Homecare re-ablement services have been widely implemented by local authorities in England, although there are widespread variations in relation to occupational therapy input within them. These services aim to improve users’ ability to manage independently at home and reduce the need for other health and social care services. It is not known whether outcomes are better for people who receive occupational therapy as part of their homecare re-ablement compared with those who do not. This thesis reports a programme of work investigating this, encompassing: a systematic review, a qualitative interview study, and a feasibility randomised controlled trial (RCT) of an occupational therapy intervention targeted at activities of daily living (ADL). For the systematic review, 11 databases were searched and 13 studies were identified comparing interventions to improve performance in ADL with routine homecare. The review found variability in the content of interventions delivered and the measures used for ADL ability. However, there was moderate evidence that the interventions led to improvements in ADL ability, although most effects were not statistically significant. Those interventions involving occupational therapists led to improvements in ADL, but the content of the occupational therapy input varied. Semi-structured qualitative interviews were completed with 12 occupational therapists working in re-ablement services and ten people who had received re-ablement services. Interviews covered experiences and opinions of the service, and were analysed using thematic analysis. Findings were categorised in three themes: (1) Re-ablement: Tasks and Activities (2) Re-ablement: Modalities and Strategies for Delivery, and (3) Facilitators and Barriers. The occupational therapists’ primary focus was delivering graded programmes to improve users’ ability to manage ADL, which they believed they were uniquely placed to provide and tailor to each individual’s needs. People using services valued this graded approach believing that it improved their confidence to manage activities. A feasibility randomised controlled trial (RCT) was conducted in which 30 re-ablement users were randomised to receive either: usual homecare re-ablement without routine OT input (control) (n=15), or usual homecare re-ablement plus a tailored OT programme targeted at ADL (intervention) (n=15). The OT programme was tailored for each participant and included: goal-setting; teaching or practising techniques; equipment and adaptations; and provision of advice or support. Outcomes were: personal and extended ADL; quality of life; falls; and health and social care service use. These were assessed at two-weeks, three and six months post re-ablement. Although there were methodological challenges due to service changes which affected usual care and trial recruitment, it was feasible to enrol and retain participants, deliver the intervention, and collect outcome data which were responsive to change. Participants in both groups showed improvements from baseline, although overall the OT group showed greater improvement; they also used homecare services less frequently and had fewer falls. However, confidence intervals were wide, reflecting the small sample. The intervention was acceptable to participants who particularly valued the tailored advice and support. The principal conclusions were that there is some evidence that interventions targeted at personal activities of daily living can reduce homecare service users’ dependency. Although the content of interventions is variable, those involving occupational therapists appear to be beneficial. Occupational therapists believed that their specialist skills and knowledge in ADL performance were essential facilitators implementing an approach which was suited to each individual’s needs and therefore to successful re-ablement. The RCT was feasible and a further powered definitive study is warranted, subject to methodological alterations. The favourable trends in the OT group indicate the potential benefits in this population group. This is the first RCT of occupational therapy in homecare re-ablement and it is therefore important in the development of the evidence base for this area of practice. A definitive RCT is needed given the widespread national and local government investment, and policy and legislation that continues to underpin the development of homecare re-ablement services.

