No description available.

This critical appraisal provides an overview of five published research papers that collectively make an original and significant contribution to the patients' perspective of outcome measurement after articular cartilage repair (ACR) of the knee. The work represents the evolution and development of the author's coherent research programme in this field over a period of 8 years. In 2003 the author conducted a comparative analysis of rehabilitative guidelines of 11 international ACR centres that identified large variations in practice. This work was significant as it resulted in the publication of the first evaluation of the evidence base for postoperative care after autologous chondrocyte implantation. The evidence base for postoperative care that was elucidated in this work served to uphold the biomedical model as being the dominant paradigm. Concurrently, the concept of patient-centred medicine was being actively promoted within primary~re in the UK and patient-reported outcomes (PRO) were being adopted as primary endpoints in new ACR clinical trials across Europe and in the USA. This gap between PRO evidence and practice prompted this researcher to evaluate patient's and orthopaedic surgeon's perspectives of the rehabilitation process using a mixed methods approach incorporating grounded theory and content analysis. These inductive pilot works were noteworthy as they indicated that not only were ACR service users willing to allow their views to be captured for research purposes but they were prepared to do so using web-based tools. Two key research questions emerged: what are the symptoms and disabilities most important to ACR patients and are current PRO measures capturing this information? To explore these questions, two commonly used knee-specific PRO measures were evaluated for item importance to ACRpatients from an online health community (OHC) using a clinical impact methodology. The emergent pattern was one of function in sports and recreation activities being important for people who had undergone ACR, more than an anterior cruciate ligament reconstruction (ACLR) cohort from the same OHC knee population. This work led to the formulation of a further research question: what is the postoperative physical activity profile of this OHC ACR population? The Tegner activity scale (TAS) is frequently used to assess physical activity level within ACR studies but this use had not previously been evaluated. The first systematic review of the TAS for ACR raised important methodological issues relating to the use and reporting of the outcome. The key findings from this review were utilised by the researcher to inform the reporting of cross-sectional TAS data for the ACR and ACLR groups from this OHC. The postoperative physical activity profile of this ACR population was one where activity levels increased with postoperative time but remained lower than expected compared with then-current clinical and normative data. The main body of this critical appraisal reviews and evaluates the papers within this research programme and the conceptual links between them. The methodological approaches used in the studies are reflected upon and the significance of the work and future directions for research are discussed.

Campath-IH is a humanised antibody which has entered clinical trials for both rheumatoid arthritis and lymphoma. The clinical trial material was expressed in, and isolated from, Chinese Hamster Ovary (CHO) cells. It is proposed that variations observed in preliminary antibody-dependent cellular-cytotoxicity (ADCC) assays, in which human mononuclear cells were used as effectors and CHO Campath-1H was compared with Campath-IH prepared from rat YO cells, are correlated to host and/or culture condition related changes in antibody N-linked glycosylation. To investigate the hypothesis, CHO Campath-1H mediated assays including ADCC, monocyte mediated cytostasis, antigen engagement and subsequent crosslinking were analysed as was the antibody N-linked carbohydrate composition. The total removal of the carbohydrate ablated ADCC activity, decreased the cytostatic effect seen with intact antibody but did not alter antigen binding. Campath-IH cDNA was recloned into Celltech Glutamine Synthetase expression vectors and transfected into mouse NSO cells for antibody isolation. Comparisons of antibody made during NSO Campath-1H development from clone to fermentor and between CHO and YO Campath-1H with the various stages of NSO antibody revealed variations in both assay response and N-linked carbohydrate structure. The glycosylphophatidylinositol (GPI)-anchored antigen CDw52 recognised by Campath-1H was isolated from Wien 133 B cell cDNA by polymerase chain reaction and sequenced in preparation for expression cloning. Two sequence variants of the antigen were present in the cDNA, differing by two amino acids outside of the antigen coding region but, at a site controlling GPI-anchor attachment. Both cDNAs were expressed in CHO cell lines for comparison but only one could be detected by Campath-IH. In vivo and in vitro studies on the two forms are described. Chimeric forms of the T cell antigen CD4, linked to either of the CDw52 antigen GPI attachment sequences, were shown to be both expressed in CHO cells and detected by anti-CD4 antibodies.

