Asthma is a chronic inflammatory condition of the airways characterised by reversible airflow obstruction, airway hyper-responsiveness and inflammatory infiltrates in the airway walls containing eosinophils, T lymphocytes and mast cells. T helper (Th) lymphocyte subsets, defined by the cytokines they secrete, are thought to play a key role in the in the initiation and perpetuation of chronic airway inflammation. Th2 cells, producing interleukin (IL)-4, IL-5, IL-9 and IL-13, are thought to be of particular importance. In contrast, Thl cells producing interferon (IFN)-y may counteract the development of Th2 responses and so down-regulate the asthmatic response. The prevalence of asthma is increasing but the reasons for this are not fully understood. In addition, some patients do not respond adequately to treatment with corticosteroids, currently the most effective anti-inflammatory agents used routinely in human asthma. There is therefore continual interest in developing new therapeutic agents for asthma. A greater understanding of the regulation of inflammatory responses in asthma will assist in the identification of potential targets for therapeutic intervention. The aims of this thesis were (i) to assess the role of the cytokine IL-18 in allergic airway inflammation by determining IL-18 levels in induced sputum in asthmatic subjects in comparison to normal subjects, and by studies in a murine model of allergic asthma using IL-18 gene deficient mice and (ii) to assess the potential antiinflammatory actions of simvastatin and thymosin beta 4 sulfoxide in the murine asthma model. IL-18 is a pro-inflammatory cytokine which can promote IFN-y secretion and, in association with IL-12, enhance the development of Thl responses. However, in some circumstances it may also stimulate Th2 responses. IL-18 therefore has the potential to suppress or exacerbate allergic airway inflammation. The role of IL-18 in both clinical and experimental asthma remains unclear. Statins are inhibitors of the rate-limiting enzyme, 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase, in cholesterol biosynthesis. As such they have been widely used as cholesterol lowering agents in clinical practice. They have previously been shown to have anti-inflammatory properties independent of their cholesterol-lowering ability in clinical studies of atherosclerotic disease and in animal models of Thlmediated inflammation. Thymosin beta 4 sulfoxide (T~4S0) is a 5 kDa peptide. Intracellularly its principal activity is to regulate actin polymerization. Corticosteroid treatment of monocytes in vitro induces the release of T~4S0 extracellularly, where it can inhibit neutrophil chemotaxis. Exogenous administration of T~4S0 has been shown to reduce neutrophilic inflammation in animal models. In this study it is shown that IL-18 is detectable in induced sputum fluid and IL-18 mRNA is expressed in induced sputum cells from asthmatic and nOlmal subjects. IL- 18 protein levels in induced sputum, and IL-18 mRNA expression in induced sputum cells were not significantly different between these groups. IL-18 production was localised to sputum macrophages. However, cigarette smoking significantly reduced IL-18 levels in induced sputum fluid in both asthmatic and normal subjects. In asthmatics, but not normal subjects, the reduction in IL-18 levels in sputum fluid was associated with reduced IL-18 mRNA expression in induced sputum cells. A murine model of allergic asthma, using BALB/C mice sensitised and challenged with ovalbumin (OVA), was used to examine the role of IL-18 in allergic responses in vivo. IL-18 gene knockout (ko) had significantly reduced bronchoalveolar lavage (BAL) total cell count and eosinophilia compared to wild-type (WT) mice. IL-18 ko mice had reduced IL-4 expression in thoracic lymph nodes, as assessed by quantitative peR, and significantly reduced OVA-specific IL-4 secretion from thoracic lymph node cultures assessed by ELISA. Serum OVA-specific IgG 1, IgG2a and IgE and total IgE levels were not significantly different between IL-18 ko and WT mice. The murine model of allergic asthma was also used to examine the anti-inflammatory activities of simvastatin and T~4S0 in a Th2-mediated, eosinophilic condition. Simvastatin treatment, either orally or intraperitoneally, and T~4S0 intraperitoneally reduced the total inflammatory cell infiltrate and eosinophilia in BAL fluid in response to inhaled OV A challenge. At higher doses of simvastatin intraperitoneally, a histological reduction in inflammatory infiltrates in the lungs was observed. Treatment with simvastatin intraperitoneally, but not orally, and T~4S0 were also associated with a reduction in IL-4 and IL-5 levels in BAL fluid. OVA-induced IL-4 and IL-5 secretion was reduced in thoracic lymph node cultures from both simvastatin-treated and T~4S0-treated mice. Neither simvastatin nor T~4S0 treatment altered serum total IgE or OVA-specific IgG 1 and IgG2a levels. The results described show that IL-18 can be detected in the induced sputum fluid of asthmatic and normal subjects and that cigarette smoking significantly reduces its levels. Studies in a murine model of allergic asthma suggest that IL-18 has a proinflammatory role in allergic airway inflammation, at least in part through its ability to induce IL-4 secretion. Both simvastatin and thymosin beta 4 sulfoxide had convincing anti-inflammatory properties in the murine model of asthma used, and these agents, or related compounds, may have therapeutic potential in human asthma.

