To some extent, 'adulthood' and 'adult identity' can be thought of as socially constructed phenomena, capable of evolving in response to societal consensus. For many typically developing young adults, the period that encompasses the transition to adulthood is thought to be elongating. In many ways, the traditional pathways to adulthood have eroded, leaving many young people feeling ambivalent about the process of growing up. Due to a combination of social and economic pressures and ideological shifts, young people are becoming increasingly likely to delay certain social role transitions, most notably marriage and parenthood, until their mid to late twenties and early thirties. Subjective adult identity, or feeling like an adult, is also thought to be taking longer to develop. For young adults with mild intellectual disabilities and their families, however, the transition to adulthood stands to be even more complicated. Developmental delay and difficulties adapting to change can have the potential to make service transitions harder to adjust to. These experiences might also be exacerbated by the fact that options for purposeful daytime activity can be limited for members of this population. Moreover, pervasive narratives of risk and vulnerability necessarily compete with a number of the normative outcomes of transition, most notably the development of self-determination and independence. Concerns about safety and security may therefore prevent parents and service providers from providing opportunities for positive risk-taking and experimentation. This is even though such experiences can make vital contributions to personal development and maturation. Through strategies such as Keys to Life and More Choice, More Chances, the Scottish Government has committed itself to help all young people to achieve positive transition outcomes. However, to date, there has been very little research undertaken to find out how young people with and without mild intellectual disabilities think and feel about the transition to adulthood, including their attitudes towards self-determination, independence, and autonomy. This thesis aimed to address this gap in the research by investigating young Scots' and their parents' experiences of, and attitudes towards growing up and adulthood. Using a mixed-methods approach, including semi-structured interviews, interactive flashcard activities, a vignette, and a questionnaire, data from over 100 participants have been collected and analysed. Our findings suggest that, despite high variation in the levels of autonomy experienced by the participants, young people with and without mild intellectual disabilities share complicated feelings towards the prospect of increased independence. Both groups, for example, hoped to work towards independence, albeit over different time frames, yet also voiced a degree of reluctance to adopt additional responsibility at home. The desire for an 'easy life', for example, appeared to be present in both groups, though genuine concerns about coping without support were more prevalent in the group with mild intellectual disabilities. Similarly, while attitudes towards parental support and interference were mostly positive in both groups, the majority of participants suggested that they would resist interference in personal, or private domains. However, there was some evidence to suggest that the young people with intellectual disabilities perceived the balance of power within their own families as more skewed towards their parents. With regards to the nature of adulthood and adult identity, our findings corroborate previous claims that individuals conceptualise adulthood in ways that are relevant and achievable to themselves. We found tentative evidence, for example, that the young adults with intellectual disabilities may prioritise interpersonal dimensions of 'responsibility' - such as looking after other people and fulfilling one's familial obligations - as being the most salient criteria for adulthood. In contrast, the typically developing participants appeared to focus on more individualistic expressions of responsibility, such as self-sufficiency, personal responsibility, and independent decision-making. Though speculative, our findings demonstrate that individuals with intellectual disabilities can have unique perspectives on universal phenomena that are not only interesting in their own right but may also have consequences for the broader literature. The implications of these findings for policy and practice are also outlined, as well as opportunities for future research.

The mechanisms that are involved in maintaining a human pregnancy to term, and the switches that lead to a normal labour and pregnancy outcome or indeed an adverse outcome such as miscarriage, pre-eclampsia (PE), fetal growth restriction (FGR) or preterm labour, are complex but the role of the placenta is crucial to them all. Heat shock proteins (HSPs) play an important role in regulating signal transduction, inhibition of apoptosis and cellular proliferation and differentiation. Apoptosis has been implicated in both PE and labour. In the apoptotic pathway, HSPs act at several stages to prevent cell death initiated by stress-induced damage. Toll-like receptors (TLR) are the principal signalling molecules through which mammals sense infection. Since these pathways play a role in oxidative stress and inflammation, both features of labour and PE, the hypothesis was that placental stress pathways (HSP70, HSP27, HSF1-2, small HSPs family, DNAJAB, HSP60, GRP78, HSP90AA, HSP90B1 and HSP105), inflammatory mediates (TLRs, MyD88 and NF-κB) and apoptotic markers (caspases (CASP) 3, 7 and 9) pathways expression would alter during labour and pregnancies complications such as PE and FGR and this would vary in different placental zones perhaps due to the variation in blood supply to each zone or link to ischemic-reperfusion (IR) injury and are some zones of placenta more susceptible to IR injury. HSPs, TLRs and caspases were examined in placentas obtained from women who delivered by caesarean section (non-labour) and were not in labour and compared to the equivalent zone of placentas obtained from women who delivered vaginally (labour) following an uncomplicated labour. Samples were obtained from 12 sites within each placenta: 4 equally spaced apart pieces were sampled from the inner, middle and outer placental regions. The expression was