456 research outputs found
The Effect of Vitamin D on Intestinal Inflammation and Faecal Microbiota in Patients with Ulcerative Colitis
No full textThis work was supported by the European Crohn’s and Colitis Organisation Fellowship awarded to Dr Mayur Garg, and St Mark’s Foundation Research Grant 2015 awarded to Prof Ailsa Hart and Dr Mayur Garg.Peer reviewe
Pause… breathe & stretch: creating an evidence-based yoga resource for mainstream schools
No full textPhysical activity (PA) benefits a range of neurological and mental health difficulties and is
also positively associated with positive outcomes on cognitive function and academic attainment in children and young people (YP). Despite these well-documented benefits of PA, current statistics reveal a concerning mental health landscape among children and YP. Recent UK figures from 2023 indicate that around 20% of 8–16-year-olds presented with a probable mental health disorder. This is a major public health concern as evidence suggests that mental health in YP is a predictor for physical health and learning outcomes, as well as mental wellbeing and life satisfaction in adulthood. Globally, about one billion children and YP attend school on any given day and spend a large amount of their waking week in schools. As such, schools provide an opportune setting for health promotion programmes. Increasing YP’s opportunities to be physically active in schools may be one method to target the mental health prevalence in children and YP.
A mode of PA that requires limited equipment and cost is yoga, which is a multi-component
and an inherently mindful practice. Yoga includes the use of physical movements and postures
combined with breathing, relaxation, and mindful techniques to improve self-regulation through awareness of bodily sensations and thoughts. There is emerging evidence that yoga can enhance physical and mental health in children and YP and may offer a complimentary or even preventative measure for mental wellbeing. However, as schools are complex systems, it is critical to explore if and how yoga could be offered as part of the school day.
The overall aim of this thesis was to make evidence-based recommendations for the
implementation of yoga in schools. To achieve this aim, the thesis had four objectives:
1. Scope the relationship between yoga programmes in schools and mental health and
cognitive outcomes (Chapter Two)
2. Identify the barriers and facilitators to implementing yoga in the school environment
(Chapter Three)
3. Develop a school-based yoga resource (Chapter Four)
4. Evaluate the feasibility of the resource (Chapter Five).
To achieve this aim, the Creating Active Schools (CAS) and Medical Research Council’s (MRC)
most recent guidance for developing and evaluating complex interventions was followed alongside behaviour change theory to create an accessible and low-cost school-based yoga programme (SBYP).
Chapter Two presents a scoping review of 59 studies synthesising the evidence of yoga in
schools and mental health and cognitive outcomes in neurotypical and neurodiverse youth (those who require additional support that is different from that received by those of the same age to ensure they benefit from education). Substantial evidence to support the use of SBYPs for the improvement of anxiety, self-concept, resilience, depression, self-esteem, subjective and psychological well-being, executive function, inhibition, working memory, attention and academic performance in neurotypical populations was found. Evidence to support SBYP in neurodiverse populations with improvements in self-concept, subjective well-being, executive function, academic performance, and attention was also found. The findings of this study provided a clear synthesis of the research field providing strong support for the use of SBYP for mental and cognitive health, as well as highlighting clear gaps in evidence between the two populations. Furthermore, only two studies in the review were conducted in the UK over 13 and 15 years ago. It was, therefore, difficult to conclude whether these programmes would be usable today or if programmes from other countries would be transferable to the UK context. Therefore, UK-specific research was required to address these uncertainties.
Chapter Three presents a qualitative study involving three key UK-based stakeholders and
drawing on behaviour change theory to identify the barriers and facilitators experienced by
stakeholders of yoga in schools and to gather recommendations for the development of future
interventions. The COM-B model was used to provide an understanding of the capabilities,
opportunities, and motivations experienced by providers and users of yoga in schools. Therefore, to address the study’s aim and to aid in the development of a future SBYP, focus groups were conducted. Eight secondary schoolteachers participated in one of three focus groups; eight yoga instructors in one of two focus groups; and seven school students (12-15 years old) in one of two focus groups. All but one of the study’s participants (n=22) were female. One of the main findings from the study was that schoolteachers have used yoga in the school environment previously but lack the psychological capability of knowledge and understanding of yoga to feel confident delivering it. Furthermore, all stakeholders stipulated that the classroom can be an inappropriate environment to host traditional types of yoga. Other barriers discussed were limited resources (time, space, and funding), and negative perceptions and beliefs from school staff and students. It was suggested that through the provision of physical opportunities, such as the training of school staff, and by creating a classroom-friendly resource, SBYPs may be more acceptable in the future. This study provided
crucial UK-focused insights that could be used to facilitate the development and subsequent
evaluation of a new SBYP.
