Schizophrenia is a highly complex psychiatric disorder with a lifetime risk of approximately 0.4-0.7%. Alterations in the major inhibitory neurotransmitter GABA have been identified in the brains of those with schizophrenia. Studies examining the nature of these differences have given variable results depending on the type of patient group, medication and the brain region where in vivo MRS GABA was measured. Chapter 5 of this thesis utilises the noninvasive imaging tool magnetic resonance spectroscopy (MRS) to investigate differences in GABA levels in two distinct areas of the brain of those with schizophrenia, whilst adjusting for important potential confounds such as antipsychotic medication dosage. GABA is also of interest due to its link with synchronised oscillatory activity, primarily gamma activity that is implicated in connectivity between different brain regions as well as cognitive functioning, thus demonstrating its potential relevance to schizophrenia research. Chapter 6 investigates differences in gamma activity between those with schizophrenia and controls induced by a static stimulus and a moving radial stimulus, both known to induce strong visual gamma responses, using magnetoencephalography (MEG) imaging methods. Because GABA and gamma measures are robust for visual cortex measures, we used visual psychophysics tasks thought to be dependent on inhibitory processes - orientation discrimination and the tilt illusion, to see if there is a behavioural deficit in schizophrenia and if this also relates to changes in GABA and gamma measures. Chapters 3 and 4 set out to validate the psychophysics and to establish whether they were appropriate paradigms for the patient group for which they were intended. Chapter 7 brings together the imaging and psychophysics to see if a relationship exists between them in both the patient and control groups.

The antipsychotic clozapine is uniquely effective in the management of treatmentresistant schizophrenia (TRS), but its use is limited by its potential to induce agranulocytosis. A substantial proportion of patients discontinue clozapine treatment, which carries a poor prognosis, and only 30-60% of patients with TRS will respond to clozapine. The causes of clozapine-associated agranulocytosis, and of its precursor neutropenia, are largely unknown although genetic factors contribute. To examine the genetic susceptibility to clozapine-associated neutropenia, I conducted a multifaceted genetic analysis in the largest combined sample studied to date. Using GWAS, I identified a novel genome-wide significant association with rs149104283 (OR = 4.32, P = 1.79x10-8), a SNP intronic to transcripts of SLCO1B3 and SLCO1B7, members of a family of hepatic transporter genes involved in drug uptake. Furthermore, I replicated a previously reported association between neutropenia and a variant in HLA-DQB1 (OR = 15.6, P = 0.015). I investigated clozapine discontinuation and clinical response in a two-year retrospective cohort study of 316 patients with TRS receiving their first course of clozapine. By studying the reasons for discontinuations due to a patient decision, I found that adverse drug reactions accounted for over half of clozapine discontinuations. High levels of deprivation in the neighbourhood where the patient lived were associated with increased risk of clozapine discontinuation (HR = 2.12, 95% CI 1.30-3.47). Female gender (HR = 0.63, 95% CI 0.41-0.96) and clinical improvement after one month of treatment (HR = 0.56, 95% CI 0.44- 0.71) were significantly associated with a good response to clozapine. However, I found that up to six months of treatment may be required to determine non-response. This thesis implicates variants that may increase susceptibility to clozapine-associated neutropenia and contributes to our current understanding of the causes of clozapine discontinuation and treatment response.

Background and aims Underactive thyroid function during pregnancy and its effects on offspring intelligence, general cognition and behaviour have long been researched and reported on. Some of the differences found for the offspring are so apparent, that is has warranted authors to suggest universal thyroid function screening during pregnancy. The current study was the world’s first randomised controlled trial to investigate the effects of treatment for suboptimal gestational thyroid function (SGTF) on offspring. The aims of this thesis are, 1) to re-analyse the intelligence scores for the offspring at age 3 years, 2) to clarify any SGTF effects by cognitive testing and behavioural questionnaires completed at offspring age 9, and 3) compare and contrast wave one and two findings. Methods and analysis 1) Data was previously collected for this analysis. Treated and untreated SGTF groups were compared by unadjusted and adjusted models. 2) I conducted the intelligence, additional cognitive testing, and collection of the completed behavioural questionnaires. All data were analysed separately (per chapter) by multivariate analysis models. 3) Comparison of intelligence results were explored by correlations and a repeated measures multivariate analysis. Results and conclusions Re-analysis of the age 3 intelligence scores revealed that the untreated SGTF group performed worse compared to the treated SGTF group (p = .008 for scores below 85). No age 9 differences in intelligence or additional cognitive tests were found. The behavioural questionnaires revealed that treatment for SGTF may have had a detrimental effect for the offspring. Intelligence score comparisons revealed no differences between the groups. These results suggest that any intelligence effects from the mother not being treated for SGTF may be present at age 3 but have disappeared by age 9. However, treatment for SGTF appeared to significantly increase behaviour problems for offspring at age 9; though not clinically significant.

