The early development and pilot -testing of a case management intervention with victims of stalking: An evaluation study

This study evaluated the early development and pilot-testing of Project IMPACT, a case management intervention for victims of stalking. The Design and Development framework (Rothman & Thomas, 1994) was used as a guide for program development and evaluation. Nine research questions examined the processes and outcomes associated with program implementation. ^ The sample included all 36 clients who participated in Project IMPACT between February of 2000 and June of 2001, as well as the victim advocates who provided them with services. Quantitative and qualitative data were drawn from client case files, participant observation field notes and interview transcriptions. Quantitative data were entered into three databases where: (1) clients were the units of analysis (n = 36), (2) services were the units of analysis (n = 1146), and (3) goals were the units of analysis (n = 149). These data were analyzed using descriptive statistics, Pearson's Chi-square, Spearman's Rho, Phi, Cramer's V, Wilcoxon's Matched Pairs Signed-Ranked Test and McNemar's Test Statistic. Qualitative data were reduced via open, axial and selective coding methods. Grounded theory and case study frameworks were utilized to analyze these data. ^ Results showed that most clients noted an improved sense of well-being and safety, although residual symptoms of trauma remained for numerous individuals. Stalkers appeared to respond to criminal and civil justice-based interventions by reducing violent and threatening behaviors; however, covert behaviors continued. The study produced findings that provided preliminary support for the use of several intervention components including support services, psycho-education, safety planning, and boundary spanning. The psycho-education and safety planning in particular seemed to help clients cognitively reframe their perceptions of the stalking experience and gain a sense of increased safety and well-being. A 65% level of satisfactory goal achievement was observed overall, although goals involving justice-based organizations were associated with lower achievement. High service usage was related to low-income clients and those lacking in social support. Numerous inconsistencies in program implementation were found to be associated with the skills and experiences of victim advocates. Thus, recommendations were made to further refine, develop and evaluate the intervention. ^

Large-Scale Testing to Study the Effects of Critical Parameters on the Aerodynamic Behavior of Long Span Bridges

Long-span bridges are flexible and therefore are sensitive to wind induced effects. One way to improve the stability of long span bridges against flutter is to use cross-sections that involve twin side-by-side decks. However, this can amplify responses due to vortex induced oscillations. Wind tunnel testing is a well-established practice to evaluate the stability of bridges against wind loads. In order to study the response of the prototype in laboratory, dynamic similarity requirements should be satisfied. One of the parameters that is normally violated in wind tunnel testing is Reynolds number. In this dissertation, the effects of Reynolds number on the aerodynamics of a double deck bridge were evaluated by measuring fluctuating forces on a motionless sectional model of a bridge at different wind speeds representing different Reynolds regimes. Also, the efficacy of vortex mitigation devices was evaluated at different Reynolds number regimes. One other parameter that is frequently ignored in wind tunnel studies is the correct simulation of turbulence characteristics. Due to the difficulties in simulating flow with large turbulence length scale on a sectional model, wind tunnel tests are often performed in smooth flow as a conservative approach. The validity of simplifying assumptions in calculation of buffeting loads, as the direct impact of turbulence, needs to be verified for twin deck bridges. The effects of turbulence characteristics were investigated by testing sectional models of a twin deck bridge under two different turbulent flow conditions. Not only the flow properties play an important role on the aerodynamic response of the bridge, but also the geometry of the cross section shape is expected to have significant effects. In this dissertation, the effects of deck details, such as width of the gap between the twin decks, and traffic barriers on the aerodynamic characteristics of a twin deck bridge were investigated, particularly on the vortex shedding forces with the aim of clarifying how these shape details can alter the wind induced responses. Finally, a summary of the issues that are involved in designing a dynamic test rig for high Reynolds number tests is given, using the studied cross section as an example.