Chapter Four details the development of the key output of this thesis; a safe, age
appropriate, and low-cost classroom-based yoga resource. Using the MRC guidance, The Behaviour Change Wheel (BCW), findings from focus groups, and additional input from experts in other professional fields, a new SBYP, ‘PAUSE… Breath & Stretch’, was developed. PAUSE is a collection of four main components including: visual classroom poster with yoga movements and breathing techniques; an additional guidance booklet and online learning HUB for teachers and a 2.5-hour teacher training session. Experts from numerous other professional fields reviewed and provided additional input to ensure the resource was robust and safe for the target population. For teachers to effectively teach their students, building teacher self-efficacy within education programmes is critical and intervention success may be dependent on it. Therefore, these resources were developed to be educational for schoolteachers as well as to provide a responsive toolkit to use during class time. To facilitate schoolteachers using the resource, each component included behaviour change techniques (BCT) designed to enable behaviour change.
Following the MRC guidance for developing complex interventions, the next stage was to
understand the feasibility of the intervention. Chapter Five therefore presents a feasibility study of PAUSE with 3 local secondary schools. This study explored schoolteacher knowledge and self-efficacy before and after attending the resource training session and at the end of the intervention duration. The study’s four main objectives included: understand how teachers use the resource week to week; assess the fidelity, usability and feasibility of the SBYP with schoolteachers; assess the acceptability and impact of the SBYP with schoolteachers and YP and; provide recommendations for refining the programme based on schoolteachers and YP’s experiences. A mixed methods design was adopted, which involved 8 secondary school teachers (from the Wellbeing, English, Food and Textiles and Information Technology departments) participating from 3 local schools. Teachers were asked to report on self-efficacy pre and post training sessions and at the end of the study. Researcher observations of the programme’s fidelity to ensure safety and provide additional feedback were conducted. Teachers also recorded weekly diaries to measure resource usage. Lastly, students and
teachers completed questionnaires at the end of the study to measure enjoyment and acceptability as well as provide qualitative feedback for resource refinements.
The results from this study indicated that the resources improved teachers’ confidence to deliver yoga with most stating they would continue to use PAUSE in the classroom. Furthermore, both students and teachers reported benefits after using PAUSE and that the resources were well designed and enjoyable. The findings inferred that the data collection methodology would need to be reviewed in further trials to support participation. However, overall, findings indicated that PAUSE has the potential to be integrated successfully into secondary schools.
This thesis has several important implications for future research and practice regarding the
promotion of yoga in schools. Firstly, this body of research adds to the evidence base supporting the use of yoga in schools to support children’s and YP’s wellbeing. Secondly, this thesis provides clear recommendations for researchers to develop and enhance future SBYPs.
Thirdly, a new feasible and acceptable yoga resource for schools in the UK to use was
developed using intervention frameworks and behaviour change theory. There are now clear
pathways for PAUSE programme refinement to improve the resources usability. The next step
should include a larger trial to understand the transferability of PAUSE to other areas within the UK and across a broader range of ages. Further, programme theory should be developed to understand how PAUSE could improve mental health and physical activity measures
Supporting vulnerable adults : citizenship, capacity, choice
No full textThe author examines theories of citizenship, capacity and choice when supporting vulnerable adults and uses the impact of the early implementation of the Adult Support and Protection (Scotland) Act 2007 as a model. Her main themes are the extent of the reach of the state and the appropriateness of this with; a discussion of the tension between autonomy and protection and consideration of whether or not vulnerability impacts on the human rights of individuals. Concepts of harm and abuse are explored. Key questions answered include: does diminished intellectual capacity limit your rights as a citizen? Does vulnerability, and being at risk of harm or abuse, limit capacity? The author also explores whether the introduction of such legislation compromises individuals’ free will and choice. The book bases itself around the Scottish legislation and draws on the emerging results of empirical research undertaken by the author over the first two years following its implementation, the first of its kind in the UK. This provides a unique focus for the central debate on autonomy and protection and the link to citizenship and capacity. Supporting Vulnerable Adults provides an excellent overview of the tensions inherent in these policies for students and for those health and social care workers, policy makers and other practitioners whose work involves the vulnerable. Ailsa Stewart is a Lecturer in the Glasgow School of Social Work, a joint school of the Universities of Glasgow and Strathclyde
Diet-microbiome-metabolomic interactions in inflammatory bowel disease and comparing patients with and without a colon
No full textThe composition and function of the gut microbiome might be distorted in individuals with Inflammatory bowel disease. Diet plays a role in shaping the gut microbiome. Refractory ulcerative colitis (UC) can result in ileal anal pouch anastomosis (IPAA), however, more than half of these patients develop pouchitis.