Extracellular vesicles (EVs) are submicron vesicles released from cells as intercellular communicators. EV research is hindered by a current lack of standardisation. However, mounting evidence suggests a role for EVs in both physiological and pathophysiological processes. Little is known about adipocyte-derived EVs despite the recognition of adipose tissue (AT) as an endocrine organ and the role of dysfunctional AT in disease. Obese AT develops regions of hypoxia and inflammation, leading to obesity-associated metabolic complications. The aim of this thesis was to explore EVs as novel adipocyte communicators, characterising their release under physiological and disease-like conditions. Nanoparticle tracking analysis (NTA) and tunable resistive pulse sensing (TRPS) were assessed for their accuracy and usability for EV quantification. NTA and TRPS both accurately quantified EVs though NTA was more user-friendly. The choice of anticoagulant, filtering and storage of EVs all affected EV concentration. Physiological EV release from 3T3-L1 adipocytes was characterised pre- and post-adipogenesis. EV generation increased prior to adipogenesis and EVs were enriched in pro-signalling fatty acids and proteins characteristic of the original cell. Therefore, EVs may aid the initiation of adipogenesis. Hypoxia was then used to pathologically generate EVs to mimic adipocyte obesity. Adipocyte EV release increased in hypoxia; these EVs were enriched in pro-signalling fatty acids and monocyte chemoattractant protein-1. Hypoxic EVs were then analysed for their interaction with macrophages (Mϕ). Hypoxic EVs may increase Mϕ migration and promote an anti-inflammatory Mϕ phenotype; further repeats are needed to confirm this. Finally, adipocyte markers were detected in plasma EVs suggesting the presence of circulating adipocyte-derived EVs in vivo. Plasma EVs were also reduced in hypercholesterolaemia patients by routine apheresis treatment. In conclusion, adipocytes release EVs which may assist intercellular communication in both physiological and disease-like conditions. Adipocyte-derived EVs can be detected in vivo and may provide novel biomarkers of obesity-associated diseases.

Multidisciplinary team working has been proposed as the means by which effective service delivery and organisation can be achieved within the operating theatre. Enhanced interprofessional communication, focus on a common goal, and valuing the contributions of team members have all been identified, within the professional literature, as elements of team working through which this objective could be realised. However, equal recognition has been given to reports of conflict and aggression experienced between professional groups within operating theatres. This thesis sets out to explore the relationship between these two phenomena in the context of the operating theatre, and explains the findings in an explanatory model of operating theatre work. The research was undertaken as a two part mixed method study. The first phase consisted of a survey of 391 operating department personnel, including surgeons, anaesthetists, nurses and operating department practitioners, employed in National Health Service operating departments in England. The survey gathered perceptions of conflict within and between staff groups, to identify the main sources of conflict, and the main protagonists. The results of the survey demonstrated the existence of the conflict related to changes in order of the operating list, and overrunning of the allotted operating time. The main professional groups involved were senior surgeons, and the nurses and operating department practitioners. Little variation was seen within the national sample. The second phase of the study consisted of ethnography within operating departments on two sites, supported by informal interviews with nurses, operating department practitioners, surgeons and anaesthetists. Field notes and interview data were analysed using Adaptive Theory through which new data and existing theory were utilised in an inductive process of theory generation. The findings reveal that working practices in the operating theatres did not conform fully to any existing model of team working. This thesis proposes that the persistent emphasis on multidisciplinary team working in the policy literature derives from a functionalist analysis of conflict. At a theoretical level the persistence of conflict can be explained via an analysis of the theoretical limitations of the functionalist model. Overcoming conflict requires a critique of functionalist solutions proposed in the literature and the application of alternative theoretical perspectives more attuned to addressing the underlying tensions inherent in the organisation of theatre work.