Formal verification and testing of software architectural models

Ensuring the correctness of software has been the major motivation in software research, constituting a Grand Challenge. Due to its impact in the final implementation, one critical aspect of software is its architectural design. By guaranteeing a correct architectural design, major and costly flaws can be caught early on in the development cycle. Software architecture design has received a lot of attention in the past years, with several methods, techniques and tools developed. However, there is still more to be done, such as providing adequate formal analysis of software architectures. On these regards, a framework to ensure system dependability from design to implementation has been developed at FIU (Florida International University). This framework is based on SAM (Software Architecture Model), an ADL (Architecture Description Language), that allows hierarchical compositions of components and connectors, defines an architectural modeling language for the behavior of components and connectors, and provides a specification language for the behavioral properties. The behavioral model of a SAM model is expressed in the form of Petri nets and the properties in first order linear temporal logic. This dissertation presents a formal verification and testing approach to guarantee the correctness of Software Architectures. The Software Architectures studied are expressed in SAM. For the formal verification approach, the technique applied was model checking and the model checker of choice was Spin. As part of the approach, a SAM model is formally translated to a model in the input language of Spin and verified for its correctness with respect to temporal properties. In terms of testing, a testing approach for SAM architectures was defined which includes the evaluation of test cases based on Petri net testing theory to be used in the testing process at the design level. Additionally, the information at the design level is used to derive test cases for the implementation level. Finally, a modeling and analysis tool (SAM tool) was implemented to help support the design and analysis of SAM models. The results show the applicability of the approach to testing and verification of SAM models with the aid of the SAM tool.

Experimental investigation of water, snow and granular ice effects on ice failure processes and impact loads

A large series of laboratory ice crushing experiments was performed to investigate the effects of external boundary condition and indenter contact geometry on ice load magnitude under crushing conditions. Four boundary conditions were considered: dry cases, submerged cases, and cases with the presence of snow and granular ice material on the indenter surface. Indenter geometries were a flat plate, wedge shaped indenter, (reverse) conical indenter, and spherical indenter. These were impacted with artificially produced ice specimens of conical shape with 20° and 30° cone angles. All indenter – ice combinations were tested in dry and submerged environments at 1 mm/s and 100 mm/s indentation rates. Additional tests with the flat indentation plate were conducted at 10 mm/s impact velocity and a subset of scenarios with snow and granular ice material was evaluated. The tests were performed using a material testing system (MTS) machine located inside a cold room at an ambient temperature of - 7°C. Data acquisition comprised time, vertical force, and displacement. In several tests with the flat plate and wedge shaped indenter, supplementary information on local pressure patterns and contact area were obtained using tactile pressure sensors. All tests were recorded with a high speed video camera and still photos were taken before and after each test. Thin sections were taken of some specimens as well. Ice loads were found to strongly depend on contact condition, interrelated with pre-existing confinement and indentation rate. Submergence yielded higher forces, especially at the high indentation rate. This was very evident for the flat indentation plate and spherical indenter, and with restrictions for the wedge shaped indenter. No indication was found for the conical indenter. For the conical indenter it was concluded that the structural restriction due to the indenter geometry was dominating. The working surface for the water to act was not sufficient to influence the failure processes and associated ice loads. The presence of snow and granular ice significantly increased the forces at the low indentation rate (with the flat indentation plate) that were higher compared to submerged cases and far above the dry contact condition. Contact area measurements revealed a correlation of higher forces with a concurrent increase in actual contact area that depended on the respective boundary condition. In submergence, ice debris constitution was changed; ice extrusion, as well as crack development and propagation were impeded. Snow and granular ice seemed to provide additional material sources for establishing larger contact areas. The dry contact condition generally had the smallest real contact area, as well as the lowest forces. The comparison of nominal and measured contact areas revealed distinct deviations. The incorporation of those differences in contact process pressures-area relationships indicated that the overall process pressure was not substantially affected by the increased loads.

