In post-haemorrhagic communicating hydrocephalus, CSF drainage is obstructed by subarachnoid fibrosis in which the fibrogenic cytokine transforming growth factor-β1 (TGF-β1) has been aetiologically implicated. Here, the hypothesis that the TGF-β antagonist Decorin has therapeutic potential for (1) reducing fibrosis and the development of hydrocephalus and (2) degrading fibrosis and resolving hydrocephalus, was tested using a rat model of juvenile communicating hydrocephalus. In the acute study, hydrocephalus was induced by a basal cistern injection of kaolin in 3-week-old rats, immediately followed by continuous intraventricular infusion of either human recombinant Decorin or PBS. In the chronic study, hydrocephalus was allowed to develop for 7 days before starting the treatment of Decorin or PBS. Ventricular expansion was measured by magnetic resonance imaging. Inflammation, fibrosis, Decorin, TGF-β/Smad2/3 activation and hydrocephalic brain pathology were evaluated by immunohistochemistry and basic histology. In the acute study continuous Decorin infusion prevented the development of hydrocephalus by blocking TGF-β- induced subarachnoid fibrosis and protected against hydrocephalic brain damage. In the chronic study Decorin had no impact on hydrocephalus, TGF-β1 levels or subarachnoid fibrosis, however the efficiency of Decorin infusion was in disrepute. The results suggest that Decorin is a potential clinical therapeutic for the prevention of juvenile post-haemorrhagic communicating hydrocephalus.

Alpha 1 antitrypsin deficiency (AATD) is the only established genetic predisposition to chronic obstructive pulmonary disease (COPD). The development of COPD in AATD is highly variable, probably relating to complex interactions between multiple genetic and environmental factors. This thesis will describe the COPD phenotypes observed in AATD and their inter-relationships, forming the basis for examining phenotypic associations with specific candidate genes and HLA class II type. Finally it examines the potential role of ambient air pollution. Associations were seen for TNFA with chronic bronchitis, SFTPB with FEV1, TGFB with small airways disease and GC with bronchiectasis, consistent with the role of protein products in pathogenesis. Of four MMPs studied, association with gas transfer occurred in two. HLA-DQA1*0301 and HLA-DRB1*04 contributed significantly to gas transfer in regression models, and anti elastin antibodies were higher in HLA-DRB1*04 and HLA-DQA1*0301 homozygotes. Ozone levels contributed to the burden of disease in cross sectional and longitudinal models of pollution exposure, whilst PM10, NO2 and SO2 were associated only in the longitudinal model. In conclusion this thesis demonstrates the importance of genetic variation and environmental factors in determining respiratory phenotype in AATD. It also suggests a key role for adaptive immunity in pathogenesis of emphysema.

The first aim of this thesis was to systematically review the literature to determine the diagnostic accuracy of ultrasound in the first trimester to screen for twin-twin transfusion syndrome (TTTS) and predict its outcome after diagnosis, as well as the effectiveness of its two main treatments. Quantitative analysis revealed that a crown rump discordance or abnormal nuchal translucency in the first trimester was useful to screen for TTTS, but after diagnosis no single test could reliably predict outcome. In both situations a negative test was not reliable for excluding TTTS or a poor outcome. Fetoscopic laser ablation (FLA) is likely to confer a benefit both in terms of survival and morbidity in survivors. The second aim was to determine what happened to biological markers in TTTS and how FLA affected them. It appeared that TTTS may be associated with abnormal placentation as maternal serum α-fetoprotein (MSAFP) approximately doubled and free β-human chorionic gonadotrophin (f- β hCG) tripled. The balance of angiogenic factors i.e. 2-3 fold increased angiogenin 2 and 1.5 fold increased soluble vascular endothelial growth factor receptor 1 appeared to favour angiogenesis in response to hypoxia or ischaemia in TTTS. Maternal cell-free messenger RNA was reliably detected and showed similar alteration in angiogenic markers. Interestingly, TTTS was associated with minimal changes in cytokine levels. In response to FLA there was an increase in transplacental haemorrhage (MSAFP increased 445%) rather than trophoblast destruction (f-hCG unchanged) as well as a transient increase in some anti-angiogenic markers. Although, in general angiogenic factors and cytokines are altered little by this therapy. If the biomarker changes detected precede the onset of clinically apparent disease, they may be useful to improve the performance of first trimester ultrasound screening. Composite tests may be more useful to predict outcome and FLA should continue to be utilised to reduce morbidity.