investigated by Western blotting (HSP70, HSF1, HSP27 and P-HSP27) and real time PCR (HSP families, HSF1-2, TLRs, MyD88, NF-κB and caspases). The first aim of this study was to examine the spatial expression of HSPs, caspases and TLR genes in placentas. Two HSF1 forms were observed in all samples which, according to the data sheet represent the phosphorylated (P-HSF1) and non-phosphorylated (NP-HSF1) forms. HSP70, HSF1 and HSP27 are expressed in a spatial manner in the placenta with the highest expression being in the middle zone in the labour group (HSF1, both forms) and in both the labour and the non-labour groups (HSP70 and HSP27). HSF1 mRNA expression was spatially distributed in the non-labour group with highest expression being in the outer zone. No spatial differences were noticed in both P-HSP27 protein expression and mRNA expression of other HSPs families, HSF2, TLRs, MyD88, NF-κB and caspases3, 7 and 9 genes. Human parturition involves interaction of hormonal, neurological, mechanical stretch and inflammatory pathways and the placenta plays a crucial role. The second aim of this study was to determine these genes expression in the non-labour group compare to the labour group at the inner, middle and outer placental zones. When non-labour groups were compared with the labour group at the three zones the changes found can be summarized as follows: HSP70 protein expression was increased in the labour group compared to the non-labour group and in contrast to that, HSP27 protein and mRNA expression were increased in the non-labour group both at the middle zone. Phosphorylated-HSP27 (P-HSP27) expression was increased in the non-labour group compared to the labour group at the inner (all ser sites) and outer (ser 15 and 78) zones. No differences were found at the middle zone. HSF1 protein expressions (both forms) was increased in the non-labour, group compared to the non-labour group, paradoxically, HSF1 mRNA expression was increased in in the labour group at the inner zone. HSPB6, HSP32 and DNAJB1 mRNA expression was increased in the non-labour group compared to the labour group at the middle zone. HSPB2, HSP90AA and HSP90B1 mRNA expression was increased in the labour group compared to the non-labour group at the outer zone. TLR5 and CASP7 mRNA expression was increased in labour group compared to the non-labour group at the middle zone. TLR9-10 mRNA expression was neglectable. No other changes were found for any other genes. PE is associated with maternal and placental oxidative stress. The third aim was to determine the expression of genes of the same pathways described above in the placenta in pregnancies complicated with PE and FGR compare to the normal pregnancies. HSPs, TLRs and caspases were examined in placentas obtained from non-labouring women who delivered by caesarean section (normal pregnancy and PE) and compared to women who delivered vaginally (normal pregnancy and PE). Samples were obtained from 12 sites within each placenta: Four equally spaced apart pieces were sampled from the inner, middle and outer, however, due to time constraints only the inner and middle zones were investigated in PE group (except HSP27 and HSP70). Samples from FGR placentas were obtained from 8 sites within each placenta represent inner and outer zones. Western blotting and qRT-PCR was used for the analysis as required. When PE (non-labour and labour) and FGR (labour only) groups were compared with the controls (non-labour and labour) at the two zones, the changes found can be summarized as follows: HSP70 was increased in the non-labour-PE group compared to the non-labour control group at the inner zone. No other differences were found. Non- Phosphorylated-HSF1 (NP-HSF1) protein expression and HSF1 mRNA expression were increased in the PE group (non-labour and labour) compared to the control group (non-labour and labour) at the inner zone. HSP27 and P-HSP27 protein expression was increased in the PE (labour) compared to the control (labour) at the middle zone. No changes were found in the mRNA expression of HSP27. There was a significant increase in P-HSP27 protein expression in labour PE compared to the labour control at the inner (ser 78 and 82) and middle (ser 15) zones. CASP7 and CASP9 mRNA expression was increased in the non-labour control compared to the non-labour PE at the inner (CASP7) and middle (CASP9) zones. CASP3 mRNA expression was increased in the labour PE compared to labour control at the middle zone. There was decreased in mRNA expression of HSPB6, TLR5 and TLR1 in the PE group non-labour compared to the controlnon-labour at the inner (HSPB6) and middle (TLR1 and TLR5) zones. Towards the end of the PhD time preliminary experiments were performed to determine if different zones of the placenta were more susceptible to heat shock and IR injury in vitro. The markers mentioned above were used and pieces of placenta from each zone were exposed to 2% oxygen then 8% oxygen for different time periods to create an IR model. The number of experiments were not sufficient to make definitive conclusions but the pilot data suggest this should be explored more in future studies include more placenta tissue exposed to IR injury and heat shock to understand how placental stress might affect placental function. Obesity is characterized by a chronic, low-grade inflammation and an impaired intracellular stress defence system. Obesity increases the risk for PE. The last aim was to screen for different HSPs and CASPs families in placentas obtained from 4 BMI groups (non-labour). In general, HSPs expression was reduced whereas caspases expression was increased in the morbid obesity group (BMI > 40) compared to the normal BMI group. This indicates reduced cellular protection and increased cellular damage respectively in placentas from obese women. In summary this thesis has reiterated the importance of controlled sampling of the placenta for studying pregnancy disorders. The results show that spatial changes in inflammatory and stress markers occur in both labour and PE. / Trying to make sense of the data is very difficult however the preliminary data from the in vitro studies suggests that further studies exposing different zones of the placenta to stress may help to understand the process that take place during stress. Clearly the bigger aim would be, one day, to try and decide which of the pathways might be targeted for therapy for pre-term labour and PE.