Microparticle surface layering through dry coating:impact of moisture content and process parameters on the properties of orally disintegrating tablets

OBJECTIVES: The aim of this study was to investigate the influence of process parameters during dry coating on particle and dosage form properties upon varying the surface adsorbed moisture of microcrystalline cellulose (MCC), a model filler/binder for orally disintegrating tablets (ODTs). METHODS: The moisture content of MCC was optimised using the spray water method and analysed using thermogravimetric analysis. Microproperty/macroproperty assessment was investigated using atomic force microscopy, nano-indentation, scanning electron microscopy, tablet hardness and disintegration testing. KEY FINDINGS: The results showed that MCC demonstrated its best flowability at a moisture content of 11.2% w/w when compared to control, comprising of 3.9% w/w moisture. The use of the composite powder coating process (without air) resulted in up to 80% increase in tablet hardness, when compared to the control. The study also demonstrated that surface adsorbed moisture can be displaced upon addition of excipients during dry processing circumventing the need for particle drying before tabletting. CONCLUSIONS: It was concluded that MCC with a moisture content of 11% w/w provides a good balance between powder flowability and favourable ODT characteristics.

The association of HIV counseling and testing with HIV risk behaviors in a random population-based survey in Kisumu, Kenya.

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.

Table 4. Trace gas concentrations from samples taken at Ginninderra

We assess the performance of an inverse Lagrangian dispersion technique for its suitability to quantify leakages from geological storage of CO2. We find the technique is accurate ((QbLS/Q)=0.99, sigma=0.29) when strict meteorological filtering is applied to ensure that Monin-Obukhov Similarity Theory is valid for the periods analysed and when downwind enrichments in tracer gas concentration are 1% or more above background concentration. Because of their respective baseline atmospheric concentrations, this enrichment criterion is less onerous for CH4 than for CO2. Therefore for geologically sequestered gas reservoirs with a significant CH4 component, monitoring CH4 as a surrogate for CO2 leakage could be as much as 10 times more sensitive than monitoring CO2 alone. Additional recommendations for designing a robust atmospheric monitoring strategy for geosequestration include: continuous concentration data; exact inter-calibration of up- and downwind concentration measurements; use of an array of point concentration sensors to maximise the use of spatial information about the leakage plume; and precise isotope ratio measurement to confirm the source of any concentration elevations detected.

The differential impact of oxytocin receptor (OXTR) genotypes on the risk of autism spectrum disorder (ASD) and resulting social communication deficits

Background: Autism spectrum disorder (ASD) is multifactorial and is likely the result of complex interactions between multiple environmental and genetic factors. Recently, it has been suggested that each symptom cluster of the disorder, such as poor social communication, may be mediated by different genetic influences. Genes in the oxytocin pathway, which mediates social behaviours in humans, have been studied with single nucleotide polymorphisms (SNPs) in the oxytocin receptor gene (OXTR) being implicated in ASD. This thesis examines the presence of different oxytocin receptor genotypes, and their associations with ASD and resulting social communication deficits. Methods: The relationship between four OXTR variants and ASD was evaluated in 607 ASD simplex (SPX) families. Cases were compared to their unaffected siblings using a conditional logistic approach. Odds ratios and associated 95 percent confidence intervals were obtained. A second sample of 235 individuals with a diagnosis of ASD was examined to evaluate whether these four OXTR variants were associated with social communication scores on the Autism Diagnostic Interview – Revised (ADI-R). Parameter estimates and associated 95 percent confidence intervals were generated using a linear regression approach. Multiple testing issues were addressed using false discovery adjustments. Results: The rs53576 AG genotype was significantly associated with a lower risk of ASD (OR = 0.707, 95% CI: 0.512-0.975). A single genotype (AG) provided by the rs2254298 marker was found to be significantly associated with higher social communication scores (Parameter estimate = 1.833, SE = 0.762, p = 0.0171). This association was also seen in a Caucasian only and mothers as the respondent samples. No association was significant following false discovery rate adjustments. Conclusion: The findings from these studies provide limited support for the role of OXTR SNPs in ASD, especially in social communication skills. The clinical significance of these associations remains unknown, however, it is likely that these associations do not play a role in the severity of symptoms associated with ASD. Rather, they may be important in the appearance of social deficits due to the rs2254298 markers association with enlarged amygdalas.