Myotonic Dystrophy (DM) is the most common form of muscular dystrophy in adults with an occurrence of about 1 in 8000 people. DM type 1 (DM1) is caused an expanded CTG triplet repeat within the 3' -untranslated region (3' -UTR) of the Myotonic Dystrophy protein kinase (DMPK) gene, while type 2 (DM2) is caused by an expanded CCTG repeat in intron I of the Zinc Finger 9 gene (ZNG9) gene. In DM, the mutant DMPK transcripts are trapped within nucleus and fOlm ribonuclear foci which interact with alternative splicing factors including MBNL and CUG-BP proteins. The abnormal levels of splicing factors lead to splicing defects contributing to the major symptoms of DM. At present, there is no treatment for DM. This study developed a series of screening and validation assays targeting different stages of DM pathophysiology. The subject of this thesis was to identify compounds and small molecules which are able to rescue molecular features of DM as a stat1ing point of therapeutic dmg development for DM. In this study, I have developed a high-throughput screen assay using an in situ hybridization protocol for compounds intenupting nuclear foci in DM patient cell lines. Enzo® Kinase, Phosphatase Inhibitor and NCGC Phatmaceutical Libraries were screened, and four compounds, Hypericin, Ro 31-8220, Gemcitabine and Chromomycin A3, which reduce or remove nuclear foci in DM cells, have been identified. Cyototoxic activities of hit compounds and their effects on molecular features of DM were examined with a series of validation assays. This study demonstrates that Ro 31-8220 alters the ratio of expansion allele of DMPK in the nucleus; Ro 31-8220 and Chromomycin A3 affect alternative splicing of SERCAl in some DMl cell lines, and eliminate or reduce nuclear MBNLl protein foci. The hit compounds identified can be a stat1ing point for dmg development for DM therapy.

Osteoporosis IS a common condition of the elderly population. No study has investigated factors that may influence the extent of geographical variation of osteoporosis diagnosis. Objectives This study aims to quantify the relationship between an individual's bone mineral density, osteoporosis and fragility fracture status and the distance between the dual energy X-ray absorptiometry (DXA) scanner and their place of residence and general practice. This study also aims to quantify the extent to which osteoporosis is diagnosed in the study region's 50-75 years of age population. Methods Data was collated from the DXA scanner of the Royal Lancaster Infirmary. Generalized linear modelling was used to investigate the factors that influence the following: osteoporosis status, previous fragility fracture status, lumbar spine T-score, femoral neck T-score and probability of undergoing a DXA scan. The proportion of osteoporotic individuals aged 50-75 years that have been diagnosed with a DXA scan was estimated by dividing the number of osteoporotic individuals aged 50-75 that were diagnosed with a DXA scan by the estimated number of osteoporotic individuals in the study region.

No description available.