This thesis explores the views and experiences of people with lung cancer, and family members, of discussing preferences and wishes for end of life treatment and care. It presents an interpretive analysis based on the application of a constructivist grounded theory approach. Study participants included: eighteen men and seven women with lung cancer and nineteen family members. Participants were mainly from lower socio-economic groups living in the north of England. Single, joint and group interviews were used to gather data. Interview transcripts were analysed using a constant comparative method and conceptual models were drawn to aid the development of the theoretical interpretation. The study found that preferences and wishes for future care and treatment were not the main concern of people with cancer; rather, any concerns for the future were about the social aspects of death. Participants talked about their experiences of facing death whilst striving to live in the present. Planning for one’s own dying and eventual death was not something that people with lung cancer reported having discussed, except when, out of concern for their families, practical arrangements needed to be made following death. The disclosure of a poor prognosis had a huge emotional effect on participants, who ascribed a variety of meanings to this news. Participants’ reported that clinicians usually focused on their disease; they did not recall being offered any ‘options’ or ‘choices’ for future care. They commented that their preferences and wishes for future treatment and care were influenced by their clinician, spouse, other family members and their knowledge of others affected by cancer. The theory ‘maintaining integrity in the face of death’ is proposed. This theory purports that patients with advanced lung cancer and their families focus on acting and talking as ‘normal’ to help them balance living in the present whilst facing death. This thesis makes several contributions to knowledge. First, it provides the views of people from an underrepresented group of cancer patients from lower socioeconomic classes who are rarely included in research. Secondly, it shows how people facing the end of their life place little importance on choice. They focus instead on living in the present and carrying on as normal, which challenges current UK policy that seeks to promote individual patient choice at the end of life through advance care planning. The study findings suggest that policy makers and health and social care professionals need to develop ways of helping people prepare for a ‘social’ rather than a physical or ‘medicalised’ death: a focus on developing advance care planning that provides information to support people’s practical needs at the end of life, delivered as a family intervention, thereby helping people living with lung cancer to maintain their integrity in the face of death.

Background: South Asians constitute the single largest ethnic minority group in the United Kingdom, yet little is known about their perspectives and experiences on end of life and its related care. Aim: To explore and critically examine views and perceptions about end of life issues among older South Asians living in East London. Methodology and methods: After gaining ethical approval, five focus groups and 29 in-depth, semi-structured interviews were conducted with total of 55 older adults (24 men and 31 women) aged between 52 to 78 years. Participants from six South Asian ethnic groups were recruited through 11 local community organisations. Where possible the focus groups and interviews were conducted in the participants' preferred language. Tape recorded multilingual data were translated and transcribed into English. Using a constructive grounded theory approach, data analysis resulted in the development of a theory of “continuity and reconstruction” that captured three categories of ‘home’; ‘family’ and ‘trust’ at end of life. Findings: The theory of “continuity and reconstruction” is explored in three ways. Firstly, the theory is explored through examination of beliefs, attitudes and expectations about the place of ‘home’ and ‘homeland’ in care of the dying. Secondly, the theory is explored as accounts of “family” in terms of how family are bound towards caring for their dying relatives at end of life and the importance of support from social networks in family care giving. Finally, the theory is explored in terms of how participants place “trust” in their family and medical professionals to lead any related discussion and to make decisions related to their death and dying. Conclusion: The theoretical framework of “continuity and reconstruction” explains how older South Asians make efforts to adhere to important social and cultural values relating to death and dying, while rebuilding and adapting those values during the challenges of living in an emigrant society. This study highlights the need for further exploration of family care giving needs among South Asian population and concludes by drawing attention to some practical implications for health professionals who are responsible for initiating end of life discussions and are involved in end of life decisions when caring for people from these ethnic minority groups.