Molecular docking and geographical information systems as tools to assess the potential impact of veterinary medicines on non-target organisms and the environment

Veterinary medicines (VMs) from agricultural industry can enter the environment in a number of ways. This includes direct exposure through aquaculture, accidental spillage and disposal, and indirect entry by leaching from manure or runoff after treatment. Many compounds used in animal treatments have ecotoxic properties that may have chronic or sometimes lethal effects when they come into contact with non-target organisms. VMs enter the environment in mixtures, potentially having additive effects. Traditional ecotoxicology tests are used to determine the lethal and sometimes reproductive effects on freshwater and terrestrial organisms. However, organisms used in ecotoxicology tests can be unrepresentative of the populations that are likely to be exposed to the compound in the environment. Most often the tests are on single compound toxicity but mixture effects may be significant and should be included in ecotoxicology testing. This work investigates the use, measured environmental concentrations (MECs) and potential impact of sea lice treatments on salmon farms in Scotland. Alternative methods for ecotoxicology testing including mixture toxicity, and the use of in silico techniques to predict the chronic impact of VMs on different species of aquatic organisms were also investigated. The Scottish Environmental Protection Agency (SEPA) provided information on the use of five sea lice treatments from 2008-2011 on Scottish salmon farms. This information was combined with the recently available data on sediment MECs for the years 2009-2012 provided by SEPA using ArcGIS 10.1. In depth analysis of this data showed that from a total of 55 sites, 30 sites had a MEC higher than the maximum allowable concentration (MAC) as set out by SEPA for emamectin benzoate and 7 sites had a higher MEC than MAC for teflubenzuron. A number of sites that were up to 16 km away from the nearest salmon farm reported as using either emamectin benzoate or teflubenzuron measured positive for the two treatments. There was no relationship between current direction and the distribution of the sea lice treatments, nor was there any evidence for alternative sources of the compounds e.g. land treatments. The sites that had MECs higher than the MAC could pose a risk to non-target organisms and disrupt the species dynamics of the area. There was evidence that some marine protected sites might be at risk of exposure to these compounds. To complement this work, effects on acute mixture toxicity of the 5 sea lice treatments, plus one major metabolite 3-phenoxybenzoic acid (3PBA), were measured using an assay using the bioluminescent bacteria Aliivibrio fischeri. When exposed to the 5 sea lice treatments and 3PBA A. fischeri showed a response to 3PBA, emamectin benzoate and azamethiphos as well as combinations of the three. In order to establish any additive effect of the sea lice treatments, the efficacy of two mixture prediction equations, concentration addition (CA) and independent action ii(IA) were tested using the results from single compound dose response curves. In this instance IA was the more effective prediction method with a linear regression confidence interval of 82.6% compared with 22.6% of CA. In silico molecular docking was carried out to predict the chronic effects of 15 VMs (including the five used as sea lice control). Molecular docking has been proposed as an alternative screening method for the chronic effects of large animal treatments on non-target organisms. Oestrogen receptor alpha (ERα) of 7 non-target bony fish and the African clawed frog Xenopus laevis were modelled using SwissModel. These models were then ‘docked’ to oestradiol, the synthetic oestrogen ethinylestradiol, two known xenoestrogens dichlorodiphenyltrichloroethane (DDT) and bisphenol A (BPA), the antioestrogen breast cancer treatment tamoxifen and 15 VMs using Auto Dock 4. Based on the results of this work, four VMs were identified as being possible xenoestrogens or anti-oestrogens; these were cypermethrin, deltamethrin, fenbendazole and teflubenzuron. Further investigation, using in vitro assays, into these four VMs has been suggested as future work. A modified recombinant yeast oestrogen screen (YES) was attempted using the cDNA of the ERα of the zebrafish Danio rerio and the rainbow trout Oncorhynchus mykiss. Due to time and difficulties in cloning protocols this work was unable to be completed. Use of such in vitro assays would allow for further investigation of the highlighted VMs into their oestrogenic potential. In conclusion, VMs used as sea lice treatments, such as teflubenzuron and emamectin benzoate may be more persistent and have a wider range in the environment than previously thought. Mixtures of sea lice treatments have been found to persist together in the environment, and effects of these mixtures on the bacteria A. fischeri can be predicted using the IA equation. Finally, molecular docking may be a suitable tool to predict chronic endocrine disrupting effects and identify varying degrees of impact on the ERα of nine species of aquatic organisms.

