Vulvar Vestibulitis Syndrome (VVS) is a chronic inflammatory condition affecting the vestibular epithelium of the vulva, which has been estimated to affect 15% of the female population (Goetsch, 1991). Many studies have attempted unsuccessfully, to elucidate the cause of this condition, and few advancesh ave beenm adet owards the understandingo f the associatedin flammatory responseT. he initial, and principal aim of this investigation was to characterise normal vestibular epithelium using electron microscopy. The ultrastructural characteristics of normal vestibular epithelium were compared with closely related epithelia, and with vestibular epithelia from VVS patients. Other aims included an investigation of the epidemiological characteristics of VVS; an assessmenot f vulvar sensitivity over several months, and an evaluation of ketoconazole as a non-invasive treatment for VVS. Transmission electron microscopy, confirmed that vestibular epithelium was non-keratinised, and closely resembled oral and vaginal mucosae. Intermediate cells were predominant, characterised by pale staining cytokeratin filaments and glycogen deposits. Leukocytes were present in small numbers. Using SEM, superficial cells were characterised by an interlacing network of rounded microridges. By comparison, vestibular epithelium from VVS patients demonstrated the presence of numerous, intensely staining, apoptotic-like cells. These cells were associated with membrane bound cytoplasmic lobules and leukocytes of varying types. A similar ultrastructural appearance was observed in post-treatment biopsies. However, apoptotic-like cells appeared heavily vacuolated, and the number of cytoplasmic bodies present was increased. Mature plasma cells, NK-like cells and macrophages were common in the dermis. Leukocyte counts, demonstrated a significantly greater number of leukocytes in the VVS biopsies compared with the controls, however, there was no statistical difference in the number of leukocytes in pre and post-treatment samples. The presence of apoptotic-like cells accompanied by a significant inflammatory cell infiltrate, may suggest a cell signalling defect, resulting in the pain associatedw ith VVS. Treatment with ketoconazolec ream was found to have very little effect on either the number of leukocytes or the frequency of apoptotic-like cells as quantified using image analysis. The epidemiological characteristics of VVS patients were investigated using a structured questionnaire interview. All of the VVS patients interviewed fulfilled the diagnostic criteria established by Friedrich (1987), and epidemiological findings were generally consistent with previous epidemiological reports. Unique to this study, HPV infections were rare, however recurrent Candida infections and cystitis were commonly reported. The 'Vulvar Algesiometer', was designed and developed in Plymouth, to assist diagnosis and assessmenot f VVS patients. Using this equipment, VVS patients demonstrate heightened vestibular sensitivity when compared with control patients. The utilisation of a pain measuring device the 'Vulvar Algesiometer', in accordance with the questionnaire and ultrastructural investigation has formed a novel and balanced approach to the study of VVS. This study has demonstrated several distinct features of VVS which have not previously been described, features which may be important in elucidating the cause of this condition. These features centre around the presence of apoptotic-like cells and associated cytoplasmic bodies which have not previously been described in association with VVS.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Science in Medicine in the branch of Anaesthesiology Johannesburg, 2014 / BACKGROUND: Chronic pain is a biopsychosocial phenomenon that can have a profound impact on people’s lives. Internationally, chronic pain is being recognised as a health priority. South Africa is a developing country with limited resources that are directed at catering for a growing population where life threatening conditions like Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS), violent crimes, and poverty predominate. Auditing the Helen Joseph Hospital Pain Management Unit (HJHPMU) is a step towards addressing the paucity of epidemiological data on chronic pain in South Africa. Clinical records are a basic clinical tool that also serves as a medicolegal document. It is essential that these records are legible and complete. AIM: The aim of this study was to describe the profile of chronic pain patients at the HJHPMU for 2011 and to determine the adequacy of record keeping. METHODOLOGY: A retrospective, contextual, descriptive study design was utilised. A consecutive sampling method was used and the study sample included the HJHPMU database and all files of adult patients that attended the HJHPMU during the period January 2011 to December 2011. Patient files were excluded from the audit if insufficient data were found. Descriptive statistics were used to analyse the data obtained during the study. Frequencies and percentages have been reported. A Chi-­‐squared test was utilised to analyse any association between gender and type of pain. RESULTS: There were 475 patients in the HJHPMU database for the year 2011 and 190 of these patients were excluded from the study due to illegible handwriting, duplication in the HJHPMU database, missing data such as no hospital number recorded, no initials to a surname, or the file not found. This resulted in a study sample of 285 patients. The HJHPMU had 215 (75,44%) pre-­‐existing patients and 70 (24,56%) new patients during the year 2011. The preponderance of patients were in the 41-­‐60 year age group, with 146 (51,23%) patients presenting in this age group. Of the 285 patients in the study, 91 (31,93%) patients were male and 194 (68,07%) were female. The most common complaint was of lower back pain (LBP). There were 97 (34,04%) patients with a diagnosis of spinal pain and 59 (20,70%) with Failed Back Surgery Syndrome (FBSS). There were 164 patients with a relevant surgical history. This included 46 (28,05%) patients that had been involved in a traumatic event, 47 (16,49%) patients that had surgery other than spinal surgery that was relevant to their pain diagnosis, and 71 patients (43,29%) that 4 had spinal surgery that was relevant to their diagnosis. A Chi-­‐squared test was performed on the relationship between gender and the type of pain, and a p value of 0.001 was found. When relating the type of pain with age, mixed pain and nociceptive pain was found to be most common in those aged >60 years (n=26), whereas neuropathic pain was found to be most common in the 41-­‐60 year age group (n=43). CONCLUSION: With the limited data from this study, the profile of patients with chronic pain in South Africa seems to not differ grossly from data collected internationally. The most pertinent finding of this study is the inadequacy of record keeping.

