'Expanding Horizons': investigating the Glasgow 2014 legacy for young people in the East End of Glasgow

The recent staging of Glasgow 2014 drew universal praise as the ‘Best Games Ever’. Yet the substantial undertaking of hosting the Commonwealth Games (CWG) was sold to the nation as more than just eleven days of sporting spectacle and cultural entertainment. Indeed, the primary strategic justification offered by policymakers and city leaders was the delivery of a bundle of positive and enduring benefits, so-called ‘legacy’. This ubiquitous and amorphous concept has evolved over time to become the central focus of contemporary hosting bids, reflecting a general public policy shift towards using major sporting mega events as a catalyst to generate benefits across economic, environmental and social dimensions, on a scale intended to be truly transformative. At the same time, the academy has drawn attention to the absence of evidence in support of the prevailing legacy rhetoric and raised a number of sociological concerns, not least the socially unequitable distribution of purported benefits. This study investigated how young people living in the core hosting zone related to, and were impacted upon, by the CWG and its associated developments and activities with reference to their socio-spatial horizons, the primary outcome of interest. An ‘ideal world’ Logic Model hypothesised that four mechanisms, identified from official legacy documents and social theories, would alter young people’s subjective readings of the world by virtue of broadening their social networks, extending their spatial boundaries and altering their mind sets. A qualitative methodology facilitated the gathering of situated and contextualised accounts of young people’s attitudes, perceptions, beliefs and behaviours relating to Glasgow 2014. In-depth interviews and focus groups were conducted before and after the Games with 26 young people, aged 14-16 years, at two schools in the East End. This approach was instrumental in privileging the interests of people ‘on the ground’ over those of city-wide and national stakeholders. The findings showed that young people perceived the dominant legacy benefit to be an improved reputation and image for Glasgow and the East End. Primary beneficiaries were identified by them as those with vested business interests e.g. retailers, restaurateurs, and hoteliers, as well as national and local government, with low expectations of personal dividends or ‘trickle down’ benefits. Support for Glasgow 2014 did not necessarily translate into individual engagement with the various cultural and sporting activities leading up to the CWG, including the event itself. The study found that young people who engaged most were those who had the ability to ‘read’ the opportunities available to them and who had the social, cultural and economic capital necessary to grasp them, with the corollary that those who might have gained most were the least likely to have engaged with the CWG. Doubts articulated by research participants about the social sustainability of Glasgow 2014 underscored inherent tensions between the short-lived thrill of the spectacle and the anticipated longevity of its impacts. The headline message is that hosting sporting mega events might not be an effective means of delivering social change. Aspirant host cities should consider more socially equitable alternatives to sporting mega events prior to bidding; and future host cities should endeavour to engage more purposefully with more young people over longer time frames.

An investigation of the clinical utility of preoperative cardiopulmonary exercise testing in patients undergoing major pancreatic surgery

Pancreaticoduodenectomy with or without adjuvant chemotherapy remains the only modality of possible cure in patients with cancer involving the head of the pancreas and the periampullary region. While mortality rates after pancreaticoduodenectomy have improved considerably over the course of the last century, morbidity remains high. Patient selection is of paramount importance in ensuring that major surgery is offered to individuals who will most benefit from a pancreaticoduodenectomy. Moreover, identifying preoperative risk factors provides potential targets for prehabilitation and optimisation of the patient's physiology before undertaking surgery. In addition to this, early identification of patients who are likely to develop postoperative complications allows for better allocation of critical care resources and more aggressive management high risk patients. Cardiopulmonary exercise testing is becoming an increasingly popular tool in the preoperative risk assessment of the surgical patient. However, very little work has been done to investigate the role of cardiopulmonary exercise testing in predicting complications after pancreaticoduodenectomy. The impact of jaundice, systemic inflammation and other preoperative clinicopathological characteristics on cardiopulmonary exercise physiology has not been studied in detail before in this cohort of patients. The overall aim of the thesis was to examine the relationships between preoperative clinico-pathological characteristics including cardiopulmonary exercise physiology, obstructive jaundice, body composition and systemic inflammation and complications and the post-surgical systemic inflammatory response in patients undergoing pancreaticoduodenectomy. Chapter 1 reviews the existing literature on preoperative cardiopulmonary exercise testing, the impact of obstructive jaundice, perioperative systemic inflammation and the importance of body composition in determining outcomes in patients undergoing major surgery with particular reference to pancreatic surgery. Chapter 2 reports on the role of cardiopulmonary exercise testing in predicting postoperative complications after pancreaticoduodenectomy. The results demonstrate that patients with V˙O2AT less than 10 ml/kg/min are more likely to develop a postoperative pancreatic fistula, stay longer in hospital and less likely to receive adjuvant therapy. These results emphasise the importance of aerobic fitness to recover from the operative stress of major surgery without significant morbidity. Cardiopulmonary exercise testing may prove useful in selecting patients for intensive prehabilitation programmes as well as for other optimisation measures to prepare them for major surgery. Chapter 3 evaluates the relationship between cardiopulmonary exercise physiology and other clinicopathological characteristics of the patient. A detailed analysis of cardiopulmonary exercise test parameters in jaundiced versus non-jaundiced patients demonstrates that obstructive jaundice does not impair cardiopulmonary exercise physiology. This further supports emerging evidence in contemporary literature that jaundiced patients can proceed directly to surgery without preoperative biliary drainage. The results of this study also show an interesting inverse relationship between body mass index and anaerobic threshold which is analysed in more detail in Chapter 4. Chapter 4 examines the relationship between preoperative cardiopulmonary exercise physiology and body composition in depth. All parameters measured at cardiopulmonary exercise test are compared against body composition and body mass index. The results of this chapter report that the current method of reporting V˙O2, both at peak exercise and anaerobic threshold, is biased against obese subjects and advises caution in the interpretation of cardiopulmonary exercise test results in patients with a high BMI. This is particularly important as current evidence in literature suggests that postoperative outcomes in obese subjects are comparable to non-obese subjects while cardiopulmonary exercise test results are also abnormally low in this very same cohort of patients. Chapter 5 analyses the relationship between preoperative clinico-pathological characteristics including systemic inflammation and the magnitude of the postoperative systemic inflammatory response. Obstructive jaundice appears to have an immunosuppressive effect while elevated preoperative CRP and hypoalbuminemia appear to have opposite effects with hypoalbuminemia resulting in a lower response while elevated CRP in the absence of hypoalbuminemia resulted in a greater postoperative systemic inflammatory response. Chapter 6 evaluates the role of the early postoperative systemic inflammatory response in predicting complications after pancreaticoduodenectomy and aims to establish clinically relevant thresholds for C-Reactive Protein for the prediction of complications. The results of this chapter demonstrate that CRP levels as early as the second postoperative day are associated with complications. While post-operative CRP was useful in the prediction of infective complications, this was the case only in patients who did not develop a post-operative pancreatic fistula. The predictive ability of inflammatory markers for infectious complications was blunted in patients with a pancreatic fistula. Chapter 7 summarises the findings of this thesis, their place in current literature and future directions. The results of this thesis add to the current knowledge regarding the complex pathophysiological abnormalities in patients undergoing pancreaticoduodenectomy, with specific emphasis on the interaction between cardiopulmonary exercise physiology, obstructive jaundice, systemic inflammation and postoperative outcomes. The work presented in this thesis lays the foundations for further studies aimed at improving outcomes after pancreaticoduodenectomy through the development of individualised, goal-directed therapies that are initiated well before this morbid yet necessary operation is performed.