Low vitamin D is associated with an increased risk of autoimmune diseases, whose pathology might involve T\(_R\)\(_e\)\(_g\) and T\(_h\)17 dysregulation. Thus, understanding how vitamin D modifies CD4\(^+\) T-cell responses holds therapeutic potential. I therefore investigated the effect of 1,25(OH)\(_2\)D\(_3\), the active form of vitamin D, upon human CD4\(^+\) T-cell differentiation. 1,25(OH)\(_2\)D\(_3\), acted directly upon human CD4\(^+\) T-cells, suppressing inflammatory cytokines (IL-17, IL-21, IFN\(_y\) and IL-22) whilst enhancing regulatory markers (CTLA-4, CD25, FoxP3 and IL-10). Consistently, 1,25(OH)\(_2\)D\(_3\)-treated T-cells suppressed division of naive T-cells stimulated by dendritic cells (DCs). Strong up-regulation of CTLA-4 by 1,25(OH)\(_2\)D\(_3\)reduced B7 expression by DCs, suggesting that enhanced CTLA-4 could be important mechanistically in 1,25(OH)\(_2\)D\(_3\)modified immunity. Furthermore, pro-regulatory effects of 1,25(OH)\(_2\)D\(_3\)were maintained under inflammatory conditions and modest suppression of established IL-17 by 1,25(OH)\(_2\)D\(_3\) was observed, supporting ability of 1,25(OH)\(_2\)D\(_3\)to control T-cell phenotype at inflammatory sites. DCs could also efficiently convert 25(OH)D\(_3\)to drive 1,25(OH)\(_2\)D\(_3\)-modified T-cell responses, which might be important in-vivo, given the low level of 1,25(OH)\(_2\)D\(_3\)in serum. Whether dysregulation of the T\(_R\)\(_e\)\(_g\)/T17 balance or response to 1,25(OH)\(_2\)D\(_3\) was associated with disease outcome in early synovitis patients was also studied. Although the TReg/T17 ratio did not stratify with outcome, T-cell responses to 1,25(OH)\(_2\)D\(_3\) were observed in all patients, suggesting that their VDR signalling is intact and that 1,25(OH)\(_2\)D\(_3\)might be useful in the treatment of synovitis.

There is a tension between the need to use antibiotics to prevent adverse outcomes from infection, and a consequence of their use, which is antibiotic (treatment) resistant infection. Actions taken to control the spread of antibiotic resistant microbes, and constraints on the use of antibiotics both give rise to ethical tensions. I consider the evaluative framework and the principles that might be used to decide a just distribution of burdens and benefits associated with the use of antibiotics. Nussbaum specifies a list of capabilities. A minimum sufficiency of each capability is required for a life of human dignity. Nussbaum’s approach provides a richer framework for the evaluation of the distribution of burdens and benefits associated with the use of antibiotics than prevailing health economic, or prevalence of disease measures. There are contexts in which we cannot assure a sufficiency of capabilities. I consider the potential for Scanlon’s contractualism to provide principles for deciding the distribution of burdens and benefits associated with the use of antibiotics under differing levels of resource constraint. Finally I consider the influence of metaphor and analogy in the context of the human relationship with microbes.

Client-centred practice underpins Occupational Therapy and is defined as a partnership between the client and therapist that empowers a client to fulfil his/her occupational roles in a variety of environments. Given the importance of this approach, there has been limited exploration of what therapists and clients experience of this approach. A mixed method design examining the view of the clients and therapists was undertaken using; a systematic review to examine worldwide evidence of a clientcentred outcomes measure, a survey of a sample of therapists’ experiences and individual client and therapist interviews. Findings from this programme of work revealed that the clients’ perspective of client-centred practice was the value they placed on the attitude and behaviour of the therapist, communicating respect and treating them as equals. Therapists valued partnership but were challenged in establishing a relationship with the client and failed to negotiate goals with them. Using a client-centred outcomes measure (the COPM) reinforced partnership, demonstrated joint goal setting and evaluated client satisfaction. Implications for practice; training needed in client-centred practice, theoretical models, interviewing, risk assessment, goal negotiation and use of outcome measures. Communication, use of language and documentation should be clientcentred and reflect the client’s needs.