Multiple Sclerosis (MS) is a chronic, progressive disease which presents as a variety of cognitive, motor and sensory deficits (Compston and Coles, 2008). Pain is one of the most common and often severe symptoms of the disease. It is associated with poorer general health, and its management is therefore an important therapeutic target. People with MS can suffer from neuropathic pain as a direct result of damage to the central nervous system, or nociceptive pain, as a result of changes to the musculoskeletal system, secondary to disease progression. This was the first epidemiological study to measure the prevalence, characteristics, and impact of MS-related pain, using validated, IMMPACT-recommended measures. Neuropathic pain, common in MS, is a challenge to manage and is shown to impact on a person health-related quality of life (HR-QOL). Subsequently, the second part of this study explored the impact of Transcutaneous Electrical Nerve Stimulation (TENS) on neuropathic pain in MS, in a randomised controlled trial. A postal survey design was used to target the MS population of the NHS Ayrshire and Arran health board area, who completed a questionnaire on their pain experience (n=302). Clinically significant pain, defined as ongoing bothersome pain, was experienced by over two-thirds (71.5%), whilst chronic pain, defined as pain present for at least six months, was experienced by over half (59.2%) of the MS population. Neuropathic pain, assessed using the PainDETECT screening tool, was experienced by almost one third (32.7%) of the sample, with a further 14.7% identified as potentially having neuropathic pain. Thus 47.4% of the sample could potentially have neuropathic pain, which is higher than previous estimates, and that experienced by the general population. Approximately half the population experienced painful tonic spasms (44.5%) and dysaesthetic pain (56.2%). Burning pain, unpleasant paraesthetic sensations (i.e. crawling, tingling), and sharp pain were commonly experienced in the population with neuropathic pain. Multiple logistic regression analysis revealed Type of MS (p=0.001) and disability level (Guys Neurological Disability Scale (GNDS) (p<0.001) as independent predictors of neuropathic pain, possibly related to the pathophysiology of the disease. Neuropathic pain was shown as statistically more severe (using the 11-point Numerical Rating Scale of pain intensity (NRS-11) (p<0.001), more emotionally unpleasant (using the SF-MPQ) (p<0.001), with greater sleep disturbance (p<0.001), than nociceptive pain. Despite over two-thirds (68.5%) of those with neuropathic pain currently using prescribed, pain-relieving medication, over half (53.7%) still experienced severe (7-10 on NRS-11) pain. The presence of neuropathic also had a significantly negative impact on HR-QOL (EQ-5D) (p<0.001). The results of the epidemiological study increase understanding of the extent and demanding nature of pain in MS. Clinically, it will also facilitate timely screening for the neuropathic pain subtype, to minimise its impact on HR-QOL. Following the epidemiological findings, a randomised, double-blind, placebo-controlled trial, explored the efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) in the treatment of chronic, neuropathic pain in MS (n=46). Participants were recruited from the MS Service, NHS Ayrshire and Arran, with a diagnosis of lower limb neuropathic pain (score of ≥19 on the PainDETECT Screening tool for neuropathic pain), experienced for a minimum of six months. For the active TENS group, standard ‘Conventional’ TENS settings were applied, whilst a low frequency, low intensity, long pulse duration electrical current was used for the placebo application, which has no known analgesic effect, but still provides a sensory stimulus. Both groups used the TENS machine for a minimum of four hours/day, for a two-week period. Two long self-adhesive, hypo-allergenic electrodes were placed paravertebrally over the lumbar spine to stimulate the spinal nerve roots. The primary outcome measure was the (NRS-11), whilst secondary outcome measures included the Neuropathic Pain Scale (NPS), and the Patients Global Impression of Change (PGIC). Level of pain related interference on function was measured using the Brief Pain Inventory (BPI). Compared to the control group, the group receiving active TENS demonstrated a statistically (p<0.001) and clinically significant reduction in the intensity of neuropathic pain over the two-week intervention period. It was particularly effective for the burning, and sharp neuropathic pain qualities, that were commonly associated with neuropathic pain in the epidemiological study. TENS was also shown to reduce the emotional unpleasantness of pain (the affective component), which was high in those with neuropathic pain in the epidemiological study. This may have implications for the role of TENS in managing the psychological aspect of chronic neuropathic pain. TENS has no effect on pain–related interference on function, possibly due to the relatively short TENS intervention period. Future studies should explore longer intervention periods to explore the longer-term effects of TENS for pain in MS. The pharmacological management of neuropathic pain is not without its challenges. TENS as an inexpensive, non-invasive modality, with no side-effects, could be considered for the management of neuropathic pain, a common phenomenon in the MS population.