This thesis presents a set of studies which investigated chronic low back pain. The specific aim of this thesis was to develop reliable methods for the assessment and rehabilitation of chronic low back pain. The two assessment methods tested were a broad based clinical evaluation and an isokinetic assessment of trunk muscle strength. The first part of the thesis describes the reliability and validity studies of the clinical methods for measuring trunk mobility, trunk muscle strength, spinal shape and palpation. A total of 27 physical tests were studied using 70 patients and 10 normal subjects. Twenty-three of these tests were found to be reliable and were incorporated into the isokinetic assessment study. The second part of the study reports the standardisation and reliability studies for the isokinetic assessment of trunk muscle strength in 70 normal subjects and 120 patients with chronic low back pain. The results showed that the main isokinetic measures were reliable for both normal subjects and patients. There was a significant learning effect from test 1 to test 2 in both normal subjects and patients. The magnitude of this learning effect was greater in patients than normal subjects. The normal subjects were followed up by a postal questionnaire in a two year prospective study to predict future back pain using the isokinetic measures. None of the measures used showed any significant differences between those subjects who developed back pain and those who did not. The third part of the thesis describes studies to develop a rehabilitation programme for patients with chronic low back pain using the isokinetic machines, both as a means of monitoring progress and as an exercise regime. The first study of 26 patients indicated that the programme was safe and effective, but also revealed a major problem with adherence to a six week exercise programme. The second study investigated the problem of adherence and examined the time course of response to isokinetic exercise by repeating the tests at three weeks and six weeks.

This thesis describes the results of dietetic led weight management for weight loss in three different groups of subjects: overweight; overweight with angina; and those whose body weight was close to the healthy upper BMI of 25 kg/m2. It forms part of a growing literature examining moderate weight loss as a success outcome in weight management. The work in this thesis addresses an important general research question; whether the effect of modest weight loss per se on established risk factors for IHD was similar across a number of subject groups. The specific aims were to examine the effect of moderate weight loss on the established IHD risk factors, fibrinogen, factor VII activity, plasma and whole blood viscosity, PAI activity and t-PA antigen. The role of modest weight loss on the adrenal hormone DHEAS was also studied. The conclusion of this thesis is that modest weight loss, (around 4%) which can be achieved through well planned dietetic management, does produce important reductions in IHD risk. The weight loss achieved was similar in groups with BMI > 28 kg/m2, with or without IHD, but less in absolute terms in individuals with baseline weights near the top of the healthy (acceptable range). Reductions in factor VII activity and RCA were related to the amount of weight loss, but the reductions were not greater in those with higher baseline values and existing IHD. The falls in factor VII activity and RCA were accompanied by falls in other established IHD risk factors, plasma lipid concentrations and blood pressure.

The primary aim of the main study was to evaluate the effectiveness of exercise consultation for promoting and maintaining physical activity over 12 months in people with Type 2 diabetes. Secondary aims were to investigate changes from baseline to 6 and 12 months in a number of physiological, biochemical and quality of life variables. 70 inactive people with Type 2 diabetes (35M 35F, mean age 57.6±7.9yrs, BMI 34.6±6.8) were given standard exercise information and randomised to receive an exercise consultation intervention (experimental group n=35) or not (control group n=35). Exercise consultation, based on the transtheoretical model, combines motivational theory and cognitive behavioural strategies into an individualised intervention to promote and maintain physical activity. Exercise consultations were delivered at baseline and 6 months and support phone calls were given 1 and 3 months after each exercise consultation. Changes from baseline to 6 and 12 months were assessed in a) physical activity (7-day recall, accelerometer, stage and processes of exercise behaviour change and cardiorespiratory fitness), b) physiological (body mass index and blood pressure), c) biochemical (glycaemic control, lipid profile, fibrinogen and microalbuminuria) and d) quality of life (Short form-36 and Well-being questionnaire). Results recorded illustrated between group differences in minutes of moderate activity and total accelerometer counts per week at 6 and 12 months (p<0.01). The experimental group increased minutes of moderate activity and total accelerometer counts from baseline to 6 months (P<0.01), with no significant decrease from 6 to 12 months (P>0.05). From baseline to 12 months a significant increase was recorded in the experimental group for minutes of moderate activity (p<0.01), but not total accelerometer counts per week (p=0.7). The control group recorded a decrease in accelerometer counts per week from baseline to 12 months (p=0.03).