Following over a decade of debate, sex-selection for non-medical reasons using PGD was prohibited by the Human Fertilisation and Embryology Act 2008. The prohibition was justified on the basis of several objections to the procedure. This thesis will consider the veracity of those objections and will focus on the objections relating to: the alleged harms to individuals and families; potential sex ratio imbalance; and sex discrimination and the impact of the prohibition upon Punjabi ethnicity women. Part I will focus predominantly on the alleged harms of the procedure. It will analyse the manner in which the principles of harm and precaution were applied and interpreted during the consultations and reviews that led to the prohibition. A comparison with the approach taken in relation to ‘saviour siblings’ will demonstrate the manner in which the principles should have been applied to sex-selection. Part II will consider the issue from the perspective of the north-Indian state of Punjab. An examination of the reasons belying the sex ratio imbalance in Punjab will demonstrate the unlikelihood of such an imbalance materialising within the UK. Sex discrimination and the impact of the prohibition upon Punjabi ethnicity women within the UK will be considered against this background.

A systematic review identified limited studies exploring oral formulation-related barriers to medicines administration in children. Owing to the lack of licensed medicines suitable for use in children, manipulation is often required to deliver a specific dose or to facilitate medicines administration. Little is known regarding the prevalence and nature of issues encountered when administering medicines to children in the domiciliary setting. This study adopted a pragmatic approach to determine the nature and prevalence of oral formulation-related barriers to medicines administration in children suffering from a range of chronic conditions. Problems reported by healthcare professionals, patients and their parents/carers were identified to inform future pharmaceutical development and improve children’s medicines. Focus groups (n=4) were conducted with healthcare professionals in the West Midlands and semi-structured face-to-face interviews (n=278) were conducted with parents/carers/young people at University Hospitals Coventry and Warwickshire. Questions explored barriers to medicines administration, refusal and manipulation. In total, 31% of interview respondents reported medicines refusal. Taste was the most commonly reported barrier to medicines administration. Almost one fifth (19%) of medicines administered to children were reported to require manipulation. Findings indicate that age-appropriate medicines are required to provide both suitable dose units and acceptable taste for paediatric patients.

This thesis evaluates and explores the effectiveness of post discharge physiotherapy exercise following total knee arthroplasty (TKA) for osteoarthritis in three ways. 1. A systematic review evaluated the effectiveness of post discharge physiotherapy exercise on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary TKA. Functional physiotherapy exercise interventions following discharge resulted in short term, but not long term, benefit. Effect sizes were small to moderate for function (0.33). Weighted mean differences were small to moderate for motion (2.9) and small for quality of life (1.66). 2. A randomised clinical trial compared the effectiveness of a post discharge physiotherapy intervention in improving patient function versus usual physiotherapy for patients undergoing primary TKA. No significant statistical differences were observed between the two groups for all outcomes. This early trial was underpowered and impacted upon by some important factors which could potentially have masked any treatment trends occurring in the home visit group. 3. Since blinding procedures are often assumed to indicate trial quality, the feasibility of achieving blind outcome assessment in a pragmatic physiotherapy rehabilitation trial involving older people was explored. Reasons for unblinding were explored and successful blinding rates of 81-91% were achieved.

Waterbirths have been available in the United Kingdom as a method of pain relief for childbirth for over two decades but the neonatal safety of birth in water remains unevaluated. Opponents of a waterbirth randomised controlled trial state randomisation would undermine women’s childbirth experience. In addition, little is known about midwives’ attitudes to waterbirths. This thesis addresses some of the lack of evidence by reporting the findings of two studies which had three aims: to investigate the feasibility of a waterbirth RCT to assess the effects of a waterbirth on the neonate, to explore women’s thoughts about participation and whether randomisation affects women’s satisfaction with their childbirth experience and to assess midwives’ attitudes to waterbirths. The first study involved a RCT with a ‘preference arm’. Eighty women were recruited: 60 in the RCT and 20 in the ‘preference arm’. Women were asked to complete questionnaires to assess their expectations for, and satisfaction with, their childbirth experience: at recruitment, after the birth and 6 weeks after the birth. Women in the randomised arm indicated willingness to partake but questioned midwives’ commitment to offering waterbirths. A Q Methodology study was undertaken to identify factors which influence midwives’ (n=31) attitudes towards waterbirths. Four factors were identified: Motivation, Risk Assessment, Confidence, Safety. Conclusion: It is feasible to organise a larger RCT to assess neonatal safety and women would be supportive. Strategies would be required to ensure midwives are confident and supportive of the waterbirth service.

