Guidelines for the management of asthma in the UK have been published (BMJ, 1990, Thorax, 1993 and 1997) and embraced by many GP practices with improved outcome for patients. The study aims to observe and follow a cohort of adult asthma subjects from differing primary health care settings over a two-year period. Also to assess a newly devised patient focused morbidity index (Q score) by comparison to an established asthma specific quality of life questionnaire (AQLQ, Juniper et al, 1993). One hundred and fourteen subjects from four GP Practices, two inner city and two suburban were studied. Morbidity was assessed by AQLQ and Q score (Rimington et al, 2001), psychological status by the hospital anxiety and depression (HAD) scale (Zigmond and Snaith, 1983). Spirometry values (forced expiratory volume in one second, FEV1), peak expiratory flow (PEF) and details of current treatment as per BTS guidelines treatment step were recorded as markers of asthma severity. Subjects were assessed at baseline, twelve and twenty-four months. A random sub set of patients was asked to repeat certain elements of the study protocol at two weeks in order to assess the reliability of the Q score. The Q score correlated from baseline to two weeks (rs=0.61) as did AQLQ symptom score (rs=0.74) both p<0.01. At baseline AQLQ symptoms correlated with PEF (rs=0.40, p<0.001) and with BTS guidelines treatment step (rs=0.25, p=0.001) as did the Q score. Similar levels of correlation were reported for FEV1 with symptoms. HAD scores also correlated to AQLQ and Q score, but there was little correlation with lung function. At one and two year follow up no significant differences were observed in subjective or objective markers of asthma. There was a significant increase (p<0.001) in the number of subjects in the higher BTS guidelines treatment steps from baseline to twelve and twenty-four months while psychological symptoms remained high for inner city patients. In conclusion the Q score yields similar results to the AQLQ and is quick and easy to use in any busy clinic. The GP practice, at the forefront of asthma care should be offering appropriate therapy and regular review. The Q score used as a patient focused morbidity index can be a useful audit tool. Altering medication can give the impression of treating asthma but with out short-term reassessment the same levels of morbidity can persist.

Clinical reasoning is the skill used when veterinary surgeons make a decision regarding the diagnosis, treatment plan or prognosis of a patient. Despite its necessity and ubiquity within clinical practice, very little is known about the development of clinical reasoning during undergraduate training. Even less is understood about how veterinary schools should be helping students improve this skill. The aim of the research presented within this thesis was to, firstly, examine the development of clinical reasoning ability within veterinary students and, secondly, to investigate possible methods to aid this process. The University of Nottingham School of Veterinary Medicine and Science (SVMS) was used as a case study for this research. In study one, focus groups and interviews were conducted with SVMS staff, students and graduates to investigate the development of clinical reasoning. A curriculum document content analysis was also performed. The findings suggested that clinical reasoning development is not optimal, with alumni facing a steep learning curve when entering practice. These results were used to design study two, in which a simulated consultation exercise utilizing standardised clients was created and implemented for final year students. The success of the simulation was measured using both quantitative and qualitative methods – all of which supported the use of the session for clinical reasoning development. The final study, also building on the findings of study one, aimed to improve the accessibility of veterinary surgeons’ decision-making processes during student clinical extramural studies placements (CEMS). A reflective Decision Diary was created and trialled with third and fourth year SVMS students. Diary content analysis showed the study aim was met, triangulated by survey and focus group findings. During the research, wider issues relating to clinical reasoning integration into veterinary curricula were unearthed. These included low student awareness of the subject and the misalignment between the skill learnt during training and the skill required when in practice. Several recommendations have been made to improve the design of the undergraduate curriculum in relation to clinical reasoning.