Cardiovascular disease (CVD) has become the most common cause of mortality worldwide, accounting for approximately 30% of all deaths. The primary pathological process that underlies it is atherosclerosis. Atherosclerosis leads to the development of flow-limiting lesions that accumulate over years to decades under the stimulus of genetic and environmental factors. These contribute to both impaired tissue oxygen delivery with resultant clinical symptoms and acute coronary syndromes carrying a significant burden of morbidity and mortality. Within the UK population, 28% of premature deaths in men and 20% in women are attributable to CVD carrying an estimated £30bn annual economic cost. Myocardial revascularisation in the form of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are established therapies for both acute coronary syndromes and symptomatic chronic disease refractory to pharmacological therapy. CABG remains the standard for patients with complex multi-vessel disease however in patients with less complex disease PCI is a reasonable alternative, and remains the gold-standard for patients with simple, focal CAD. The long-term results of CABG are limited by the failure of conduit grafts leading to recurrent symptoms, MI and/or repeat revascularization that carries with it a significant excess risk. Despite advancements in surgical technique and adjunctive medical therapy, the commonly used saphenous vein grafts are constrained by a cumulative graft failure rate of 50% at 10 years. Intracoronary stents, used for PCI are limited by the restenosis or thrombosis of stented vessel segments, phenomena that also confer significant morbidity and mortality. Vein graft disease (VGD) and in-stent restenosis (ISR)/thrombosis share similar pathological features related to the response to vessel injury, principally thrombosis, the development of neointimal hyperplasia, impaired endothelialisation and accelerated atherosclerosis. Gene-therapy remains a potential alternative to the use of pharmacotherapy for the prevention and treatment of these important clinical entities. Preclinical studies have provided a greater understanding of the underlying mechanistic pathways in both VGD and ISR and have provided insight into potential pathophysiological targets for manipulation with gene therapy. However, as yet, translation to the clinical setting has been less successful. Although stent technology and associated clinical outcomes continue to improve, preclinical studies suggest that gene therapy with a safe and stable vector expressing endogenous proteins that restore normal vessel physiology can be an intuitive alternative to cytotoxic drugs for the prevention of stent complications. The principal aim of this PhD was to investigate alternative approaches to the prevention of coronary in-stent restenosis. It was initially planned to do this using a gene therapy approach with development and delivery of therapeutic viral vectors to a large animal model of ISR. Subsequently an interest was taken in the role of microRNAs in the development of neointimal hyperplasia and the potential for their therapeutic modulation in the prevention of ISR and use as cardiovascular biomarkers. Initial experiments focused on the assessment of adenoviral and lentiviral vectors for the transduction of human coronary artery smooth muscle cells (HCASMC). The dedifferentiation of vascular smooth muscle cells (VSMC) to a proliferative and migratory phenotype from their differentiated contractile state is a key process in the development of neointimal hyperplasia. Unmodified adenoviral (Ad5) and second-generation lentiviral vectors were used to transduce HCASMC in vitro. Successful gene expression was achieved with both vectors, however, in keeping with previous studies significant transduction with Ad5 could only be obtained at higher viral concentrations. Lentivirus was much more efficient, showing significant cell transduction at low viral doses. It was initially planned to take this vector forward to an in vivo model but it unfortunately proved time consuming and prohibitively expensive to produce in large enough titres. Adenoviral vectors were therefore used for in vivo delivery. A local delivery catheter approach, for the delivery of an adenoviral vector was tested ex vivo and successful viral transduction of explanted porcine coronary arteries was obtained. The Clearway RXTM (Atrium Medical) perfusion balloon catheter was designed to deliver a therapeutic agent directly to intra-coronary lesions. It was therefore hypothesized that it may be able to effectively deliver a gene-delivery vector. A porcine model of coronary stent delivery and overexpansion has been shown to develop consistent vessel injury and the development of neointima. This was therefore used to assess the ability of the Clearway RX to deliver an adenovirus expressing β-galactosidase. Measurable viral transduction of the arterial wall was not obtained most likely due to the Clearway being unable to maintain viral contact with the vessel for long enough to achieve significant transduction. Similar issues affected the only other commercially available local delivery