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.

Aspects of the biology of Lutraria lutraria (L.) (bivalvia : Mactracea)

The life history of a population of Lutraria lutraria in a depth of 7m at Hunterston, Ayrshire is discussed. Much of the present population Is thought to have settled in 1967. The functional morphology of Lutraria is described and related to its life as a large, deep-burrowing bivalve. Lutraria spawned in late spring and continued to do so through the summer in 1979 and 1980. Animals became spent in August and September. Unsuccessful attempts were made to induce spawning in the laboratory. Artificial fertilization was successful but development did not proceed beyond the ciliated gastrula stage. Larvae of Lutraria were not identified in plankton samples and young stages were not encountered in sieved sediment samples. The biochemical cycle of the total animal and five component parts (gonad and visceral mass, digestive gland, adductor muscle, siphon and 'other' tissue) is investigated. A marked increase in weight, reflected in an increase in weight of the component parts, was recorded in Autumn 1979. This is thought to be related to an exceptional increase in the phytoplankton at this time. Although a relationship between the biochemical cycle and reproductive cycle remains uncertain, definite seasonal changes were recorded in the respiration rate of Lutraria. At 10°C, the maximum rate of a standard 20g animal was 0.1283m1s 02/g. dry wt./hr. in May 1980 and the minimum rate was 0.O59mls 02/g. dry wt./hr. in October 1980. The effect of temperature on respiration rate was also investigated. Significant differences were recorded for five experimental temperatures (10°C, 15°C, 20°C, 25°C and 30 °C) in August and October but only between two temperatures (10 C and 30 C) in April. There was a decrease in respiration rate at 30 C in August and October, but an increase in April. Respiration rate is affected by a reduction in oxygen tension. A variety of responses were recorded with a small degree of regulation shown. Individuals of Lutraria were able to survive 48 hours under anaerobic conditions. In fully oxygenated conditions heart rate ranged from 4-15 beats per minute with an average of 8 beats per minute. Heart beat was markedly affected by changes in temperature and oxygen tension, increasing to a maximum 22 beats per minute at 25 C, and decreasing to a minimum 2 beats per minute in anaerobic conditions. Heart rate is reduced (12 beats per minute to 5 beats per minute) on exposure to air. Lutraria exhibits an intermittent pattern of pumping activity. Under normal conditions 35% of the time is spent pumping and this Increases as oxygen is reduced (3.00mls 02/litre) to 65% of the time spent pumping. 15. Under normal conditions the respiratory flow varies between 0.382 litres per hour and 1.023 litres per hxir. Adult Lutraria maintain their ability to burrow, albeit slowly.

Trapping phosphorus (III) into polyoxometalates: synthesis, characterisation and electronic behaviour study

The introduction of electronically-active heteroanions into polyoxometalates (POMs) is one of the emerging topics in this field. The novel clusters have shown unprecedented intramolecular electron-transfer features that can be directly mediated by the incorporated heteroanions. In this thesis, we will focus on the study of phosphite (HPO32-) as new non-traditional heteroanions, discover HPO32- templated nanostructures, investigate their electronic behaviours as well as understand the self-assembly process of HPO32--templated species. The thesis starts with incorporating HPO32- into POM cages. The feasibility of this work was illustrated by the successful trapping of HPO32- into a “Trojan Horse” type {W18O56} nanocage. The reactivity of embedded {HPO3} was fully studied, showing the cluster undergoes a structural rearrangement in solution whereby the {HPO3} moieties dimerise to form a weakly interacting (O3PH···HPO3) moiety. In the crystalline state a temperature-dependent intramolecular redox reaction and structural rearrangement occurs. This rearrangement appears to proceed via an intermediate containing two different templates, a pyramidal {HPO3} and a tetrahedral {PO4} moiety. {HPO3} templated POM cages were then vigorously expanded and led to the isolation of five either fully oxidised or mixed-valence clusters trapped with mono-, di-, or tri- {HPO3}. Interestingly, an intriguing 3D honeycomb-like host-guest structure was also synthesised. The porous framework was self-aggregated by a tri-phopshite anion templated {W21} cluster with a {VO4} templated Wells-Dawson type {W18} acting as a guest species within the hexagonal channels. Based on this work, we further extended the templating anions to two different redox-active heteroanions, and discovered a unique mixed-heteroatom templated system built by pairing redox-active {HPIIIO3} with {TeO3}, {SeO3} or {AsO3}. Two molecular systems were developed, ie. “Trojan Horse” type [W18O56(HPO3)0.8(SeO3)1.2(H2O)2]8- and cross-shaped [H4P4X4W64O224]32-/36-, where X=TeIV, SeIV, AsIII. In the case of {W18(HPO3)0.8(SeO3)1.2}, the compound is found to be a mixture of heteroleptic {W18(HPO3)(SeO3)} and homoleptic {W18(SeO3)2} and {W18(HPO3)2}, identified by single crystal x-ray diffraction, NMR as well as high resolution mass spectrometry. The cluster exhibited similar temperature-dependent electronic features to “Trojan Horse” type {W18(HPO3)2O56}. However, due to the intrinsic reactivity difference between {HPO3} and {SeO3}, the thermal treatment leads to the formation of an unusual species [W18O55(PO4)(SeO3)]5-, in which {HPO3} was fully oxidised to {PO4} within the cage, whereas and lone-pair-containing {SeO3} heteroanions were kept intact inside the shell. This finding is extremely interesting, as it demonstrated that multiple and independent intramolecular electronic performance can be achieved by the coexistence of distinct heteroatoms within a single molecule. On the other hand, the cross-shaped [H4P4X4W64O224]32-/36- were constructed by four {W15(HPO3)(XO3)} building units linked by four {WO6} octahedra. Each building unit traps two different heteroatoms. It is interesting to note that the mixed heteroatom species show self-sorting, with a highly selective positional preference. Smaller ionic sized {HPO3} are self-organised into the uncapped side of {W15} cavity, whereas closed side are occupied by larger heteroatoms, which is surprisingly opposed to steric hindrance. Density functional theory (DFT) calculations are currently underway to have a full understanding of the preference of heteroatom substitutions. This series of clusters is of great interest in terms of achieving single molecule-based heteroatom-dependent multiple levels of electron transfer. It has opened a new way to design and synthesise POMs with higher diversity of electrical states, which may lead to a new type of Q-bits for quantum computing. The third chapter is focused on developing polyoxotungstate building blocks templated by {HPO3}. A series of building blocks, {W15O48(HPO3)2}, {W9O30(HPO3)} {W12O40(HPO3)2} and hexagonal {W6O18(HPO3)} have been obtained. The first four building blocks have been reported with {SeO3} and/or {TeO3} heteroanions. This result demonstrates {HPO3} has a similar reactivity as {SeO3} and {TeO3}, therefore studying the self-assembly of {HPO3}-based building blocks would be helpful to have a general understanding of pyramidal heteroatom-based molecular systems. The hexagonal {W6O18(HPO3)} is observed for the first time in polyoxotungstates, showing some of reactivity difference between {HPO3} and {SeO3} and {TeO3}. Furthermore, inorganic salts and pH values have some directing influence on the formation and transformation of various building blocks, resulting in the discovery of a family of {HPO3}-based clusters with nuclearity ranging from {W29} to {W106}. High resolution mass spectrometry was also carried out to investigate the cluster solution behaviour and also gain information of building block speciation. It is found that some clusters experienced decomposition, which gives rise to potential building blocks accountable for the self-assembly.

