament. Chapter 8 which illustrates how parliament had the right to be consulted in all important matters of state, brings together the main points of the earlier chapters and offers further illustrations of the essential role which parliament played in the conduct of national affairs. Whether or not the system can be regarded as constitutionally sound, the estates in Scotland could observe parliament's day-to-day operation with some satisfaction. All in all, there is little convincing evidence that parliament was as weak as some historians would have us believe.

Music copyright in the digital age: creators, commerce and copyright - an empirical study of the UK music copyright industries

Copyright markets, it is said, are ‘winner takes all’ markets favouring the interests of corporate investors over the interests of primary creators. However, little is known about popular music creators’ ‘lived experience’ of copyright. This thesis interrogates key aspects of copyright transactions between creators and investors operating in the UK music industries using analysis of various copyright related documents and semi-structured interviews with creators and investors. The research found considerable variety in the types of ‘deal’ creators enter into and considerable divergence in the potential rewards. It was observed that new-entrant creators have little comprehension of the basic tenets of copyright, but with experience they become more ‘copyright aware’. Documentary and interview evidence reveals creators routinely assign copyright to third party investors for the full term of copyright in sound recordings: the justification for this is questionable. An almost inevitable consequence of this asymmetry of understanding of copyright and asymmetry of bargaining power is that creators become alienated from their copyright works. The empirical evidence presented here supports historic and contemporary calls for a statutory mechanism limiting the maximum copyright assignment period to ten-years.

Regional variation and change in the history of English strong verbs

This thesis investigates how the strong verb system inherited from Old English evolved in the regional dialects of Middle English (ca. 1100-1500). Old English texts preserve a relatively complex system of strong verbs, in which traditionally seven different ablaut classes are distinguished. This system becomes seriously disrupted from the Late Old English and Early Middle English periods onwards. As a result, many strong verbs die out, or have their ablaut patterns affected by sound change and morphological analogy, or transfer to the weak conjugation. In my thesis, I study the beginnings of two of these developments in two strong verb classes to find out what the evidence from Middle English regional dialects can tell us about their origins and diffusion. Chapter 2 concentrates on the strong-to-weak shift in Class III verbs, and investigates to what extent strong, mixed and weak past tense and participle forms vary in Middle English dialects, and whether the variation is more pronounced in the paradigms of specific verbs or sub-classes. Chapter 3 analyses the regional distribution of ablaut levelling in strong Class IV verbs throughout the Middle English period. The Class III and IV data for the Early Middle English period are drawn from A Linguistic Atlas of Early Middle English, and the data for the Late Middle English period from a sub-corpus of files from The Penn-Helsinki Parsed Corpus of Middle English and The Middle English Grammar Corpus. Furthermore, The English Dialect Dictionary and Grammar are consulted as an additional reference point to find out to what extent the Middle English developments are reflected in Late Modern English dialects. Finally, referring to modern insights into language variation and change and linguistic interference, Chapter 4 discusses to what extent intra- and extra-linguistc factors, such as token and type frequency, stem structure and language contact, might correlate with the strong-to-weak shift and ablaut levelling in Class III and IV verbs in the Middle English period. The thesis is accompanied by six appendices that contain further information about my distinction of Middle English dialect areas (Appendix A), historical Class III and IV verbs (B and C) and the text samples and linguistic data from the Middle English text corpora (D, E and F).