catheter, the GENIETM which forms a therapeutic drug reservoir between two occlusive balloons. Again, long enough incubation times to mediate unmodified Ad5 arterial transduction could not be obtained and the pigs tolerated the procedures poorly. To overcome these issues a virus-coated stent was developed using the spray-coatable YukonTM stent system and a Poloxamer 407 gel with thermoreversible properties. Poloxamer 407 has previously been used to successfully augment adenoviral transduction in small animal models. This system was therefore tested in the porcine model. No viral transduction of the vessel wall was obtained and analysis of distal organ sites confirmed off-target viral sequestration. Interest turned to the investigation of the role of microRNAs (miRs) in the development of in-stent restenosis. miRs are short, non-coding ribonucleic acids that act to control gene expression at a posttranscriptional level. Several miRs have been shown to play key roles in establishing smooth muscle and endothelial cell fate, tissue homeostasis and are now implicated in the complex regulation of the phenotype of cell types involved in vascular remodelling and the development of ISR. Using in vitro models of VSMC proliferation and migration, the dynamic expression of regulatory miRs implicated in the control of VSMC phenotype was assessed. These experiments suggested that miR-21, miR-146a, miR-221 and miR-365 overexpression may contribute to the promotion of a dedifferentiated VSMC phenotype in the development of human neointimal lesions. The results for miR-143 and miR-145 were less clear however. It was hypothesised that expression patterns of these regulatory miRs in the vasculature would alter in response to stent-induced injury. All previously reported studies in this area have used in-vitro or in-vivo rodent models of vascular injury. A more clinically relevant large animal (porcine) model of in-stent restenosis was therefore utilised to assess the expression levels of miRs previously reported to play a role in VSMC regulation as well as novel targets. RNA was extracted from vessels snap frozen at the time of sacrifice and changes in miR expression within the vessel wall were determined using quantitative real time PCR (qRT-PCR). Using an electrolysis method to achieve stent dissolution it was possible to use in-situ hybridization to co-localise dysregulated miRs within neointimal lesions. Both miR-21 and the miR-143/miR-145 cluster appear to play a key role in the regulation of VSMC phenotypic switch and are shown to be both dynamic and significantly upregulated in developing neointima following stent implantation.

Mood problems are common in stroke survivors, as are communication difficulties, which are experienced in around a third of patients. Patients with communication difficulties have a greater risk of depression. Despite this they are often excluded from trials that either treat or prevent depression using talking-therapies, such as Motivational Interviewing (MI). Through a series of studies this thesis aims to explore the feasibility of widening access to MI for patients with moderate to severe communication difficulties. In the first study, a secondary analysis of data from an earlier MI trial with stroke patients explored the communication characteristics of participants. Patients receiving MI were shown to benefit in mood compared to those receiving usual care, and this was more prominent in those with communication difficulties. The analysis found that no individual component of communication could account for changes in mood outcome. This highlighted the need for suitable tools to assess communication and mood in patients with communication difficulties post-stroke. Through a series of integrative reviews, tools suitable for the screening and assessment of communication and mood in patients with communication difficulties were explored. A number of tools were available, however few had been adequately validated in this patient group. Of the tools considered in the review, a small number were identified as suitable. Using the tools identified, a feasibility study explored delivering MI to patients with communication difficulties after stroke. The study found that with the implementation of aids and adaptations for communication difficulties, it is possible to deliver MI to patients with moderate to severe communication problems. The final study explored the implementation of the intervention from the perspective of staff involved in the trial. Firstly, views of screening and recruitment were explored through interviews and analysis of the trial screening log. Further interviews were held with MI therapists before and after the trial. Perceived barriers to their roles within the study included holding dual roles, and facilitators included feedback from supervisors. This thesis has contributed to knowledge, showing that through the use of aids and adaptations for communication difficulties, it is feasible to widen access to MI for patients with moderate to severe communication problems. The thesis has further added to knowledge through exploring staff views of implementing the intervention.