This thesis aims to investigate differences in microbiome and metabolome composition between study cohorts, identify microbiome-metabolome interactions and explore the influence of dietary compounds on these interactions.
148 participants were recruited and categorised: pouches made for UC (PUC), pouches made for familial adenomatous polyposis (PFAP) and UC with an intact colon (UC). Dietary data, faecal samples, blood, and urine were collected. Biofluids analysis included 16S rRNA gene sequencing, nuclear magnetic resonance, and liquid chromatography-mass spectrometry for short chain fatty acid (SCFA), bile acid and tryptophan metabolites quantification.
Multivariate analysis identified a discriminatory microbiome and metabolites between UC (intact colon) and PUC (UC no colon). The PUC group ingest less fibre, fruit, and vegetables and had lower scores of adherences to the WHO dietary guidelines compared with UC group. PUC show reduced microbiome diversity, reduced abundance of Firmicutes, Ruminococcaceae, Lachnospiraceae, Faecalibacterium, Roseburia, Alistipes and lower concentrations of propionate and butyrate, and higher abundance of Escherichia coli, Enterobacteriaceae and Fusobacterium compared to UC. Elevated serum neopterin, kynurenine and cholic acid were found in PUC compared with UC.
Starch consumption positively correlated with neopterin, and Proteobacteria in PUC and protein intake positively correlated with alpha diversity, Firmicutes, Faecalibacterium and Rumminococcus. Adherence to the WHO dietary guidelines correlated with microbiome diversity and SCFA. Correlation matrix adjusted for false discovery rate showed differentiated diet-microbiome-metabolome communication links between PUC and UC.
These data suggests that pouch metabolic profile can be clearly differentiated from the colon and targeting the gut microbiome through diet may have therapeutic potential for pouch patients.Open Acces
Advancing minimally invasive aspects of flexible gastrointestinal endoscopy
No full textThe technological developments seen in recent years have facilitated remarkable progress in the field of flexible gastrointestinal (GI) endoscopy. Smaller high-resolution charge-coupled devices (CCDs) have facilitated the manufacture of ultrathin (UT) (<6mm) endoscopes, while the introduction of device assisted enteroscopy (balloon-assisted and spiral enteroscopy) has allowed endoscopists to access the deep small bowel (SB) without the need for recourse to major surgery. Furthermore, the application of double-balloon colonoscopy (DBC) has shown promise to improve outcomes in patients with ‘technically difficult’ colons. Although these 3 types of innovative endoscopic technologies all share the potential capacity to enhance minimally invasive patient care, research into their optimal role and effectiveness (particularly within UK clinical practice) remains limited.
This thesis has examined the potential role of this selection of advanced flexible GI endoscopic technologies for the enhancement of minimally invasive patient care. The first study evaluated transnasal upper GI endoscopy in the UK and confirmed that within this clinical paradigm, transnasal endoscopy using UT endoscopes, is a feasible, effective and more acceptable alternative to patients than conventional oral upper GI endoscopy. The next series of studies were dedicated to device assisted enteroscopy (DBE in particular) and showed that DBE is capable of providing a safe and effective, minimally invasive alternative to major surgery in selected cases. A comparison of spiral enteroscopy as an alternative to DBE, showed that spiral enteroscopy (in its current, manual form), appears to be inferior to DBE in its ability to facilitate deep enteroscopy. The final study evaluated technically difficult colonoscopy and included the development and validation of a score for technical difficulty which may in the future be applied to routine clinical practice. This study also highlighted the usefulness of DBC as a potentially more effective tool than conventional colonoscopy for technically difficult cases.Imperial Users Onl
Perianal fistula: improving diagnosis and understanding
No full textPerianal sepsis is poorly understood both in the literature and by patients and clinicians. This limits our ability to develop a clinical trial which would help determine best practice in perianal Crohn’s disease. This thesis aims to establish the necessary background for a clinical trial in perianal Crohn’s disease, to develop an improved understanding of the natural history of perianal sepsis and explores the use of novel imaging technology to improve evaluation, understanding and communication as to the nature of perianal fistulas.