The aim of this thesis was to investigate why some referrals to outpatient clinics made by General Practitioners lead to continuing hospital attendance. A cohort of 392 patients referred to six outpatient clinics by General Practitioners during 1987 were studied from the time of their first attendance until visits ceased up to two years later. Six consultant clinics were studied in three specialties: rheumatology, vascular surgery and dermatology. For each specialty a clinic in both a teaching hospital and a district were included. The cohort members were similar to that found in most adult outpatient clinics: predominantly middle-aged or elderly with a greater proportion of women. A wide distribution of disease severity scores was observed in each clinic. The patients had to wait up to 35 weeks from the date of referral until seen for the first visit. A `continuing attender' was defined as someone in the highest quintile of visits made. Patients who were referred for therapy were more likely to continue attending. The principal reason for 'continuing attendance' as perceived by patients, General Practitioners and hospital doctors was the necessity for consultant supervision. In addition, analysis of observable clinical and non-clinical data was performed. This showed that diagnosis, disease severity and the grade of doctor seeing the patient in the clinic influenced the numbers of visits made and the numbers of weeks of attendance. Different diagnoses had different predictive values: rheumatoid arthritis and peripheral vascular disease patients were most likely to return for four or more visits. Increasing disease severity scores made discharge progressively less likely and seeing a consultant made discharge four times more likely at the first visit and nine times at the second visit. Taken together these three variables could predict up to 80% of discharge decisions in this cohort of patients. (Sensitivity 81%, specificity 75%.) The disease severity scales we employed failed to detect major changes in this variable for the cohort as a whole or within individual specialties. Patients however considered their visit had produced improvement in their condition in 46% of cases. 62% expressed satisfaction with their visits to the clinic. In so far as the idea of consultant review of all cases at every visit cannot be met, it might still be possible for consultants to effectively manage the resources within their own clinic setting. Casenote review with junior staff at the end of a clinic could usefully be performed on patients making a third or subsequent visit. This would be especially valuable where the diagnosis and a measure of disease severity suggest that the patient should be discharged. The results conclude that such an educational activity, combined with formal guidelines to junior staff on the 'Clinic Discharge Policy' are worthy of further study as potential means of reducing unnecessary attendances. This work has shown that it is possible to make useful observations on data such as age and diagnosis which are routinely gathered in the outpatient clinic. It is also suggested that it might prove useful to record prospectively other data such as patient satisfaction, the proportion of patients seen by different grades of doctors and disease severity. The use of such readily collected data would be of value not only to the clinicians engaged in the work of the clinics, but also to the General Practitioners who make referrals to them and to those who plan the services.

The effects of undertaking a three week supervised exercise programme followed by a twelve week home based exercise programme, were investigated with adults in an abstinence treatment programme within four alcohol problem clinics. A randomised experimental design was used with physiological and psychological variables being measured at baseline, on entry to the programme, at 1 month, following the intervention programme and then at time points from baseline at 2 months and 5 months. Recruitment to the study of 165 subjects exceeded expectation. Of these 117 completed the first stage with 61 in the exercise group (n-46 male: n=15 female) and 56 in the placebo control group (n=43 male n=13 female). The findings of this study indicate that the inclusion of a three week programme of exercise in an abstinence rehabilitation programme improves fitness, strength, physical activity and physical self-perceptions and that these improvements are maintained for a further month by undertaking a home based exercise programme. At five months however, only improved fitness is maintained. There is no evidence that exercise can be linked to maintaining abstinence levels. Under reporting of drinking behaviour was high. At two months 27% and at 5 months 35% of those identified by the CDT blood test as drinking, at levels associated with relapse, self reported abstinence or low levels of alcohol intake. These findings have clinical relevance to physiotherapists and other health care professionals, as they indicate that problem drinkers have low aerobic fitness and low self perceptions. Inclusion of a three week programme designed to improve fitness and strength, followed by a home based programme, may be beneficial in improving these parameters with the possibility of increasing physical activity.