Approximately 70% of spinal cord injured patients suffer from pain and it is estimated that in 40-50% of these, the pain is of central neuropathic origin. This pain can be perceived to originate at, or below the level of injury and both evoked and spontaneous pain can occur. Neuropathic pain after spinal cord injury (SCI) is difficult to treat and often poorly controlled by the currently available analgesics so that development of better treatments is an important need. Current ideas about the treatment of SCI pain are that different approaches may be needed to treat the different types of pain (e.g. evoked and spontaneous, at level and below level) as they may have different mechanisms. However, this mechanistic approach to treatment is hampered by a poor understanding of the underlying mechanisms. This in turn depends on development of animal models and pain assessment techniques suitable for mechanistic studies. In this thesis, several rodent SCI models have been investigated using a range of assessment techniques some of which were developed in the course of the study. Contusion injuries at a low thoracic level are currently the most popular model used to investigate central neuropathic pain in rodents. However this model and the assessments used with it are subject to a number of limitations. We therefore began by re-evaluating this model using a relatively severe (200 kdyn) injury since this is indicated in the literature as being necessary for the development of robust signs of neuropathic pain. We found that this model showed robust signs of tactile allodynia and thermal hyperalgesia of the forepaws and in addition by developing new tests, were able to demonstrate cold allodynia and hyperalgesia. Although the hindpaws also showed responses that would normally be interpreted as mechanical allodynia and thermal hyperalgesia, the absence of accompanying supraspinally mediated behaviours (including licking following heat stimuli) indicated that the enhanced responsiveness to these stimuli might not give rise to pain. Further investigation using operant testing supported this idea and tract tracing suggested that this may be due to substantial interruption of ascending nociceptive pathways. Testing over the back at locations confirmed electrophysiologically to involve sensory processing at, above and below the injury level supported the idea that increased sensitivity in this model developed at and above, but not below level. In addition, observations on the forepaws suggested evidence of spontaneous pain which has never been described in SCI models previously and provides an important opportunity for studying the underlying mechanisms. Because the 200 kdyn low thoracic model proved unsuitable for the study of below level pain we next investigated whether a less severe injury at this level would provide a better model. Injuries of 150 kdyn were found to result in most of the same indicators of pain following forelimb testing as were seen following 200 kdyn injuries but all signs were less pronounced, in particular, indicators of evoked pain. Testing over the back led to increased sensitivity below level which had not been evident in the 200 kdyn model, providing an opportunity for below level testing. However, interpretation of hindpaw tests remained equivocal. Because the low thoracic model showed features that suggested forelimb assessments were particularly useful for the assessment of above level pain of different modalities as well as spontaneous pain, we investigated the effect of moving the injury closer to the segments assessed by such tests. Injuries at the T3/T4 level were found to lead to enhancement of all of the behavioural signs seen in the 200 kdyn low thoracic injury animals, especially signs of spontaneous pain. This model may therefore be optimum for the assessment of above/at level pain. The work presented in this thesis provides the clearest and most comprehensive data yet on the utility of models of SCI for the investigation of central neuropathic pain and represents a significant advance in the field. The finding that injuries at low thoracic levels may (depending on injury severity) be unsuitable for assessment of below level pain has implications for previous studies of the mechanisms of post SCI pain, many of which have used exclusively hindlimb assessments in these models. The hope is that an improved understanding of the models used here and an improved ability to investigate different modalities of evoked pain, and in addition spontaneous pain, will enhance the quality of future research in this area and lead to both a better understanding of central neuropathic pain mechanisms and the development of more effective analgesics for this type of pain.

The peripheral nerve disorder Guillain-Barré syndrome (GBS) accounts for the most common cause of acute acquired paralysis in the Western World. Circulating anti-ganglioside antibodies (Abs) are considered important mediators of this disease. Research conducted in a mouse model of GBS has the revealed the neuromuscular junction (NMJ) as a potential site of anti-ganglioside Ab-binding, due to this structure lying outside the blood-nerve barrier. The ganglioside composition of the neural and glial components of the NMJ determines which of these structures are bound and in the following subjected to complement-mediated injury. Some patients suffering from the acute motor axonal neuropathy (AMAN) forms of GBS recovery very rapidly from paralysis; it has been proposed that in these patients the injury was restricted to the distal motor axons and nerve terminals (NTs), which are able to regenerate over a short time-frame. To test this hypothesis, the mouse model of GBS was combined with in and ex vivo imaging of the NMJ in the ventral neck muscles of mice expressing cytosolic fluorescent proteins in their axons (cyan fluorescent protein: CFP) and Schwann cells (green fluorescent protein: GFP). Following confirmation of the stability of NMJs in these mice over time, optimisation of in vivo imaging procedures and determination of the most advantageous Abs for these kinds of investigations, 45 mice were subjected to a single in vivo topical application of anti-ganglioside Ab followed by a source of complement. Group A (n=15) received Ab that selectively bound to the NTs, group B (n=15) received Abs that bound both to the NTs and the perisynaptic Schwann cells (pSCs) and group C (control animals; n=15) only received complement. Evolution of the injury was documented by in vivo imaging, and following euthanasia the muscles were reimaged ex vivo both quantitatively and qualitatively, either immediately, or after 1, 2, 3 or 5 days of regeneration (each n=3 per group). Within 15 minutes of complement application, a rapid loss of CFP overlying the NMJ could be seen; in group A, the GFP signal remained unchanged, whereas in group B the GFP signal was also lost. In group C no changes to either CFP or GFP were observed. At 24h, 6% of the superficial NMJs in group A and 12% of the NMJs in group B exhibited CFP; the CFP-loss extended proximally until the axons formed little bundles. In both groups, CFP returned within the next five days (group A: 93.5%, group B: 94%; p=0.739), with the recovery of CFP being preceded by a return of GFP-positive cells overlying the NMJ in group B. Both in groups A and B, the pSCs exhibited processes which extended beyond the normal NMJ boundaries and very occasionally accompanied by axonal sprouts. This behavior was similar to that of pSCs challenged by traumatic denervation of their NMJ, albeit the changes observed in the Ab-mediated injury were lower in frequency and less dramatic when compared to those observed following traumatic denervation. The rate of motor NT-regeneration corresponds well to rates observed following the application of spider or snake toxins, which mediate selective injury to the NTs. Auxiliary investigations revealed that the loss of CFP at the NMJ correlated with a loss of axonal architectural proteins (neurofilament (NF) heavy and light) and a return of CFP at the NMJ was accompanied by a return of NF heavy. Ultrastructurally, the injured NTs resembled NTs undergoing degeneration following a traumatic denervation of the endplate and following five days of regeneration, the NMJs exhibited a physiological morphology. The results described above indicate that following a single anti-ganglioside Ab-mediated and complement-mediated attack, independent of whether there are healthy and mature pSCs overlying the NMJ, the murine NT is capable of recovering its architectural, axolemmal and ultrastructural integrity very rapidly. This data supports the notion that an equivalent mechanism may account for the rapid recovery seen in some clinical cases of AMAN.