(A) Epidemiology of perianal sepsis – understanding the origin
Perianal abscesses and fistulas are common and represent a significant caseload within the NHS. Current understanding of the relationship between abscess and fistula comes from often old, mostly single institution studies. The same can be said about the natural history of perianal fistulising Crohn’s disease, where once again much of the epidemiological knowledge is derived from (sometimes historic) long-term population cohort studies, which are often single centre studies lacking therefore external validity and often lack the diversity of population.
Using Hospital Episode Statistics (HES) and a local hospital database we have established a new estimate for the rate of fistula formation following perianal abscess, using national data over a fifteen-year period, and quantified independent predictors of fistula following abscess which include inflammatory bowel disease, female gender and the location of the anorectal abscess.
(B) Assessing outcomes for perianal Crohn’s disease
The lack of objective assessment tools for determining outcome following treatment of Crohn’s anal fistula means that investigators often use multiple outcome measures, that these varies between studies, and that new measures are often created. This thesis describes the creation of a core outcome set for fistulising Crohn’s disease. Core outcome sets are groups of outcome measures that have been identified through a systemic review and a Delphi process, and ratified by key stakeholders, which fundamentally includes patients. They are the outcomes which are thought most valuable and should, at the minimum, be reported in every study of that condition. We have developed an eight-domain outcome set for fistulising Crohn’s disease after surveying 187 surgeons, gastroenterologists, nurses, radiologists and patients from across the UK.
(C) Creating a novel objective outcome measure
There is no standardized, reproducible measure for clinicians to use to assess the effect of medical treatment of Crohn’s anal fistula. Currently the success of treatment is subjectively assessed clinically or radiologically. A local pilot study of specialist GI radiologist review of MRI scans before and after treatment with infliximab demonstrated that the radiologists were only in universal agreement on the status of a fistula around three-quarters of the time. This thesis has created the necessary background information to create a robust activity-based MRI score based on fistula volume calculation. The aim is that it will both serve as an objective adjunct to decisional algorithms, which also include clinical score and fistula anatomy, and to allow the development of predictive factors based on an objective assessment of response to treatment.
(D) Improved evaluation, understanding and communication of the nature of perianal fistulas.
Perianal Crohn’s fistulas are complex and recurrence/reoperation rates are high. With each surgical intervention, scar tissue forms, distorting anatomy. Whilst conventional 2D pelvic MRI is effective at defining anatomy and guiding surgery, it remains difficult for surgeons to conceptualise complex fistula. Judicious surgery relies on knowledge of exact fistula morphology in relation to the anal sphincter; without this accurate appreciation of the anatomy, injudicious, imprecise or aggressive surgery can result in incontinence and/or recurrence.
This thesis describes a variety of different media of 3D reconstruction of the anorectum including the sphincter and the fistula tract(s), including the creation of 3D static images, digital animations, augmented reality platforms and 3D printed models. The 3D reconstructions have been created with the aim of improving conceptualization for trainees, patient understanding and surgical decision-making through the 3D modelling of perianal Crohn’s disease.Open Acces
Optimising the medical management of ileoanal pouch related complications and discovering novel therapeutic avenues through metabonomic profiling
No full textRestorative proctocolectomy is considered a quality of life surgical procedure in patients with ulcerative colitis who fail to respond to conventional medical therapies and in some patients with Familial Adenomatous Polyposis.
This thesis explores the current management of chronic primary idiopathic pouchitis through a systematic review and meta-analysis. Following this review I have explored the clinical utility of antibiotics and biologics in a cohort of patients with both chronic primary idiopathic pouchitis and pre-pouch ileitis. I have found that the treatment options for chronic pouchitis and pre-pouch ileitis are limited and that long-term treatments such as antibiotics and biologics are ineffective in a significant proportion of patients often leading to a permanent ileostomy.
I have also explored the effect of some non-medical therapies including biofeedback and the Renew® anal insert for incontinence and evacuatory problems and have shown that they may be a useful adjunct in the treatment of these pouch related complications.