EuroClonality/BIOMED-2 guidelines for interpretation and reporting of Ig/TCR clonality testing in suspected lymphoproliferations.

PCR-based immunoglobulin (Ig)/T-cell receptor (TCR) clonality testing in suspected lymphoproliferations has largely been standardized and has consequently become technically feasible in a routine diagnostic setting. Standardization of the pre-analytical and post-analytical phases is now essential to prevent misinterpretation and incorrect conclusions derived from clonality data. As clonality testing is not a quantitative assay, but rather concerns recognition of molecular patterns, guidelines for reliable interpretation and reporting are mandatory. Here, the EuroClonality (BIOMED-2) consortium summarizes important pre- and post-analytical aspects of clonality testing, provides guidelines for interpretation of clonality testing results, and presents a uniform way to report the results of the Ig/TCR assays. Starting from an immunobiological concept, two levels to report Ig/TCR profiles are discerned: the technical description of individual (multiplex) PCR reactions and the overall molecular conclusion for B and T cells. Collectively, the EuroClonality (BIOMED-2) guidelines and consensus reporting system should help to improve the general performance level of clonality assessment and interpretation, which will directly impact on routine clinical management (standardized best-practice) in patients with suspected lymphoproliferations.

Production d'IgG sialylées en CHO et impact sur leurs fonctions effectrices

La sialylation des N-glycanes du fragment Fc des immunogobulines G (IgG) est une modification peu fréquente des IgG humaines. Pourtant, elle est l’objet de beaucoup d’attention depuis que deux articles fondateurs ont été publiés, qui montrent l’un que la sialylation des IgG diminue leur capacité à déclencher la cytotoxicité cellulaire dépendant de l’anticorps (ADCC), et l’autre que les IgG sialylées en α2,6 seraient la fraction efficace des IgG intraveineuses (IgIV) anti-inflammatoires. Les anticorps monoclonaux thérapeutiques, qui sont le plus souvent des IgG recombinantes produites en culture de cellules de mammifère, connaissent depuis la fin des années 90 un succès et une croissance phénoménaux sur le marché pharmaceutique. La maîtrise de la N-glycosylation du Fc des IgG est une clé de l’efficacité des anticorps monoclonaux. Si les IgG sialylées sont des molécules peu fréquentes in vivo, elles sont très rares en culture cellulaire. Dans cette étude, nous avons développé une méthode de production d’IgG avec une sialylation de type humain en cellules CHO. Nous avons travaillé principalement sur la mise au point d’une stratégie de production d’IgG sialylées par co-expression transitoire d’une IgG1 avec la β1,4-galactosyltransférase I (β4GTI) et la β-galactoside-α2,6-sialyltransférase I (ST6GalI). Nous avons montré que cette méthode permettait d’enrichir l’IgG1 en glycane fucosylé di-galactosylé mono-α2,6-sialylé G2FS(6)1, qui est le glycane sialylé présent sur les IgG humaines. Nous avons ensuite adapté cette méthode à la production d’IgG présentant des profils de glycosylation riches en acides sialiques, riches en galactose terminal, et/ou appauvris en fucosylation. L’analyse des profils de glycosylation obtenus par la co-expression de diverses combinaisons enzymatiques avec l’IgG1 native ou une version mutante de l’IgG1 (F243A), a permis de discuter des influences respectives de la sous-galactosylation des IgG1 en CHO et des contraintes structurales du Fc dans la limitation de la sialylation des IgG en CHO. Nous avons ensuite utilisé les IgG1 produites avec différents profils de glycosylation afin d’évaluer l’impact de la sialylation α2,6 sur l’interaction de l’IgG avec le récepteur FcγRIIIa, principal récepteur impliqué dans la réponse ADCC. Nous avons montré que la sialylation α2,6 augmentait la stabilité du complexe formé par l’IgG avec le FcγRIIIa, mais que ce bénéfice n’était pas directement traduit par une augmentation de l’efficacité ADCC de l’anticorps. Enfin, nous avons débuté le développement d’une plateforme d’expression stable d’IgG sialylées compatible avec une production à l’échelle industrielle. Nous avons obtenu une lignée capable de produire des IgG enrichies en G2FS(6)1 à hauteur de 400 mg/L. Cette étude a contribué à une meilleure compréhension de l’impact de la sialylation sur les fonctions effectrices des IgG, et a permis d’augmenter la maîtrise des techniques de modulation du profil de glycosylation des IgG en culture cellulaire.