Clinicopathological and community studies have demonstrated misdiagnosis in Parkinson’s disease (PD). Clinical trials of antiparkinson medication have also shown a subset of patients labelled as having PD have normal functional brain dopaminergic imaging. Conditions commonly misdiagnosed as PD include Essential tremor (ET), vascular Parkinsonism (VP) and dystonic tremor (DT). This thesis examines the accuracy of clinical diagnosis of PD in a community setting by identifying misdiagnosed cases and supervising antiparkinson medication withdrawal. Prescription database searches and GP case record review were carried out in 92 West Scotland GP practices within a population of 511,927. 610 patients on antiparkinson medication for a PD diagnosis were identified and age-adjusted prevalence was 129.5 per 100,000. Patients were invited for assessment if there was (a) no increase in dopaminergic drug dose or (b) no recorded progression of disease over time, suggestive of possible misdiagnosis. 64 patients were assessed and this was supplemented with FP-CIT SPECT scanning in 25 uncertain cases. Patients considered unlikely to have PD were advised to reduce and discontinue antiparkinson drugs, with repeat PD motor scoring over 6 months. 33 of 64 patients (51.6%) successfully completed antiparkinson medication withdrawal. An age, sex and disease duration matched control group was also assessed. The selection criteria allowed identification of a high proportion of misdiagnosed cases and FP-CIT SPECT was a useful diagnostic tool for assessing patients (previously diagnosed as PD) in whom there was diagnostic doubt.

Aims The Sodium Iodide Symporter (NIS), which is located in the basolateral membrane of the thyroid follicular cell, catalyses an active transport mechanism allowing Iodide, an essential component of the thyroid hormones Tri-iodothyronine(T3) and Thyroxine(T4), to accumulate in the thyroid gland. Differentiated thyroid cancers retain the appearance and function of normal thyroid cells, and can, therefore, trap iodine. Radioiodide scintigraphy and therapy are based on the uptake of radioiodide by NIS in thyroid tissue, which can concentrate all isotopes of iodine. Breast cancer is the most common type of cancer in women in the UK, and is the second most common cause of cancer-related death in women in the UK. This situation remains true in Scotland, with breast cancer representing 27.5% of all female cancers. Despite a reduction in mortality figures between 1994 and 2004 of 18%, five year survival in Scotland remains only 80.2% for patients diagnosed between 1997 and 2001. When breast cancer recurs and becomes metastatic it is treatable, but not curable. Median overall survival of patients with metastatic disease remains poor, and is currently between one and two years. It is clear that metastatic breast cancer remains a challenging clinical issue and novel treatments are required. Radionuclides play an important part in the management of malignancy, including prostate cancer, neural crest tumours, and thyroid cancers. There is evidence that there may be a role for radionuclide therapy in breast cancer via the NIS mechanism. This was first suggested by Tazebay's landmark work in 2000, which demonstrated that a significant proportion (87%) of breast cancers contained detectable NIS protein by immunohistochemistry(IHC). Experimental design Tumour samples from patients with breast cancer were analysed by immunohistochemistry and ribonucleic acid(RNA) analysis, and this was correlated with functional activity of the NIS protein, by scintigraphic scanning of patients with metastatic breast cancer. Results Twenty-four patients had a Tc99m Pertechnetate scan; 20 patients had their RNA analysed; 22 patients had IHC performed on their tumour samples. NIS was detected only in the control Graves thyroid RNA and paraffin embedded cells extracted from a NIS expressing cell line. Breast tumour sample RNA did not demonstrate NIS. By IHC, 15 cases were defined as truly immunopositive, with the criteria for true positivity being a Histoscore of > 150, or demonstration of membrane staining. Seven cases were negative by the above criteria. Tc99m Pertechnetate uptake was observed in 11 of 24 patients who were scanned ie 46%. Of these 15 patients with positive expression of NIS in their breast cancer tissue sample, as measured by immunohistochemistry, 14 cases were also scanned. Of these, eight patients(57%)demonstrated uptake of Tc99m Pertechnetate on scintigraphy ie were true positives; six did not, ie their screening test (IHC) had incorrectly predicted positive uptake on subsequent scanning (false positive screening). Therefore, a positive predictive value of 57% was observed when using IHC as a screening test for detecting those patients who would go on to have a positive scan. In contrast, six patients had negative NIS expression by IHC, and no uptake on scintigraphy, ie true negatives. Only one patient had a false negative screening IHC result. A negative predictive value of 