The development and use of an unstructured health diary to describe the experiences of patients with low back pain, and its po'tential to predict outcome in new episodes of low back pain presenting in primary care Background: Back pain is among the most common syndromes presenting in primary cafe in the United Kingdom. It has proved to be very costly and complex to treat Recent advances in the knowledge base of the natural history of the condition and the ability to predict which patients are most at risk of not recovering have had little effect in reducing the disability associated with it Recent advances in and the recognition ofqualitative research methods have provided an alternate research design to gain rich insights into how low back pain affects patients. Aims: The aim of this study was to develop an unstructured health diary, describe how back pain affects patients over a one week period from diary entries, and explore the diary's potential usefulness in predicting outcome in patients with new episodes of low back pain presenting in primary care. Methods: Following recruitment into the study, patients were invited to record their experiences of low back pain in an unstructured diary each day during the first week ofthe episode. Measures ofdisability and anxiety/depression were collected at presentation, two weeks post-presentation and six weeks postpresentation, using well validated outcome measures; Roland and Morris Disability Questionnaire (RMDQ) and the Hospital Anxiety and Depression Questionnaire (HAD). Patients were categorised at six weeks into one of three recovery groups; fully recovered (FR), partly recovered (PR) or not recovered (NR) based onRMDQ scores. Diary data was analysed inductively and thematically using well-established conventions for ensuring that the process was grounded in patient data. PreliminaIy and secondary diary data analysis was assisted by the qualitative software package, ATLAS. Diary data was then used to describe the rich accounts of patients experiences of their low back pain, and then tested against recovery group data to search for differences in the frequency of references to individual themes. Aphenomenological framework guided the collection and analysis ofdiary data Findings: Eighty five full data sets (completed questionnaires and diaries) were included in the analysis. The relationship between recovery groups at six weeks and all other quantitative data was analysed. HAD scores and duration of symptoms were the only two variables found to be related to recovery groups. A total of49 preliminaly themes were identified from the diary data during the initial analysis. Ofthese, three (Emotional, Physical and Functional) were categorised as major themes based on the number of times they were refetred to in the diary text. Some individual themes with commonality of meaning were merged to create much broader major themes ('Illness narrative', 'Coping strategies' and 'Relationships & roles~. The frequency of references made to each theme was recorded and tested against recovery groups. Patients who ended up in the FR group made significantly fewer references to negative physical, negative functional and illness narrative issues. This group also made significantly more reference to negative emotional, coping strategies and relationships & roles issues. Rich accounts of how their low back pain had affected them over a one week period also emerged from the diary data Discussion and Conclusions: The findings from the quantitative data support existing knowledge about low back pain; outcomes are not affected by age or gender for example, but are related to anxiety/depression and duration of symptoms. Diary data from patients who end up fully recovering is different to that from those who don't recover. It is proposed that patients who make frequent reference to negative emotional issues in a diary may be 'unburdening' themselves of negative emotions, making the diary a potentially therapeutic tool. It is also proposed that those patients who fully recover make more frequent reference to coping strategies and relationship & roles issues. This may be highlighting that they have better skills with which to cope with low back pain and are more readily given permission to enter the 'sick role' by family members. Temporary exclusion from responsibilities is thought to be a precursor to recovery from illness. These findings are encouraging as certain aspects of qualitative diary data appear to have potential in improving the ability to predict good outcome from low back pain six weeks after onset Further exploration ofboth the predictive and therapeutic potential of diary data is recommended.

The projects described in this thesis 'investigate the psychophysical properties and .neural correlates of cutaneous and muscle pain in healthy volunteers and in a small patient group. A total of four experiments are reported; two in healthy volunteers and two in patients with lateral epicondylitis The first experiment investigated psychophysical differences between intradermal, subcutaneous and intramuscular pain induced by hypertonic saline injections. The pain descriptors used by the subjects were d~fferent between the three injections. The profile of pain, including the intensity and time course and response to each single injection, was similar between intradermal and intramuscular injections whereas results were inconsistent with subcutaneous injections. The second study, employing the methods developed in the first, used functional magnetic resonance imaging (fMRI) of the brain to undertake a comparison of the neural activation patterns associated with intradermal and intramuscular pain.