Type 1 diabetes is an autoimmune disorder caused by the destruction of insulin secreting ß cells in the pancreas. The aim of this project is to explore the potential of using solid-coated microneedles to target skin dendritic cells with an auto-antigen to induce tolerance for the treatment of type 1 diabetes. A novel coating formulation has been developed to accommodate peptides with different lipophilicities. The optimised coating formulation and electro-polishing of the microneedle surface were key factors which enhance the efficiency of peptide delivery. Optimised coating formulation did not show adverse effects on peptide bioactivity or trigger a pro-inflammatory response. The delivery route (microneedle vs. intradermal injection) was shown to be the main factor that influenced the clearance of peptide from murine skin in vivo. Other factors such as temperature, skin hydration state and peptide solubility were also shown to have effects on peptide clearance. Two autoantigens were used to induce tolerance in non-obese diabetic mice – a potent mimotope m31 and endogenous antigen WE14. The proliferation profile of transferred carboxyfluorescein succinimidyl ester labelled BDC2.5 T cells in pancreatic lymph nodes in non-obese diabetic mice was used as a readout for the development of immunological tolerance. The results herein provide the first demonstration that WE14-coated microneedles were able to induce tolerance in vivo, showing reduced proliferation of BDC2.5 T cells. Additionally, this project examined the potential of short-term topical application of betamethasone to enhance peptide-induced tolerance. Both human and mouse dendritic cells showed a pro-tolerogenic state after treatment with topical application of betamethasone in vitro. However, full dose betamethasone was shown to have systemic toxicity in vivo, resulting in depletion of CD11c+ dendritic cells and CD4+ T cells. Diluted topical betamethasone facilitated a small effect on BDC2.5 proliferation; however no advantage on enhancing antigen specific immunotherapy was observed.

Transforming growth factor-beta (TGF-β) drives the development of immature LC from hematopoietic progenitor cells and shapes the cells functions. Here I showed that two LC model cells, MuLC and MDLC, used exchangeably in the research, differ significantly in their phenotype and immune responses. Discrepancies between these models were specifically visible during stimulation with type-I IFN, where MuLC failed to up-regulate ISG levels. Yet both MuLC and MDLC demonstrated low susceptibility to HIV-1 infection, even in the absence of SAMHD-1. This post-entry restriction was conferred by the action of TGF-β on differentiation cells as indicated by our study. Indeed, in the absence of TGF-β supplementation, derived cells showed MDDC phenotype related to high susceptibility of the cells to HIV-1 infection during co-infection with SIV-Vpx. Additionally blocking of the TGF-β signalling, reversed the restrictive phenotype of LC. Importantly this pattern was also confirmed in skin extracted real epidermal LC versus dermal DC, suggesting that SAMHD-1-independent restriction activity operates in TGF-β derived cells. Accordingly to PCR analysis virus replication in LC is interrupted prior to integration, suggesting the role of additional restriction factors at early stages of virus infection or lack of essential viral dependency factors such as dNTPs. Interestingly maturation of MDLC with a synthetic bacterial triacylated lipopeptide or TNF-alpha significantly increased their susceptibility to HIV-1 infection, which may explain why HIV-1 acquisition is increased during co-infection with other STIs. In summary, our study strongly supports the action of SAMHD-1-independent HIV-1 restriction mechanisms in LC. A better understanding of the balance between HIV-1 restriction and propagation from LC to CD4+ T cells may help in the development of new microbicides or vaccines to curb HIV-1 infection at its earliest stages.

This thesis is a qualitative study of infertility clinicians in the UK, exploring how they manage ethical issues: a study that uses empirical methods to explore ethical questions. I use a broadly Aristotelian conception of the relationship between theory and practice to develop a methodology for considering practical ethical issues. I then show how this approach, when allied with contemporary qualitative methodologies, can provide particularly valuable insights and produce practical recommendations. An important element of my approach is that a close attention to actual practice can also result in refining and developing our ethical theories and principles – practice informs theory just as theory can inform practice. This account of the ethical decision-making processes of infertility clinicians can not only highlight new ethical problems, but also develop more nuanced moral norms and ethical theories to deal with the conflicts and issues that arise in the clinical setting. Infertility treatment is a speciality that has attracted much attention from the public and bioethicists. The focus has been predominately on the dramatic aspects such as the status of the embryo or underlying issues such as the ethical boundaries of procreative liberty. Relatively little, however, is known about the everyday moral workings of infertility clinics: how clinicians approach ethical issues on a daily basis; what for them are troubling issues; and how they resolve ethical conflict. This study aims to gain insight into the way clinicians actually make ethical decisions. Moving on from this, it critically evaluates such processes and offers both an analysis of the strengths and weaknesses of the clinicians’ ethical decision-making and considers how this form of decision-making can be extended and supported in practice. The aims of this thesis are to contribute to the debate on both how ethical decision-making in the infertility clinic can be improved and, more generally, how bioethics can make a useful contribute to practical problems.