The objective of this thesis was to assess the impact of altering macronutrient intakes on hepatic lipid metabolism. Two separate studies were performed, with liver triglyceride content being the principal outcome of both. In the first study 32 healthy and centrally overweight males were randomised to 2 periods, each of 2 weeks, of either a high fructose or glucose intake in a non-crossover fashion. Isoenergetic status was maintained by providing foodstuffs during the first period, followed by a 6 week washout and then a second period of ad libitum overfeeding. In the second study 55 patients with biopsy proven non-alcoholic fatty liver disease were randomised to 3 months 5g a day of capsules containing either n-3 polyunsaturated fatty acid or oleic enriched sunflower oil. The main findings are summarised. High intakes of fructose and glucose in the isoenergetic period resulted in a stable weight, and no change in hepatic, serum and ectopic triglyceride content. There was a raised serum uric acid with fructose. During the hyperenergetic period there was a tendency for greater uric acid with fructose, whilst both groups had a matched weight gain, elevation of liver biochemistry and an increase in hepatic, serum and muscle triglycerides. Changes in liver biochemistry and triglycerides were associated with changes in weight. During both periods there was calorimetric evidence for a shift in whole body metabolism towards that reflective of a high carbohydrate intake. There was no alteration in renal function or cardiovascular haemodynamic parameters or consistent change in insulin resistance. The n-3 polyunsaturated versus oleic acid study resulted in significant alterations of serum fatty acid profiles between the groups, which were in line with the capsules’ contents. These changes however failed to translate, in the whole group, to any detected metabolic or hepatic changes beyond a reduction in serum triglyceride with n-3 polyunsaturated fatty acids. Only 43 of the 55 patients had elevated liver triglycerides on baseline MRI. Amongst this 43 there was a reduction in liver triglyceride with n-3 polyunsaturated fatty acids, but no other associated metabolic changes. The uric acid findings support the notion of fructose and glucose differing in their pre triose metabolism. There was however no differing outcomes in terms of lipid synthesis or storage. There was a suggestion of reduced liver triglycerides with n-3 polyunsaturated fatty acids though this was an isolated result only found amongst those with a steatotic liver at baseline. Ultimately the exquisite sensitivity of the liver to nutrient intakes was highlighted by the 0.8% gain in weight in the fructose / glucose study resulting in a 24% increase in liver lipid. This affirms the notion that dietary energy intakes have a profound influence on hepatic metabolism, but there is no evidence from this thesis that this influence is macronutrient specific. In the future macronutrient comparisons need to be made.

No description available.

Lymphatic filariasis (LF) is an incapacitating disease caused by three filarial nematodes belonging to the family Onchocercidae, namely Brugia timori, Wuchereria bancrofti and Brugia timori. An estimated 90% of lymphatic filariasis cases globally are caused by Wuchereria bancrofti. To evaluate the success of the Global Program to eliminate Lymphatic Filariasis it is essential to monitor the frequency of larval infection in the mosquito vector. Molecular methods to detect Wuchereria bancrofti DNA in mosquitoes have been in existence since 1996. However these methods have not been widely adopted due to the high cost associated with them and the inability of these assays to distinguish between immature and infectious stages in the mosquito vector. The overall aim of this project was to modify, as previously described in literature, the Laney real time PCR assay to permit it to be used in an end point Reverse Transcriptase (RT)-PCR ELISA format. The endpoint PCR-ELISA uses inexpensive conventional thermocyclers and inexpensive reagents and probes. To accomplish this overall goal the specific objectives were to produce a positive control RNAs for Wb-cut-1.2 L3 specific RT-PCR and Wb-TPH RT-PCR that detects any stage of the parasite, and to adapt the detection of both transcripts to a PCR-ELISA format. Positive RNA controls were prepared and purified using template cDNA made available through FR3, subsequent development and optimization of the RT PCR ELISA was achieved through the adaptation of the Onchocerca volvulus O150 PCR ELISA protocol. We found a 16-fold difference in the limit of detection between the ELISA assay and conventional end point RT-PCR when we did a 2-fold dilution series of PCR products for both Wb-Cut-1.2 and Wb-TPH. This indicates that our assay was 16 times more sensitive than the use of regular agarose gel electrophoresis to analyze PCR products. The limit of detection with ELISA and gel analysis were comparable when a 10-fold dilution series of the positive control RNA template was done. The RT-PCR ELISA takes a day to complete and up to three 96 well plates a day can be processed compared to the limited number of samples that can be analyzed by gel electrophoresis a day. It is anticipated that our assay will be used in the molecular xenomonitoring of Wuchereria bancrofti providing earlier time-point assessments of LF infection in endemic areas. In areas that were once endemic, our diagnostic tool will play a pivotal role in monitoring LF resurgence.