Purpose: Advanced radiotherapy treatments for Non-Small-Cell Lung Cancer (NSCLC) rely on conforming the radiation dose to the tumour geometry as tightly as possible; this increases the probability of killing the tumour cells while simultaneously reducing the radiation dose to nearby tissues and to organs at risk, subsequently reducing normal tissue reactions. Unfortunately, patient breathing is likely to compromise the method during implementation, as the breathing motion causes the tumour to move periodically out of the path of the radiation beam, while normal, healthy tissue periodically moves into the line of the beam. The aim of this project is to establish a simple breath-monitoring system which is inexpensive, easy to use and patient friendly; this could be achieved by developing a device that is considered to be non-invasive, and which also does not rely on connections to the treatment machine; it is based on a simple instrumented belt using strain-gauges which monitor the chest-to-wall motion during the breathing cycle. Methods and Materials: A total of fifty volunteers participated in this study. Three methods of breathing were used: free-breathing, audio-prompted breathing and visual feedback breathing, with synthesised breathing as the ‘ideal’ pattern. The breathing monitor was used in order to investigate the difference between various training regimes for helping subjects to modify their breathing patterns into a desirable pattern. Results: The results show that audio prompting — the method most commonly used in the clinic to date — was the least effective of the methods tested, resulting in large amplitude and phase variations compared to the other methods. Visual feedback (not currently used) is demonstrated as being far superior in regulating a subject’s breathing: this method produces far tighter control over both the amplitude and phase of the breathing pattern in comparison to any other method investigated. Conclusions: It is concluded that the current methods of regulating breathing in patients undergoing radiotherapy for lung tumours are inappropriate, and that a far better approach would be to use visual feedback.

Clostridium difficile (C.difficile) infection (CDI) has the potential to be a severe or fatal infection, occurring predominantly in the elderly and other vulnerable patients (NHS England, 2014, a). Since 2010, the Infection Prevention and Control Team in association with staff across an acute Trust have undertaken a collaborative daily checklist review which later became known as the daily review checklist process (DRCP) for all CDI patients. This review included feedback at ward and organisational levels. The DRCP incorporated completion of a checklist through contemporaneous clinical patient assessment and ward level examination of infection prevention and control practices. A grounded theory approach was used to explore the influence of the DRCP on the care and management of patients with CDI. The study consisted of two distinct phases. Phase 1 included a retrospective documentary analysis that examined all checklists (n=928) completed between July 2010 and December 2011. Phase 2 explored the perceptions of different groups of staff (Infection prevention and control practitioners [IPCPs], matrons, ward based staff and senior managers) concerning the influence the DRCP had on the care and management of patients with CDI. The findings from Phase 1 highlighted that the DRCP was used as a form of real time monitoring, providing organisational surveillance to assure safe and effective infection prevention and control practice for inpatients and appropriate and timely responses when care or standards of infection prevention and control may have been suboptimal. Phase 2 findings indicated that staff perceived that the DRCP had been influential in the care and management of patients with CDI. Three main themes were developed: education and learning, developing and sustaining relationships and leadership and change management that offer an explanatory framework for understanding the interactive processes that may have contributed to the care and management of patients with CDI. In terms of education and learning, ward staff valued the situated nature of learning provided by the review process. The DRCP also appeared to conceptualise CDI as an illness suggesting embodiment. Traits such as approachability and helpfulness of the key players involved in the DRCP (IPCPs and matrons) appeared to be fundamental to the DRCP and were particularly significant for developing and sustaining relationships and team work between staff. Finally the DRCP illustrated clinical leadership in practice with the IPCP and matron providing leadership and assistance in the care and management of patients with CDI. The DRCP evolved from a checklist serving as an instrument of surveillance and monitoring to an interactive educative facilitative process assisting staff in the care and management of patients with CDI and in compliance with general infection prevention and control practice. What emerged during the evolution of the DRCP was the influence of a human factors approach and the impact that communication, teamwork, situated learning and leadership had on the process. The key implication that emerged from this study included the contribution of human factors theory to behavioural change and improved patient outcomes. Incorporated within this was the influence situated learning can make to effecting change in knowledge and compliance and the impact relationship development can have on infection prevention and control practices and potentially processes that require different professionals to work together to improve patient outcomes.