Osteoarthritis (OA) is the most common arthritic condition. It is a debilitating disease of the joints, characterised by articular cartilage degradation. Effective, disease-modifying drugs are not currently available for the treatment ofOA. Matrix metalloproteinase (MMP) and a disintegrin, a metalloproteinase and a thrombospondin motif (ADAMTS) proteases are capable of degrading all components of the extracellular matrix (ECM). Their activities are normally balanced by tissue inhibitors of metalloproteinases (TIMPs). Together MMPs, ADAMTSs and TIMPs regulate the normal turnover of extracellular matrix. Unbalanced proteolysis of the cartilage ECM is central to the current dogma of OA pathogenesis. This thesis profiled the expression of all human MMP, ADAMTS and TIMP genes in synovium and cartilage tissues, comparing OA and control samples. This has provided a comprehensive picture of proteolysis in the joint. Using TaqMan® low-density array technology (TLDA), these samples were then profiled for the expression of 268 cytokines and their receptors, to delineate important and novel factors involved in the control ofmetalloproteinase expression in OA. In OA synovium, the genes with the most significantly increased expression were MMP28, ADAMTSJ6, ADAMTS17 and TIMP2. MMPJO, ADAMTS4 and ADAMTS9 were the genes with the most significantly decreased expression. TLDA data revealed a potential increase in TNFSFll signalling in OA cartilage. Recombinant human TNFSFll (rhTNFSFll) stimulation assays were carried out in chondrocytes. rhTNFSFll regulated the expression of TNFRSFllB, RANTES, Collagen XAJ, iNOS, NFATc1, TRAF6 and c-fos. Interestingly, rhTNFSFll also increased the expression of MMPI, MMP3, and MMPJ3 in primary chondrocytes and MMP13 and ADAMTSJ6 in C281I2 immortalised chondrocytes. rhTNFSFll stimulation did not activate p50 or p65 NF-KB subunits or MAPKs in primary chondrocytes. TNFSFll is able to signal in primary chondrocytes, however, the pathway and mechanism remains to be clarified.

Wntl Inducible Secreted Protein 3 (WISP-3/CCN6) is a member of the CCN (Cysteine rich 61/Connective tissue Growth Factor/Nephroblastoma Overexpressed) family of matricellular proteins. WISP-3/CCN6 is mutated in Progressive Pseudorheumatoid Dysplasia (pPRD), a rare disease of articular cartilage degeneration. The expression of WISP-3/CCN6 in osteoarthritis at the mRNA and protein level was investigated. To determine the role of WISP-3/CCN6 in chondrocyte biology the WISP-3/CCN6 gene was stably transfected into immortalised chondrocytic (C-281I2) cells. The effect of stable WISP-3/CCN6 over-expression on metalloproteinase gene expression was investigated.. The expression of WISP-3/CCN6 mRNA was significantly up-regulated in osteoarthritic cartilage extracts compared to post.-mortem .controls. Immunohistochemistry of osteoarthritic cartilage sections revealed that WISP-3/CCN6 protein expression was upregulated in areas of cartilage damage and was often localised to the pericellular matrix surrounding chondrocytes. The steady state mRNA levels for the aggrecanases ADAMTSI, ADAMTS4 and in particular, ADAMTS5 were significantly lower in clonal C-28/I2 cell lines stably over-expressing WISP-3/CCN6 compared to controls, while MMPIO mRNA was significantly up-regulated. Treatment with lithium chloride, which can mimic activation of canonical \Vnt signalling, led to a de-repression of ADAMTS5 mRNA and enhanced up-regulation ofMMPIO in the WISP-3/CCN6 clones. Treatment with the cytokines Interleukin In and Oncostatin M up-regulated ADAMTS5 mRNA and .down-regulated MMPI0 mRNA in the WISP-3/CCN6 clones. These data demonstrate that WISP-3/CCN6 may repress ADAMTS5 mRNA expression in chondrocytic cells by inhibiting canonical Wnt signalling. In addition, inflammatory pathways may oppose WISP-3/CCN6 activity. WISP-3/CCN6 may therefore be protective against cartilage degradation and could be up-regulated in osteoarthritis as a protective or reparative response. The WISP-3/CCN6 mediated up-regulation ofMMPlO also apparently involves Wnt signalling suggesting alternative mechanisms of WISP3/ CCN6 interaction with this signalling pathway. These divergent responses suggest that the role ofWISP-3/CCN6 is context dependent.