The complexity of healthcare is increasing due to new discoveries in the treatment of disease, the multiple pathologies of an ageing population and changes in working patterns and job roles. In addition, an increase in professional, regulatory and public scrutiny has led to revelations of poor care leading to preventable disability and death. Inquiries into sub-standard care have uncovered a number of professional lapses, in particular failures in teamwork and leadership. Medical undergraduates are future doctors. Their ability to work effectively within teams and to lead when necessary will therefore have a significant impact on the health of the population. In order to improve leadership and teamwork abilities we must be able to assess them. A literature review searching for a tool to assess teamwork and leadership in the medical undergraduate was carried out. As a consequence of an unsuccessful search, a tool was developed and evaluated, using data from existing tools and from a series of focus groups with medical undergraduates. The focus groups and an examination of the reasoning of assessment participants also informed a study on the justifications for failing to challenge poor performance by a more senior member of staff. The tool data showed adequate validity and reliability for formative assessments in a simulated environment. The focus groups and examination of reasoning highlighted the continued existence of the medical hierarchy, with steep authority gradients. This tool can be used in formative assessments, but further research is required before it is used outside the simulated environment and consideration must be given to psychometrics, feasibility and cost. The teaching and assessment of teamwork and leadership, should be given more time in the undergraduate curriculum and medical schools, regulatory bodies, deaneries and trusts should collaborate on minimising the unprofessional behaviours of senior healthcare personnel.

The natural selection imposed by host immunity and antimalarial drugs has driven extensive adaptive evolution in Plasmodium falciparum, leading to an ever-changing landscape of genetic variation. We have carried out whole-genome sequencing of 93 P. falciparum clinical isolates from Malawi and used population genetic methods to investigate the genetic diversity and regions under selection. In addition, by computing XP-EHH, PCA and FST we have compared the Malawi isolates to five dispersed others (Kenya, Mali, Burkina Faso, Cambodia and Thailand), and identified genes potentially under positive directional selection. Geographic stratification of genetic diversity in the populations followed continental lines and small population differences were observed within Africa. Positive directional selection signals were identified at or near pfdhps, pfcrt, pfmdr1 and pfgch1 (known drug targets) and in several merozoite invasion ligands (e.g., msp3.8, trap and ama1). We discuss the role of drug selection in promoting fixation of alleles between populations with differing adaptation to local drug pressure. Analysis of copy number variation in Malawi provides a detailed catalogue of new and previously identified gene deletions and duplications with critical roles in cytoadherence, gametocytogenesis, invasion and drug response. This work provides the first genome-wide scan of selection and CNV in Malawi to guide future studies in investigating parasite evolution, changing malaria epidemiology, and monitoring and evaluating impact of malaria interventions as they are deployed.

Chemical control of mosquito vectors, via indoor residual spraying or insecticide treated bed nets, is an integral component of malaria control strategies. Limited availability of insecticides licensed for public health and the rapid development of resistance in mosquito populations to these insecticides, in particular to some pyrethroids, may compromise vector control efforts. With the exception of mutations in the insecticide target sites, relatively little is known about the genetics of pyrethroid resistance in malaria vectors. In some populations candidate effector genes, e.g. cyp6p3 or cyp6m2 in An. gambiae s.s. from Akron, Benin, have been identified as being over expressed in resistant strains but the underlying mechanisms responsible for the increased expression remain unknown. In this study, a combination of quantitative PCR, genetic mapping and microarray tools were used to investigate the mechanisms responsible for pyrethroid resistance in two African major malaria vectors, Anopheles gambiae and An. arabiensis. The current work was unable to confirm an association of these known candidates in either a laboratory colony established from Akron or in recent field caught material. Therefore a genetic mapping approach was adopted using field collected mated females to generate F2 isofemale lines. A major QTL on chromosome 3R was identified which coincides with a genomic region previously implicated in pyrethroid resistance in East African populations. This is the first genetic mapping of insecticide resistance using natural out-bred populations of Anopheles and the advantages and limitations of this approach are discussed. In a second experiment, genetic loci involved in permethrin resistance in An. arabiensis were mapped by establishing genetic crosses between a permethrin resistant strain from Chad and a susceptible strain from Mozambique. A single QTL on chromosome 2R was identified in the F2 progeny that accounts for ~24% of the phenotypic variance. This QTL coincides with a large cluster of detoxification genes. Pyrethroid resistance is not associated with target-site mutations in this population. Finally, microarrays were used to identify genes differentially expressed between a backcross population, generated by crossing the F1 population from the resistant Chad strain and the susceptible Mozambique strain of An. arabiensis back to the parental resistant strain, with the susceptible strain. A number of candidate genes were identified, including the P450 genes cyp4h24 and cyp9j5, but neither of these were located within the boundaries of the QTL on 2R. These findings support the presence of metabolic resistance in this population and fine mapping of the identified QTL as well as further investigation of the microarray hits is warranted.