No description available.

Cell-based therapies have been proposed as novel approaches to treating Osteoarthritis and Rheumatoid Arthritis. A non-invasive means of monitoring cell populations, post implantation could prove valuable in the clinical translation of such therapies. We propose the use of superparamagnetic iron oxide nanoparticles (SPIONs; internalised by cell populations) with magnetic resonance imaging (MRI) to image and track cell populations in vivo. We investigate the potential of commercially available SPIONs (SiMAG, Lumirem, Nanomag and P904) as potential labelling/tracking agents for in vivo investigations. Human mesenchymal stem cells (hMSC) and porcine chondrocytes were labelled with SPIONs under passive incubation conditions in either serum free media or serum containing media (24 hrs). SiMAG (10 μgFe/ml) demonstrated greatest potential with highest comparative internalised Fe content (labelled in serum free media) in vitro. SPION-labelled cell population maintained viability and proliferative capacity apart from SiMAG-labelled chondrocytes (10 μgFe/ml). Furthermore, SiMAG-labelled hMSC populations demonstrated successful differentiation down mesodermal lineages and retained key cell surface markers. MRI visibility thresholds were investigated (in vitro and ex vivo). Dose dependant contrast was generated only by SiMAG-labelled populations in vitro when MR imaged. In vitro minimum visibility of SiMAG-labelled populations was influenced by various ex vivo tissues with similar contrast developing in muscle and fat tissue samples but not for ligament. Finally, an ex vivo model of articular cartilage damage confirmed the potential clinical application of SPIONS as cell tracking agents at optimised conditions (cell dosage and SiMAG concentration) using a clinical system. An AIA murine model (Rheumatoid Arthritis) and a MNX rat model (Osteoarthritis) were implemented to image and track implanted SiMAG-labelled MSCs (murine) in vivo for 7 and 29 days, respectively. Additionally, clinically relevant functional outcomes were also monitored. Relevant in vitro assessment was performed where mMSCs efficiently internalised SiMAG with no impairment on cell activity. Good contrast was generated in both studies with SiMAG-labelled cell population located within the synovial cavity after 7 days (mouse study) and 29 days (rat study) by MRI. Administration of MSCs significantly reduced joint swelling in the mouse study without influence from the presence of SiMAG. mMSCs significantly influenced weight bearing asymmetry with little influence on paw withdraw threshold indicating potential antinocieotive properties of MSCs. In summary, SiMAG has demonstrated great potential as a labelling and tracking agent to be implemented for imaging and tracking cell populations.

This thesis discusses comprehensively the issue of exploitation from a normative perspective specifically relating to clinical trials within developing countries using a normative definition. Exploitation is defined from an unfairness perspective as the unfair use of an individual (group of individual) by another. In order to ease the flow of the arguments within this thesis, unfairness will be assessed from two different perspectives: a procedural perspective and an outcome perspective. The procedural perspective discusses whether the procedures followed when obtaining informed consent from the potential participants fulfilled the requirements of informed consent or failed to do so. Though the use of this approach it is concluded that informed consent is not a necessary condition for the avoidance of exploitation. Similarly, it is concluded that even if morally transformative, valid consent is given by potential participants, exploitation may still be lurking in the shadows of the interaction between the trial participants and the researchers/sponsors. The outcome perspective of unfairness focuses on the effect of the interaction on the parties involved within it and whether they benefit from their interaction with each other, are not affected by it, or are actually harmed as a result of the interaction. As an extension of this argument, the thesis will also consider the post-trial perspective of the interaction. The thesis concludes that post-trial access (reasonable availability) has a very narrow view of benefit and does not ensure that there is a fair share of the benefits between the parties involved. Instead of this narrow approach, a wider, post-trial benefit approach is adopted in order to prevent exploitation. Further discussion within the thesis will include, the requirements of an ethical review, the makeup of the review boards, and priority decision making in keeping with the current research ethics discussion in the literature.