This thesis is divided into four chapters, the first of which is theoretical and synoptic. The method of chapter 1 is threefold. Firstly, an examination of the idea of the late career, including previous research on the subject, common perceptions and archetypes, and a consideration of the nature of artistic self-consciousness as it influences the late career. Secondly, a discussion of old age in literature, including the context of gerontology, our typically equivocal picture of old age as both decaying and spiritualized, and a consideration of the mode of creativity of the aged. Thirdly, an examination of literary "endings": the point at which the poet is faced with formal conclusions and "last things." A number of topics associated with or generated by the late career are considered, particularly the summational impulse, confrontation with death, and engagement with posterity: three perspectives supplied by the moment of ending. In the three chapters which follow, I examine the structure of the late careers of Hardy, Yeats and Stevens, in particular the points of crisis and self-renewal, and including in each case works which precede the final phase. The evolving attitude of each poet to old age is examined, and a number of topics which seem intrinsic to the late career: monumental intentions and their decay, the fate of the poet's work in posterity, the dividing of the mortal body from the poetic corpus, the old man's introjected sexuality, and the heightened dualism of old age. Finally, in each case the "final gestures" of the poet are considered: his attempts to confront the demands of the literary "ending. "

Interaction with chlorethylclonidine has been used to subdivide populations of α1-adrenoceptors in some tissues. WB 4101 can distinguish high and low affinity states of the receptor. The present study was carried out to determine if different populations or affinity states of α1-adrenoceptors distinguished by either of these compounds, could explain the variation in α1-adrenoceptor agonist affinity found amongst rabbit arteries. Five arteries were studied whose affinity for noradrenaline vary between 4.8 and 6.4. These were the thoracic aorta, renal, superior mesenteric, ear and ovarian arteries. WB 4101 was found to be equally effective in antagonizing noradrenaline on all arteries. Chlorethylclonidine caused a 20-fold rightward shift of the noradrenaline dose-contraction curve in the thoracic aorta; but had little or no effect on the other vessels. Thus, the combination of different proportionsof subsets of α1-adrenoceptors distinguished by WB 4101 or chlorethylclonidine does not explain the variation in α1-adrenoceptor affinity found in these rabbit arteries.

No description available.

O Vírus Linfotrópico de Células T Humanas do tipo 2 (HTLV-2) é considerado pouco patogênico, mas o diagnóstico sorológico é importante para aconselhamento e acompanhamento. Os testes confirmatórios mais utilizados são o Western-Blot (WB) e a reação em cadeia de polimerase (PCR). Entretanto, em populações de alto risco como usuários de drogas intravenosas e a população indígena, cerca de 50% dos resultados indeterminados pelo WB resultaram como positivos para a infecção do HTLV-2, quando testadas pela PCR. Uma hipótese para a insensibilidade do teste WB utilizado no Brasil seria pelo uso de proteínas recombinantes procedentes de cepas que não circulam em nosso país. Outra possibilidade é o nível de imunossupressão, que pode acarretar uma menor produção de anticorpos anti-HTLV-2 circulantes. A carga proviral do HTLV-2 pode ser também um fator da pouca estimulação do sistema imune, o que resulta baixa quantidade de anticorpos circulantes. Este estudo testou três hipóteses e os resultados mostraram uma alta homologia na região do envelope viral quando alinhada com a seqüência de aminoácidos da proteína K55 utilizada no WB, independente do perfil do teste. A carga proviral do HTLV-2, assim como o estado de imunessupressão dos pacientes não foi importante para perfis indeterminados do Western-Blot. / Despite the human T-cell lymphotropic virus type 2 (HTLV-2) is considered low pathogenic, the serological diagnosis is important for counseling and monitoring. The most used confirmatory tests are Western Blot (WB) and PCR. However, in high-risk populations, about 50% of the indeterminate WB results when tested by PCR, in our study, confirmed the presence of HTLV-2. A hypothesis for the insensitivity of the WB used in Brazil would be the use of recombinant proteins from strains that do not circulate in our country. Another possibility is the level of immunosuppression, which may lead to lower production of anti-HTLV-2 circulating. The viral load of HTLV-2 can also be a factor of little stimulation of the immune system, resulting low amount of antibodies. This study tested the three hypothesis and we showed that high homology in the region of immunogenic viral envelope when aligned with the sequence of amino acids of the protein K55 (HTLV-2) of WB kit, the proviral load and immunessupression state were not important for inconclusive WB profiles.