In this thesis, the pleiotropic effects of statins on the disruption of prenylation and membrane rafts were investigated in immune effector cells. T cells and NK cells were extracted from various groups of patients treated with statins and proliferation and cytotoxicity respectively, measured ex vivo. In a study of patients with cardiovascular disease, a 23% reduction in T cell proliferation and 43% reduction in NK cytotoxicity were observed. In a normal volunteer study where healthy subjects received simvastatin (40mg per day) for 4 weeks, a comparable reduction in T cell proliferation was not apparent, however a 30% reduction in NK cytotoxicity was observed. In vitro statin treatment further reduced proliferation and cytotoxicity whereas addition of farnesyl and geranylgeranyl transferase inhibitors had little or no effect. In conclusion, this thesis has demonstrated that statins have a multitude of applications and effects. The pleiotropism of statins due to reduced prenylation was observed in vitro by western blot in multiple signalling pathways and confirmed with the use of FT and GGT inhibitors in these pathways. However, the lack of functional effect of FT and GGTIs indicated that prenylation has a lesser impact on the functions of immune effector cells than cholesterol depletion of rafts. The comparable results obtained with MßCB indicated that the reduction of cholesterol in the membrane by statins was disrupting rafts and therefore disrupting signalling pathways to a greater extent than prenylation inhibition. It is however likely to be a combination of both processes that contributes to the pleiotrophic effect of statins.

There is a widespread view in medicine and amongst the general public that modern medicine is primarily a scientific enterprise and that the activities of clinicians rest on a secure basis of evidence-based science. As a clinician with a first degree in the arts, I have felt instinctively that this was not wholly the case. This thesis will examine the scientific nature of medical practice, identify and analyse what else is required, apart from science, for someone to be a good doctor, and suggest ways in which these additional attributes might be developed in medical education. I shall begin by examining the scientific evidence-base of medicine. It will emerge that there are three aspects to medical science: firstly, systematic knowledge of the systems of the body and their pathology, secondly, qualitative research, and thirdly, randomised controlled trials. Of the three only the first is truly science, but since science is a large family, the randomised controlled trial and qualitative research can be seen as members. Assuming, therefore, that there is some kind of evidence-base for contemporary medicine, I go on to ask how this evidence-base is modified in clinical practice. It emerges that there are a number of important modifications. Firstly, evidence must be individualised to the specific patient in the same way as a detective uses evidence in his investigation of a particular case. Secondly, doctors draw on wider sources of information than just the scientific evidence-base when they are treating patients. For example, patients' anecdotes and stories about themselves and the origins of their complaints are an important source of information in constant use. Thirdly, all the information in use by doctors is interpreted by them in the light of their knowledge of the individual patient and the patient's views must be sought on treatment decisions in the form of consent.

No description available.

The World Health Organisation's (WHO) 'Health for All by the Year 2000' (HFA2000) resolution is intended to promote improvements in the equality of health care provision, the basis of which is universal accessibility to basic health care. The Jordanian Government, in accordance with HFA2000, has attempted to improve accessibility in rural communities by providing an extensive network of basic rural health clinics which are intended to be acceptable and accessible to all communities. Within this context, the research considers two interrelated themes. The first theme considers changes in health and illness practices, and particularly the wide-scale and rapid acceptance of modern medical services at the same time as `traditional' Arabic medicines are becoming relatively unimportant in the north east Badia. This study highlights the connections between health and illness discourses in the past, Bedu social values, and the wider social economic milieu, and how these are reflected in the forms and use of Arabic medicines. The literature widely assumes that culture, `traditional' social structures and attitudes inhibit the acceptance and effective utilisation of modern medical services, and that education, for example, is a key way to address this problem. This research engages with this assumption by evaluating the significance of social values, education and health awareness programmes, knowledge of health issues, together with socio-economic changes in explaining the acceptance of modern medicine and the adoption of preventative medicine and practices, together with changing attitudes to children's health. The second key theme of this research is to examine the extent to which basic government health services have been made accessible to the nomadic, sedentarising and settled rural population of the north east Jordan Badia, and specifically their children, a particularly vulnerable group, and whether this explains patterns of health and illness behaviour. To this end, the importance of geographical, organisational (health service), economic and social factors is evaluated in explaining variations in accessibility mediating the effective utilisation of these services at family level.