86% was seen when using immunohistochemistry as a screening test for detecting those patients who would have a negative scan. Sensitivity was 88%, with a specificity of 50%. Conclusions This data has shown that the prevalence of patients with metastatic breast cancer expressing NIS on IHC is relatively high (68%), when compared with one other published study of similar patients. Also, it has been demonstrated that a high proportion of NIS IHC positive patients who were scanned (57%) demonstrated uptake of Tc99m Pertechnetate in breast cancer primary or metastases. It can be concluded that IHC does act as a useful screening test for those who may ultimately benefit from radioisotope treatment. The most appropriate radioisotope for therapy remains to be determined.

This thesis describes the behavioural compensatory responses and metabolic changes in response to a single exercise session and training programmes in overweight and obese women and consists of a literature review (Chapter 1), a general methods chapter (Chapter 2), three experimental chapters (Chapter 3- Chapter 5) and a general discussion and conclusions chapter (Chapter 6). Experimental chapter 3 presents a study which aimed to investigate the impact of a single moderate-intensity cycling exercise session with energy expenditure of approximately 2 MJ on appetite measures, energy intake and metabolic variables in response to four ad libitum meals in overweight and obese females. Twelve sedentary, overweight and obese women underwent one exercise and one control trial each over two consecutive days. Appetite and metabolic variables such as glucose, insulin and triglycerides were measured frequently and four buffet meals were served throughout each trial. The findings suggest that a single exercise session performed by overweight and obese women does not elicit compensatory responses in appetite and energy intake and reduces triglyceride concentration by 17% in response to an ad libitum breakfast consumed 14 hours after exercise. Chapter 4 aimed to examine the extent to which changes in physical activity outside of the exercise intervention and energy intake contribute to individual differences in body fat loss induced by exercise training programmes. To determine this, thirty-four overweight and obese sedentary women participated in a structured and supervised 8-week exercise programme consisting of 150 minutes of cycling exercise per week. Body composition, total energy expenditure and components such as exercise, activity, sedentary and sleeping energy expenditure as well as energy intake from 7-day weighed intake were determined before and during the last week of the exercise intervention. The findings indicate that overweight and obese women who during exercise intervention achieve lower than predicted fat loss are compensating by being less active outside exercise sessions. The aim of Chapter 5 was to investigate how physical, fitness and metabolic characteristics of overweight and obese women are influenced by two 8-week supervised aerobic exercise programmes with exercise sessions conducted twice per week for the duration of 75 minutes and with exercise sessions conducted 5 times per week for the duration of 30 minutes. Thirty-four women were randomised into either long and less frequent or short and more frequent cycling exercise groups. Body composition, fitness and metabolic variables were measured prior and after the intervention. The findings indicate that frequency and duration of exercise sessions does not alter the effects of an exercise programme on health related outcomes which were evident in the absence of weight loss, when the total volume of exercise undertaken is the same. Based on obtained data the following conclusions have been drawn: Overweight and obese women do not compensate in terms of appetite and energy intake for the energy expended in a single exercise session, when this is in line with recommended expenditure for individual exercise sessions aimed at body weight and body fat reduction. Compensatory responses in terms of changes in energy intake are also not evident in overweight and obese women participating in an 8-week exercise training programme. However, predicted body fat loss can be expected to match the amount of fat actually lost only in those who do not decrease physical activity outside exercise sessions. A single exercise session with energy expenditure similar to that recommended for individual exercise sessions aiming at body mass and body fat reduction, reduced triglyceride concentration by 17% in response to an ad libitum breakfast consumed 14 hours after exercise. Changes in fitness, insulin resistance, diastolic blood pressure and waist circumference in sedentary overweight and obese women induced by an 8-week exercise programme incorporating 150 minutes of exercise per week are independent of frequency and duration of exercise sessions with 2 x 75 minute exercise sessions per week and 5 x 30 minute exercise sessions per week eliciting similar changes.