The second focus of the thesis is to try and understand the mechanisms that drive the development of pouchitis. I undertook a systematic review to explore what was already known about the gut microbiota and its role in health and disease of the pouch. I then utilised next generation sequencing technologies to include metataxonomics, nuclear magnetic resonance and mass-spectrometry gas chromatography to link the gut microbiota with the metabolic signatures in serum, urine, faeces and mucosal tissue. I used these techniques to compare patients with pouchitis against healthy controls and patients with Familial Adenomatous Polyposis.
These studies have highlighted the importance of the Firmicutes phylum and their role in the production of short chain fatty acids. I have found that a depletion in short chain fatty acids may contribute to the development of pouchitis. Future work may build on methods to increase short chain fatty acid delivery to the pouch through methods such as dietary interventions, distal feeding prior to continuity surgery or direct short chain fatty acid supplementation delivered topically to the pouch.Open Acces
Endoscopic excision of pre-cancerous complex colon polyps: improving outcomes and developing new endoscopic instruments/techniques
No full textWith improved access to colonoscopy services and the recent advent of the National Bowel Cancer Screening Programme, the number of complex polypectomies performed in the United Kingdom has increased significantly. Almost all complex pre-cancerous colon polyps can now be resected endoscopically, preceded by a thorough patient preparation and a careful lesion assessment. This thesis investigates the endoscopic management of complex colon polyps, including modifications to improve existing polypectomy techniques and the development of new endoscopic platforms and instruments. The thesis initially examines existing practice and includes a prospective audit of the short and long-term outcomes of piecemeal Endoscopic Mucosal resection (p-EMR) technique at a tertiary endoscopic centre. Several salvage modifications to the p-EMR technique, such as the addition of a cautious application of ablative modalities, are described to manage complex fibrotic
polyps. Post-polypectomy bleeding is the most common serious p-EMR complication and factors associated with bleeding risk along with the preclinical use of a new potential haemostatic and sealing agent are investigated.
En-bloc excision of complex colon polyps to ensure complete excision remains an important goal for the therapeutic endoscopist. A main body of the work in this thesis describes the development of a new device for endoscopic submucosal dissection (ESD) incorporating novel design and electrosurgical properties. The development of combined endoscopic/surgical platform is also described to improve access and facilitate the radical treatment of complex rectal polyps. Finally, to approach the management of complex colorectal polyps in a “holistic way”, a clinical service enhancement, the polyp multi-disciplinary meeting has been initiated and evaluated.Open Acces
Clinical, microbiological and metabolic features of patients with Crohn’s disease and intestinal failure
No full textThe pathogenesis of inflammatory bowel disease (IBD) involves the interaction between an individual’s genes, gut microbiota and environmental factors. The Crohn’s disease (CD) microbiome is characterised by a reduction in Firmicutes and an increase in Proteobacteria. The CD metabonome consistently shows a reduction in secondary bile acids (SBAs) and an increase in stool and serum primary bile acids (PBAs). Very few studies have examined the multiomic profile in patients with Crohn’s disease-intestinal failure (CD-IF).
I present two retrospective case-control studies and one prospective multiomics study. I identified the following risk factors for the development of IF in patients with CD: female gender, ileocolonic involvement, penetrating disease and non-exposure to biologic medications. Patients with CD-IF are twice as likely to be in remission compared to patients with CD (without IF) and the strongest factor associated with active disease, was the presence of a surgical anastomosis to colon in continuity compared to those with an end enterostomy.
For the multiomics study, stool, serum and urine samples from CD-IF patients were analysed. 16s rRNA sequencing demonstrated an expansion of aerotolerant and facultative anaerobic microorganisms, with a decrease in obligate anaerobes; the CD-IF gut luminal environment has a higher oxygen content. Metabonomic profiling showed a higher serum and faecal cholic acid and chenodeoxycholic acid in active disease compared to remission; this is in keeping with the theory that loss of bowel length leads to loss of farnesoid X receptor (FXR) and Fibroblast growth factor 19 (FGF19) and an increase in hepatic synthesis of PBAs. Expectedly, an almost absence of serum SBAs was observed in CD-IF. Multiomics changes seen with active disease could be a cause or a consequence of disease activity, or secondary to the anatomic changes or changes in diet and parenteral nutrition.
Open Acces
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