Telomeres are regions of tandem repeats at the ends of chromosomes ensuring chromosome stability or inducing replicative senescence when critically short. Telomerase extends telomeres and its catalytic subunit, telomerase reverse transcriptase is tightly regulated at multiple levels. Cancerous cells prevent telomere-mediated senescence to attain unlimited proliferation, in most cases by enhancing telomerase activity. Chronic myeloid leukaemia is characterised by the translocation, t(9;22), in haematopoietic stem cells. The resulting fusion protein exhibits constitutive tyrosine kinase activity in the cytoplasm, promoting cellular proliferation, inhibiting apoptosis and impeding cell adhesion. Changes in telomere biology have been observed in chronic myeloid leukaemic cells. The current study aimed to investigate telomere biology in 18 chronic myeloid leukaemia patients at various time intervals from date of diagnosis. Although telomeres were significantly shorter in patients compared to controls, results point to complex telomere dynamics in the malignancy. Increased telomerase activity did not necessarily accompany telomere lengthening and increased transcription of the telomerase catalytic subunit was not necessarily indicative of telomerase activity. Ultimately the current study could not detect any trends between telomere length, telomerase activity and telomerase catalytic subunit expression in chronic myeloid leukaemia patients. Together with inherent patient-to-patient variation and the high cost per assay, measurement of telomere biology does not appear to hold prognostic value in chronic myeloid leukaemia and does not warrant inclusion into a routine test repertoire.

Thesis advisor: Callista L. Roy / Purpose: The purpose of this research was to address the gap in the literature related to frail older adults' experience of participating in clinical trials. Background: Frail older adults are generally underrepresented in the population of research volunteers from which evidence-based guidelines are derived. To improve care for frail older adults, research must be expanded to specifically target this population. Most of the users of healthcare today are greater than 65 years old, use more health care services than any other age cohort and suffer from coexisting illnesses for which they take several prescribed medications. Since the number of elders is increasing within the general population, it is important to reach a more thorough understanding of frail older adults' experience. Acquiring a better understanding of their experience will give the investigator more insight into barriers of recruitment, retention, and factors affecting elders' decision to participate in research. Method: Using a qualitative descriptive approach involving semi-structured interviews, a cohort of participants age 65 and older was asked about their experience of participating in research studies. Data analysis used an interpretive paradigm involving the methods of Miles, Huberman, and Saldana (2014). Results: Participants identified the main factors influencing their decision to participate as the opinions and encouragement of family members with the strongest influence being a recommendation from their doctor. Participants were varied in the emotions evoked by their participation in the study procedures. The majority of participants stressed how important it was to them to receive feedback in the form of results of studies in which they had participated. The majority of participants stated that receiving feedback or research results was the exception. Conclusions: Data generated from this study related to the experience of frail elder participation in clinical trials will be useful in designing future clinical trials to be more inclusive of this patient population. Keywords: frail elders, research participation, clinical trials, chronic illness, qualitative, multmorbidity / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