Evaluating the efficiency of community-based HIV testing and counseling strategies in sub-Saharan Africa

Thesis (Ph.D.)--University of Washington, 2016-08

The impact of the MARINET initiative on the development of Marine Renewable Energy

Marine Renewable Energy Conversion systems comprise wave energy and tidal stream converters as well as offshore-wind turbines for electrical generation. These technologies are currently at different stages of development but are mostly at the pre-commercial stage and require research to be undertaken at a series of scales along the path to commercialization. However each of these technologies also needs specific research infrastructures in order to conduct this research. The aim of the MARINET initiative is to coordinate research and development at all scales (small models through to prototype scales, from laboratories through to open sea tests) and to allow access for researchers and developers to infrastructures which are not available universally in Europe, including test facilities for components such as power take-off systems, grid integration, moorings and environmental monitoring so as to ensure a focusing of activities in this area. The initiative offers researchers and developers access to 45 research facilities as well as to the associated network of expertise at all scales in Offshore Marine Renewable Energy technology research and development. The aim of this paper is to present this MARINET initiative that was started in 2011, bringing together a network of 29 partners spread across twelve countries. Details of the MARINET Transnational Access (TA) program are presented, for which over 260 applications were received throughout the 5 official calls for proposals. In particular, statistics on applications and completed projects are presented which provide an overview of the global development progress of the different offshore renewable energy conversion technologies at a European level. It also provides a good overview of the current research activity, as well as evidence of the requirement for specialised research facilities, in this burgeoning field.

Computational modeling of laser-induced delamination testing of thin films

Thin film adhesion often determines microelectronic device reliability and it is therefore essential to have experimental techniques that accurately and efficiently characterize it. Laser-induced delamination is a novel technique that uses laser-generated stress waves to load thin films at high strain rates and extract the fracture toughness of the film/substrate interface. The effectiveness of the technique in measuring the interface properties of metallic films has been documented in previous studies. The objective of the current effort is to model the effect of residual stresses on the dynamic delamination of thin films. Residual stresses can be high enough to affect the crack advance and the mode mixity of the delimitation event, and must therefore be adequately modeled to make accurate and repeatable predictions of fracture toughness. The equivalent axial force and bending moment generated by the residual stresses are included in a dynamic, nonlinear finite element model of the delaminating film, and the impact of residual stresses on the final extent of the interfacial crack, the relative contribution of shear failure, and the deformed shape of the delaminated film is studied in detail. Another objective of the study is to develop techniques to address issues related to the testing of polymeric films. These type of films adhere well to silicon and the resulting crack advance is often much smaller than for metallic films, making the extraction of the interface fracture toughness more difficult. The use of an inertial layer which enhances the amount of kinetic energy trapped in the film and thus the crack advance is examined. It is determined that the inertial layer does improve the crack advance, although in a relatively limited fashion. The high interface toughness of polymer films often causes the film to fail cohesively when the crack front leaves the weakly bonded region and enters the strong interface. The use of a tapered pre-crack region that provides a more gradual transition to the strong interface is examined. The tapered triangular pre-crack geometry is found to be effective in reducing the stresses induced thereby making it an attractive option. We conclude by studying the impact of modifying the pre-crack geometry to enable the testing of multiple polymer films.

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.