Background: Diabetes-related Microvascular complications are associated with significant morbidity, mortality and economic burden. Effective treatments for microvascular complications, apart from improved metabolic and blood pressure control, are lacking. Hence, improved understanding of the pathogenesis of these complications is needed to develop new treatments. Obstructive sleep apnoea (OSA) is very common in type 2 diabetes (T2DM) and has been shown to stimulate the same harmful pathways as hyperglycaemia, particularly those that are involved in the pathogenesis of microvascular complications. Hence, it is plausible that OSA is associated with microvascular complications in patients withT2DM. Aims: To explore the interrelationships between OSA and microvascular complications in patients with T2DM and the possible mechanisms behind such relationship. Methods: A cross-sectional study of South Asians and White Europeans with T2DM were randomly recruited from the outpatients of two secondary care diabetes clinics in the UK. Patients were extensively characterised including assessments for OSA and microvascular complications. Results: Patients (n=234) were included in the analysis. OSA prevalence was 64.5%. OSA patients had worse metabolic profile than those without OSA. The prevalence of all microvascular complications (except cardiac autonomic neuropathy) was higher in patients with OSA compared to patients without. After adjustment for a wide range of confounders, OSA remained independently associated with microvascular complications. OSA and hypoxaemia severity correlated with the severity of complications. Based on blood samples and skin biopsies collected during the study, patients with OSA had increased oxidative and nitrosative stress and impaired microvascular regulation compared with patients without OSA. Furthermore, ethnic differences in OSA accounted for some of the ethnic differences in microvascular complications. Conclusion: I have identified a novel association between OSA and microvascular complications in patients with T2DM, with increased nitrosative stress and oxidative stress and impaired microvascular regulation as possible mechanisms. Further prospective observational and interventional studies are needed to assess the impact of OSA and its treatment on the development and progression of microvascular complications.

The role of the periaqueductal grey (PAG) in the central control of micturition was investigated in urethane-anaesthetised rats, with the aims of furthering understanding of the central control of micturition and identifying novel therapeutic targets for urinary incontinence. Experiments using microinjection of GABAA agonists and antagonists into the midbrain showed that transmission through a localised region of the caudal ventrolateral PAG (cvlatPAG) is critical for reflex voiding and the micturition pathway is normally subject to tonic inhibitory GABAergic control. Experiments to determine the role of dopamine in controlling micturition by selectively lesioning dopamine-containing neurons in the cvlatPAG and microinjection of dopamine agonists and antagonists were inconclusive and require further work. Micturition could however be suppressed completely by trains of electrical stimulation applied throughout the midbrain. Microinjection of an excitatory amino acid over the same area reduced the frequency of micturition without disrupting the pattern of voiding. Though further work is required to determine the mechanism by which electrical stimulation inhibits reflex micturition, collaboration with clinical colleagues has indicated the exciting translational potential of electrical stimulation of the midbrain in human patients to treat urinary disturbances that have proven refractory to pharmacotherapy.

Conservative non-pharmacological evidence-based management options for Chronic Obstructive Pulmonary Disease (COPD) primarily focus on developing physiological capacity. With co-morbidities, including those of the musculoskeletal system, contributing to the overall disease severity, further research was needed. This thesis presents a critical review of musculoskeletal management approaches used in COPD, which concluded there is insufficient evidence for using musculoskeletal interventions in COPD management. With a paucity of literature exploring chest wall flexibility and clinical guidelines advocating research into thoracic mobility exercises in COPD, a focus on thoracic spine motion analysis was taken. Soft tissue artefact (STA) threatens the validity of existing in vivo measurement techniques. Having measured and reported unacceptable levels of STA, an alternative approach was developed and tested for reliability as part of this thesis. This technique, along with other measures, was subsequently used to evaluate cervico-thoracic musculoskeletal changes and their relationship with pulmonary function in COPD. In summary, subjects with COPD had reduced spinal motion, altered posture and increased muscle sensitivity compared to controls. Reduced spinal motion and altered neck posture were associated with reduced pulmonary function and having diagnosed COPD. Results from this thesis provide evidence to support inception of a clinical trial of flexibility exercises in COPD.