A dissertation submitted to the Faculty of Science, University of the Witwatersrand, Johannesburg, in fulfilment of requirements for the degree of Master of Science in the School of Molecular and Cell Biology. Johannesburg, 2016. / Telomeres play significant roles in maintaining genome stability, regulating cell proliferation and apoptosis. The role of telomere biology and telomerase reactivation has been studied extensively in cancers. Telomerase has been previously associated with driving chronic kidney disease (CKD) advancement and most frequently due to HIV infection. However, the mechanism by which telomerase activation contributes towards disease progression beyond its canonical function of telomere maintenance is poorly understood. Telomerase is a ribonucleoprotein whose main function is telomere maintenance. Telomerase activity is dependent on expression of the rate-limiting human telomerase reverse transcriptase (hTERT) component. In addition to telomere maintenance, hTERT is implicated in other non-telomere related functions that promote cellular proliferation. Expression of hTERT is predominantly regulated at the transcription level where variation in promoter and minisatellite (MNS16A) sequences alter its expression. This variation has been implicated to confer susceptibility to diseases such as cancer and ageing disorders in non-African populations. Data on variation and pathogenicity of telomere-associated genes in African populations is limited and warrants further research. Thus bioinformatics analysis was performed to elucidate variation within the human TERT gene and promoter in different populations. The promoter, MNS16A and relative telomere length (RTL) were also evaluated in 159 African study participants with and without CKD. TERT common variants are equally distributed across populations with limited data on connection to the effects of the variants in African populations. Further bioinformatics analyses revealed significant difference (p<0.0001) in distribution of promoter variant rs2853669 between African and non-African populations. No common promoter mutations were identified in our study population. Interestingly, the long MNS16A variant suggested to increase TERT expression was significantly overrepresented in individuals with CKD regardless of HIV status. For the first time, a strong association of the long MNS16A variant with CKD regardless of HIV status is reported, implicating MNS16A as a potential risk factor in CKD.

Currently there is no curative therapy for Chronic Myelogenous Leukemia (CML), and patients must remain on the current prescribed treatment, tyrosine kinase inhibitors (TKI), indefinitely. Although many patients can survive in the chronic phase of the disease under TKI treatment, some patients do progress to the terminal blast crisis phase of the disease. Patients in this terminal phase do not respond to TKI treatment. We evaluated the therapeutic benefit of targeting the oncogene c-MYC in CML, using the CML cell line K562. This was achieved by inhibiting the enzyme O-linked β-N-acetylglucosamine Transferase (OGT), using two indirect inhibitors 2-deoxyglucose and Azaserine, and the direct inhibitor ST078925. Treatment with these inhibitors resulted in decreased half-life of c-MYC protein in K562, reduced c-MYC protein in K562 cells, and reduced K562 cell growth. Together these results suggest that targeting c-MYC through OGT may be a potential therapeutic option for patients with CML.

Renal transplantation is the optimum treatment for end-stage renal failure. B cells have been identified in chronic allograft damage (CAD) and are associated with the development of tertiary lymphoid tissue within the human renal allograft. To investigate this pathology we utilized a mouse model of renal transplantation. A mouse model of kidney transplantation was first described in 1973. Although the mouse model is technically difficult it is attractive for several reasons: the mouse genome has been characterized and in many aspects is similar to man and there is a greater diversity of experimental reagents and techniques available for mouse studies than other experimental models. We reviewed the literature on all studies of mouse kidney transplantation to report the donor and recipient strain combinations that have been investigated and the resultant survival and histological outcomes. Some models of kidney transplantation have used the transplanted kidney as a life-supporting organ, however in many studies the recipient mouse’s native kidney has been left in situ. Several different combinations of inbred mouse strains have been reported, with varying degrees of injury, survival, or tolerance due to haplotype differences. Both cellular and humoral rejection processes have been observed. This model has been exceptionally useful as an investigational tool to understand multiple aspects of transplantation including acute rejection, cellular and humoral rejection mechanisms and their treatment. Furthermore this model has been used to investigate disease mechanisms beyond transplant rejection including intrinsic renal disease and infection-associated pathology. We performed renal transplantation in mice to model CAD and identified B cells forming tertiary lymphoid tissue with germinal centres. Intra-allograft B220+ B cells comprised of IgMhigh CD23- marginal zone, IgMlo CD23+ follicular zone and IgMlo CD23- transitional-type B cells similar to spleen, and these compartments had elevated expression of CD86. Depletion of B cells with anti-CD20 was associated with an improvement in CAD but only when administered after transplantation and not before. Isolated intra-allograft B cells were cultured and shown to synthesise multiple cytokines, the most abundant of these being GRO-α (CXCL1), RANTES (CCL5), IL-6 and MCP-1 (CCL2). Tubular loss was associated with T cell mediated injury and interstitial fibrosis, whilst type III collagen deposition driven by F4/80+ macrophages and PDGFR-β+ and transgelin+ fibroblasts, all of which were reduced by B cell depletion. In this report we show that intra-allograft B cells are key mediators of chronic damage to the transplant allograft kidney by cytokine orchestration of T cell, macrophage infiltration and fibroblast activation.