Gastric cancer is the final outcome of a well-defined process of inflammation, remodelling of the gastric mucosal architecture and finally carcinogenesis. In humans, the trigger to develop gastric epithelial inflammation is infection with Helicobacter pylori. Whilst the pathological progression following Helicobacter infection has been well described, the reasons why some individuals progress towards gastric carcinogenesis, whilst others do not, remain relatively poorly understood. Previous studies in transgenic mice have demonstrated an association between classical pathway NF-κB signalling and Helicobacter induced gastric pathology. However the roles of specific NF-κB family members and of alternative pathway NF-κB signalling have not previously been investigated. We hypothesised that individual NF-κB proteins would play specific roles in determining the onset of Helicobacter induced gastric pathology, and that these pathways may influence the eventual outcome of Helicobacter infection. To address these hypotheses we used transgenic mice with constitutive deletions of NF-κB1, NF-κB2 and c-Rel, along with the established H. felis model of murine gastric cancer. Animals were studied at 6 and 48 weeks post infection. NF-κB1 null mice developed gastric inflammation and atrophy even without infection when aged to 1 year. These animals also developed more advanced gastric atrophy and metaplasia when infected with Helicobacter felis for 1 year. c-Rel null mice demonstrated similar epithelial pathology to wild-type mice, but following long-term infections developed significant atypia in infiltrating lymphoid cells, in keeping with c-Rel playing a role in gastric lymphomagenesis. In contrast NF-κB2 null mice developed minimal pathology at both 6 and 48 weeks following infection, and hence appear to be resistant to gastric corpus atrophy in response to Helicobacter felis infection. These findings confirm the previously known role for classical pathway NF-κB signalling in epithelial cancers, and suggest that this is an NF-κB1 specific effect, rather than being mediated by c-Rel. We provide the first description of c-Rel null mice showing enhanced gastric lymphomagenesis, and also describe profound resistance to Helicobacter induced gastric pathology in mice with abrogated alternative pathway NF-κB signalling, a pathway that has not previously been investigated in studies of epithelial carcinogenesis.

Background During a period of continuing changes in society and increasing availability of medical information, publication of patients’ views on experiences of health and illness have gained greater prominence. By contrast, studies of medical perspectives have tended to concentrate on reported discontent and implications for workforce planning while leaving broader insights and concerns under-investigated. Since the applied skills of highly trained and publicly funded clinicians are vital for safe and effective delivery of the nation’s health care, it seemed important to explore new ways to consider components of medical professionalism and to set these in current NHS contexts. Rationale and fieldwork Focussing attention on the individual perspectives of NHS doctors in order to hear and understand their experiences of work was central to development of this thesis. An interpretive epistemological approach to biographical narratives as told by a group of 12 doctors drawing on 25 years of NHS experience included use of Situational Analysis Mapping to support detailed analysis of their richly informative, first-hand accounts. As knowledgeable and reflective informants with stories from diverse clinical specialties and differing personal viewpoints, their narratives produced a range of views and observations shaped by their lived experiences as clinicians. Poetic representation of sociologically-informative narrative extracts provided an effective vehicle for engaging mixed audiences and has evoked emotionally resonant reactions from doctors. Findings Strong connections between individuals’ core principles and enacted responses were evident; doctors identified preferred working practices which they believed supportive of delivery of high quality health care. Key aspects of professionalism, including professional autonomy, self-regulation and application of clinical knowledge, were challenged by progressive introduction of new working processes and regulatory mechanisms. Increased recording of clinical and administrative data for performance monitoring and achievement of targets produced reactive strategies in individuals and teams while challenging their sense of professional position or developed medical identity. Poorly performing colleagues and difficult team interactions caused much disruption while blurred ethical boundaries exposed contestable decision-making and demonstrated the limited effectiveness of external regulatory monitoring. Conclusions This research indicates that contemporary NHS doctors may experience conflict between what is expected in managed medical practice and their interpretation of best professional performance. Better understanding of these fundamental relationships could constructively contribute to reconsideration of contemporary medical professionalism and assist with progressive workforce preparation for an effective future NHS.