Commotio retinae describes retinal opacification following trauma and affected 16% of British soldiers suffering major trauma. The macula was affected in 55% of soldiers and 31% of civilian cases, permanently reducing vision to less than 6/9 in 26% of cases, associated with photoreceptor degeneration. In an experimental rat model, commotio retinae was more readily induced by high velocity ballistic injury (20m/s) than low velocity weight drop (2-7m/s). In rats, after experimentally induced commotio retinae, photoreceptors died by a combination of necrosis (central to the impact site) and apoptosis (peripheral to it), demonstrated by morphological changes on electron micrographs and TUNEL staining. Photoreceptor death after commotio retinae was associated with reduced ERG a-wave amplitude. Apoptosis occurred through the intrinsic pathway, mediated by caspase 9 but not involving any of the classical executioner caspases (3, 6 and 7). Inhibition of caspase 9 reduced photoreceptor death and improved retinal function, assessed by a-wave amplitude. Clinical studies suggested a protective effect of female gender after commotio retinae, but progesterone treatment increased photoreceptor death after ballistic injury in the experimental model.

Glucocorticoids (GC) are regulators of permissive and adaptive physiology. GC excess can lead to metabolic complications including type 2 diabetes and metabolic syndrome. Levels are regulated by 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), which reactivates GC. 11β-HSD1 activity is deregulated in a range metabolic disorders in which GC levels are normal. I hypothesise that 11β-HSD1 is a critical regulator of adipose tissue sensitivity to GC excess, and that through 11β-HSD1 depletion adipose tissue will be desensitised to GCs and resist metabolic deregulation. Using 11β-HSD1 KO mice in a model of GC excess we demonstrate that 11β-HSD1 mediates the adverse metabolic effects of GC excess on a global scale. I further investigated brown adipose tissue (BAT) with GC excess. I demonstrate that 11β-HSD1 regulates BAT activity and mitochondrial function, possibly suppressing BATs thermogenic potential. I extended my studies to examine the potential for white adipose tissue (WAT) to assume markers of thermogneic and mitochondrial function in the context of 11βHSD1 and GC excess. The data suggest 11β-HSD1 may suppress the potential of WAT to assume a ‘BAT-like’ profile. These data show 11β-HSD1 loss of function confers a protective phenotype with GC excess and demonstrates it’s role in mediating the metabolic phenotype associated with GCs. These data support the idea that GCs can influence BAT and WAT thermogenic potential and may increase knowledge of metabolic dysregulation in humans suffering form GC excess. This therefore highlights 11β-HSD1 as an exciting potential target for the treatment for the metabolic disease associated with GC excess.

Analysis of the amino-acid co-substitution patterns has long promised the prediction of protein structure but has failed to deliver. One possible reason is that most methods presume that co-substitution is indicative of residue-residue contact, yet the extent to which this conjecture is true is unproven. Here, a method is developed to investigate the relationship between specific co-substitution types and their propensity to occur at different physical separations in a protein structure. Amino-acids are typically segregated into two types; hydrophilic residues, predominantly found on the protein surface, and the hydrophobic residues in the protein interior. Thus, the propensity of a given amino-acid substitution occurring at the surface must differ from that in the interior of the protein, the implications of this for co-substitution has never previously been considered. To allow a definition of surface and buried residues, the cross-over point demarcating the surface residues from the protein interior was calculated here, using a Half Sphere Exposure with a radius of 13 A, as 20 HSEu, above which value a residue can be considered buried, and below which it can be considered to be on the surface.

This thesis describes the impact of service delivery initiatives (SDIs) on patients’ waiting times within radiology departments. A systematic review of the literature (71 studies included) found the following broad type of SIDs: extended scope practice, quality management, productivity-enhancing technologies, outsourcing, pay-for-performance and multiple interventions. Ninety-six percent of the studies used either the pre- and post-intervention without control or the post-intervention only designs; but these designs are fundamentally weak and prone to bias. Furthermore, this thesis also described a case-study for the evaluation of the impact on patients’ waiting times of a 320-slice computed tomography (CT) scanner, speech recognition reporting and extended-working-hours within the Birmingham Heartlands Hospital (Heart of England NHS Foundation Trust), Birmingham. The evaluation combined the interrupted time series (ITS) design and qualitative interviews with healthcare professionals in a mixed methods approach. The mixed methods approach leverages the strengths of the quantitative and qualitative methods, so that the triangulation of the findings of one research method might be strengthened when supported by the findings of the other research method. The thesis used a distinctive implementation of ITS segmented regression which accounts for the changing trends of patients waiting times – an approach referred to as ITS ‘segmented spline’ regression.