ANCA-associated vasculitis (AAV) is characterised by macrophage and neutrophil infiltration at the site of injury. Animal models have been used to study the disease and to try different treatment approaches. The aim of this study was to investigate the involvement of the innate immune system in AAV. This was done by looking at different innate immune system components such as macrophages and neutrophils. There were a large number of CD68+ cells in the crescent region of the kidney following treatment with anti-MPO antibodies and LPS. Serial section staining has shown that these cells are more likely to be classically activated macrophages. Furthermore, gene expression studies have confirmed the up regulation of genes associated with classically activated macrophages such as calprotectin. In addition, there was an up regulation of genes associated with macrophages accumulation such as CCR2 and CX3CR1. These macrophages could be involved in secreting TGF-β, which was up regulated, which can lead to an increase in extracellular matrix such as collagen. Blocking macrophage accumulation was evaluated using anti-mouse CCR2 which was effective in depleting GR1+ blood monocytes. However, there was no significant difference on the disease outcome following treatment with anti-mouse CCR2. This suggests a lesser role of macrophages in the development of vasculitis or that disease was mild and so an effect could not be identified. In addition, I investigated the variability in ANCA-induced neutrophil degranulation from healthy donors. I purified human neutrophils from healthy donors and treated them with different ANCA IgG samples. I found that these neutrophils responded differently to the same ANCA IgG as measured by neutrophil degranulation using ELISA. I tried to study the resulting metabolites using mass spectrometry but there was a considerable degree of technical variation which prevented making final conclusions. However, this was a novel approach and provided me with good ideas on how to take it further. I also looked at the III effect of pre-treating neutrophils with simvastatin. I found a significant reduction in ANCA-induced neutrophil degranulation following treatment with a statin. In conclusion, preventing macrophage infiltration did not have an effect on the development of the disease in mice. This could be because the disease was mild or because resident macrophages are more important than infiltrating ones. In addition, the microarray experiment has provided interesting results that could be used to find common pathways in mouse, rat and human. It also provided more information on genes that are upregulated in the kidney following AAV induction. This could be used to arrange the genes into pathways and biological processes to study the involvement of macrophages and other components of the innate immune system. Finally, simvastatin significantly reduced ANCA-induced neutrophil degranulation.

The global incidence of allergic reaction has been rising for years, especially within westernised urban areas. There is evidence that the interaction between pollen grains, environmental pollution and meteorological change is increasing the allergenicity of the pollen grain and consequently, increasing the misery of hay fever sufferers. Laboratory experiments have shown that the interaction of pollen with atmospheric oxidants such as ozone and nitrogen dioxide NO₂ can alter protein molecules that are present within the pollen grains via post-translational modification of the protein. Within the laboratory, birch pollen was exposed to atmospherically relevant exposures of gas phase NO₂ and ozone under a range of environmentally relevant conditions (temperature and relative humidity RH). The effects of the exposures on the biochemistry of the pollen grains were probed using proteomic approach. The morphological changes of unexposed and exposed pollen samples to RH, rainwater and NO₂, where observed under fluorescence microscopy and scanning electron microscope. The discoveries suggest that interaction between gas pollutants and pollen do exist and cause protein specific modifications; nitration. Detailed analysis of London Ambulance data compared to London temperature data is presented. The relationships established will allow for prediction of likely changes in ambulance demand (and illness types) that will be caused by seasonal temperature changes, increased frequency and intensity of extreme weather events, due to climate change, in the future. The study applied statistical analyses to examine short-term associations between birch pollen count with allergic related illnesses recorded in the London Ambulance data, temperature and NO₂.

High frequency activity (>100 Hz, HFA) is suggested to be related to seizure genesis, but the mechanism of the HFA is not clear. In the present work HFAs and epileptic features including electrographic seizures (trains of hypersynchronous population spikes lasting ~46 sec) and interictal discharges (abrupt potential deflections, ~40 ms) were induced in rat hippocampal slices by increasing potassium concentration in artificial cerebrospinal fluid (8-10 mM, ACSF). We demonstrated that 1) the HFA was formed mainly by synchronous firing of pyramidal neurons while a subset of interneurons might contribute the HFA; 2) the frequencies of the HFAs were region-specific (186 Hz in CA1 and 240 Hz in CA3), and seizures were present only in CA1; 3) build-up of HFA preceding seizures was observed and it was disrupted by refractory periods triggered by interictal discharges, which were abrupt potential deflections present between seizures every 0.8 sec; 4) interictal discharges have both pro- and anti-effects on seizure genesis, and the dual consequences might be due to modifying HFA; 5) synaptic transmission through glutamatergic and γ-aminobutyric acid-ergic synapses were not essential in HFA formation but they were related to the modulations of HFA. Our findings suggested the crucial role of HFA in the seizure genesis and the potential value in seizure prediction by monitoring the HFA.