Background: In chronic obstructive pulmonary disease (COPD), understanding the problem of poor patient participation in evidence-based self-management (SM) and pulmonary rehabilitation (PR) programmes (together referred to as SM support programmes) is critical. This thesis aimed to improve understanding of poor patient participation and retention in these programmes; how participation might be improved; and how might patients be better supported with their SM. Methods: Using the Medical Research Council guidance on complex interventions this thesis (1) quantified the 'actual' patient participation and completion rates; (2) explained, using theory, the factors that influenced participation in studies of SM support including the programmes among chronic disease and COPD patients; and (3) explored patient and expert stakeholders' perspectives on the reasons for non-participation in SM support programmes, how participation might be improved, how might patients be supported with their SM. Results: (1) Among 56 studies, high study participation rates and completion rates were seen however, the incomplete reporting of participant flow confused the problem of participation. (2) Among 31 studies, participation among patients with chronic disease including COPD was shown to be influenced by their 'attitude' and 'perceived social influence/subjective norms'; 'illness' and 'intervention perceptions'. (3) From 38 interviewees, besides patients' beliefs, non-participation was also influenced by resignation and denial of the illness; health systems; and programme organisational factors. Professionals building relationships and supporting patients with their SM alongside programme organisational improvements might encourage patient participation in SM and the programmes. Conclusions Patient participation is a complex behaviour, besides socio-behavioural factors, participation behaviour can by influenced by a mix of several health system and programme organisational factors. Changing the behaviour of health professionals and indeed the wider health system, towards normalising a patient partnership approach, with implementation of SM support in routine care might help more patients to consider participation in their care and improve patient participation in COPD SM support programmes.

The increased risk of atherothrombosis in chronic kidney disease (CKD) has been under extensive examination for decades now. However, a treatment tailored for CKD patients is yet to be found. Current management plans can only tackle comorbidities and mostly fail. This thesis study examines the current literature related to CKD and thrombosis. The aim is to find a target suitable for therapeutic exploration. Normalizing the risk of thrombosis in CKD patients could curb a huge margin of their morbidity and mortality. In recent years, molecular biology studies attributed the extreme thrombogenicity in CKD to the retained uremic toxins. Indolic compounds are uremic toxins with a well described point of thrombotic activation. Of them, indoxyl sulfate is to be highlighted since it was shown to that it is one of the strongest pro-thrombotic uremic toxin. It is possible to therapeutically target this CKD specific cause of hyperthrombogenicity. Further research is very much needed in this area.

Transactive response DNA-binding protein of 43 kDa (TDP-43) is the major protein found within pathological inclusions in Amyotrophic Lateral Sclerosis (ALS) and Frontotemporal Lobar Degeneration (FTLD) (Neumann et al., 2006). TDP-43 is a ubiquitously expressed protein mainly involved in RNA metabolism. It is a member of the heterogeneous nuclear ribonucleoprotein (hnRNP) family and in its normal state is predominantly found in the nucleus. In its pathological state TDP-43 is cleaved, phosphorylated, ubiquitinated, and located in cytoplasmic or nuclear inclusions. Along with ALS and FTLD, TDP-43 is also observed in many other neurodegenerative diseases. Pathological TDP-43 inclusions have been previously reported in cases of Chronic Traumatic Encephalopathy (CTE) (King et al., 2010)(McKee et al., 2010)(Saing et al., 2012)(Hazrati et al., 2013), however no previous study has reported on the incidence and extent of TDP-43 cellular inclusions in a large cohort of autopsy cases diagnosed with CTE. This study finds that TDP-43 inclusions are a frequent feature of CTE, as TDP-43 inclusions are identified in 43% (20/47) of subjects in a CTE+, FTLD-, low-likelihood-of-AD cohort. Furthermore, this study finds that in CTE there is no consistent initial focus of TDP-43 pathology which spreads to neighboring regions as the disease progresses. Despite the lack of a clear progression of TDP-43 pathology, a TDP Staging Scheme for CTE which accurately reflects the extent and severity of TDP-43 pathology in not only the study cohort, but likely in all subjects without FTLD, was established. Four stages were identified: TDP Stage 0 showed no TDP-43 inclusions in the substantia nigra, dorsolateral frontal cortex, or dentate gyrus; TDP Stage 1 showed inclusions in either the substantia nigra or the dorsolateral frontal cortex; TDP Stage 2 showed inclusions either in the dentate gyrus or in both the substantia nigra and the dorsolateral frontal cortex; and TDP Stage 3 showed inclusions in the substantia nigra, dorsolateral frontal cortex, and dentate gyrus. Finally, a correlation was found between the presence of TDP-43 inclusions and the levels of activated microglia in the dorsolateral frontal cortex of CTE+ subjects. This finding aligns with the theory that the pathological changes of TDP-43 found in CTE are driven by the pro-inflammatory cytokines released by chronically activated microglia.