Conceptualisation, design and development of a primary school based child healthy weight intervention

INTRODUCTION: In common with much of the developed world, Scotland has a severe and well established problem with overweight and obesity in childhood with recent figures demonstrating that 31% of Scottish children aged 2-15 years old were overweight including obese in 2014. This problem is more pronounced in socioeconomically disadvantaged groups and in older children across all economic groups (Scottish Health Survey, 2014). Children who are overweight or obese are at increased risk of a number of adverse health outcomes in the short term and throughout their life course (Lobstein and Jackson-Leach, 2006). The Scottish Government tasked all Scottish Health Boards with developing and delivering child healthy weight interventions to clinically overweight or obese children in an attempt to address this health problem. It is therefore imperative to deliver high quality, affordable, appropriately targeted interventions which can make a sustained impact on children’s lifestyles, setting them up for life as healthy weight adults. This research aimed to inform the design, readiness for application and Health Board suitability of an effective primary school-based curricular child healthy weight intervention. METHODS: the process involved in conceptualising a child healthy weight intervention, developing the intervention, planning for implementation and subsequent evaluation was guided by the PRECEDE-PROCEED Model (Green and Kreuter, 2005) and the Intervention Mapping protocol (Lloyd et al. 2011). RESULTS: The outputs from each stage of the development process were used to formulate a child healthy weight intervention conceptual model then develop plans for delivery and evaluation. DISCUSSION: The Fit for School conceptual model developed through this process has the potential to theoretically modify energy balance related behaviours associated with unhealthy weight gain in childhood. It also has the potential to be delivered at a Health Board scale within current organisational restrictions.

Connected Hopf algebras of finite Gelfand-Kirillov dimension

Following the seminal work of Zhuang, connected Hopf algebras of finite GK-dimension over algebraically closed fields of characteristic zero have been the subject of several recent papers. This thesis is concerned with continuing this line of research and promoting connected Hopf algebras as a natural, intricate and interesting class of algebras. We begin by discussing the theory of connected Hopf algebras which are either commutative or cocommutative, and then proceed to review the modern theory of arbitrary connected Hopf algebras of finite GK-dimension initiated by Zhuang. We next focus on the (left) coideal subalgebras of connected Hopf algebras of finite GK-dimension. They are shown to be deformations of commutative polynomial algebras. A number of homological properties follow immediately from this fact. Further properties are described, examples are considered and invariants are constructed. A connected Hopf algebra is said to be "primitively thick" if the difference between its GK-dimension and the vector-space dimension of its primitive space is precisely one . Building on the results of Wang, Zhang and Zhuang,, we describe a method of constructing such a Hopf algebra, and as a result obtain a host of new examples of such objects. Moreover, we prove that such a Hopf algebra can never be isomorphic to the enveloping algebra of a semisimple Lie algebra, nor can a semisimple Lie algebra appear as its primitive space. It has been asked in the literature whether connected Hopf algebras of finite GK-dimension are always isomorphic as algebras to enveloping algebras of Lie algebras. We provide a negative answer to this question by constructing a counterexample of GK-dimension 5. Substantial progress was made in determining the order of the antipode of a finite dimensional pointed Hopf algebra by Taft and Wilson in the 1970s. Our final main result is to show that the proof of their result can be generalised to give an analogous result for arbitrary pointed Hopf algebras.