Section A presents a literature review on the topic of personal therapy for therapists. Section B presents a cross-national empirical study. Drawing on the theory of planned behaviour, the study explored the influence of subjective norms (social stigma) on clinical psychology students’ attitudes towards seeking personal therapy. A total of 462 students from Argentina (n = 121), England (n = 211), and the US (n = 211) completed a survey on demographic characteristics, well-known predictors of seeking therapy, perceived social stigma for receiving therapy, and attitudes towards seeking therapy. Results revealed significant cross-national differences, with Argentinean students showing the lowest levels of perceived social stigma for receiving therapy (M = 5.02, SD = 1.60), followed by English (M = 4.57, SD = 1.61) and Americans (M = 3.22, SD = 2.35). English students showed significantly less positive attitudes towards seeking therapy (M = 22.60, SD = 2.97) than their Argentinean (M = 24.89, SD = 2.94) and American (M = 24.27, SD = 3.17) counterparts. Hierarchical multiple regression analyses revealed that perceived social stigma predicts students’ attitudes towards seeking therapy, even after controlling for the effects of other predictors of therapists’ therapy-seeking behaviours, among English (ß = -.26, p < .001), and American (ß = -.34, p < .001) students but not among Argentinean students. The hypothesised role of nationality as a moderator of the relationship between perceived social stigma for receiving therapy and attitudes towards seeking therapy was confirmed. Implications for research and training are discussed. Suggestions are made for English and American clinical psychology training programs to raise awareness on social stigma associated with receiving therapy. Section C presents a critical appraisal of the process of conducting the present major research project, including learning outcomes, limitations, implications, and areas for future research.

Part A provides an overview of the literature pertaining to influences on the research activity of clinical psychologists. The need for ongoing research within the profession is outlined and the evidence for the role of different factors associated with research activity is described and evaluated. Further investigation is recommended in the areas of the research training environment and the practice context. Part B reports an empirical study looking at how components of the theory of planned behaviour may mediate the impact of factors within the research training environment (RTE) on research intention in a sample of UK clinical psychologists. Low levels of clinical psychologist research activity are repeatedly highlighted within the literature. Several potential influences have been identified with the majority of investigation directed towards the RTE and mediators of this factor. A model has been proposed using the theory of planned behaviour to explain research activity and preliminary support has been found for this. The current study took a more in-depth look at the active ingredients of the RTE, as well as aspects beyond training in the workplace. Factor analysis revealed two second order factors within the RTE that differed from an earlier two-factor solution in the literature. These were labelled stimulation and expectations. The relationship between stimulation and intention to do research was shown to be mediated by theory of planned behaviour components, whilst expectation maintained a direct relationship with intention. Thematic analysis of comments from clinical psychologists relating to influences on their research activity supported some of these findings, but also identified new barriers and facilitators of research activity relating to the work environment. Further research exploring both training and practice contexts is called for and implications for training and practice are made. Part C is a critical appraisal of the project, which considers learning points and skills gained from the process of undertaking the study. Future directions for developing research skills are discussed and personal reflections on how the implications of the project may be incorporated into future roles are provided.

Section A: The effectiveness of acute phase psychological therapies for chronic major depression: A literature review. This review critically evaluates the literature pertaining to the use of psychotherapy for people experiencing moderate to severe chronic depression. It concludes that people with chronic major depression (CMD) experience a greater reduction in depressive symptoms from extended periods of treatments and from combined therapy, both in the form of psychotherapy and pharmacotherapy, but also integrative therapies which combine different therapeutic models and modalities. Section B: This study explored participants’ experiences of ways in which group person based cognitive therapy (PBCT) for people with chronic major depression facilitated or hindered therapeutic change. Qualitative methodology was used to explore the experiences of six participants who had completed the 12-week group. Transcripts of the semi-structured interviews were analysed using Interpretative Phenomenological Analysis. Five super-ordinate themes emerged: experiences of depression before the group; the group experience; perceived changes; role of external factors; desire for more. Participants reported a changing experience of depression with regard to the way in which they related to and managed their symptoms, viewed themselves, and managed challenging situations. This study indicates that PBCT may be a suitable intervention for adults with CMD, and enhances previous findings which suggest that briefer mindfulness practices may be more acceptable to people experiencing current symptoms of depression. Section C: In a critical appraisal of the study described in section B, this section discusses the author's learning and reflections pertaining to research skills developed, applying the findings to clinical practice, and gives consideration to further research.

No description available.

Epilepsy affects 50 million people world-wide. Since 1982, the Western Infirmary Epilepsy Unit has provided a specialist service for over 6900 people with suspected and established seizure disorders. The twelve studies detailed in this thesis discuss the management of epilepsy in different patient populations, and explore beneficial and adverse effects of antiepileptic drugs (AEDs). AED development has allowed advances in pharmacological treatment of localisation-related epilepsies. Thus, outcomes were investigated in 550 such patients followed-up at the epilepsy clinic over 13 years (Paper i). Of these, 312 (57%) became seizure-free on medication. Those with hippocampal sclerosis had the poorest outcome (p<0.01), and a higher incidence of febrile convulsions (p<0.001). Although many patients benefited from AED therapy, results may be biased, given this cross-sectional study analysed data from both newly diagnosed patients, and those with drug-resistant seizures. Many people with epilepsy take more than one AED, although supportive evidence is sparse. Hence, polytherapy outcomes in 2881 patients registered with the Epilepsy Unit database were examined (Paper ii). Of these, 1617 (56%) were seizure-free, with 332 (21%) taking more than one AED (287 on two, 86%; 42 on three, 13%; 3 on four, 1%). There were 40 duotherapy and 28 triple therapy combinations resulting in seizure freedom. Therefore, combining two or three, but rarely four AEDs may be useful for patients not responding to monotherapy. Because this was a retrospective analysis of newly treated patients and those with refractory epilepsy, the analysis was subject to bias. Lack of a control group was also a weakness. Epilepsy Unit staff are therefore now examining similar outcomes in a large population of newly treated patients only. To establish the place of recently marketed AEDs in clinical practice, four studies examined prospectively the efficacy and tolerability of the novel agent, topiramate, in uncontrolled epilepsy. Adjunctive topiramate was administered in 170 patients with refractory seizures (Paper iii). Seizure frequency and adverse events were monitored. Patients were followed-up until seizure freedom for ≥ 6 months, ≥ 50% or <50% seizure reduction, intolerable side-effects, or lack of efficacy occurred. Seizure freedom was achieved in 39 (23%) patients. A ≥50% reduction in seizure frequency was reported in 80 (47%) others. Doses were often lower than those in regulatory studies. Efficacy as monotherapy was also demonstrated. Using the same end-points, topiramate was added to AED regimens of 64 patients with learning disabilities and epilepsy (Paper iv). Remission from seizures was established in 16 (25%). In similar fashion, levetiracetam was started in 156 patients with uncontrolled epilepsy (Paper v). Of these, 40 (26%) became seizure-free, many on low doses. When the drug was added to AED regimens in 64 patients with learning disabilities, 24 (38%) became seizure-free for at least 6 months (Paper vi). Caregiver quality-of-life scores improved significantly with levetiracetam (p<0.001). It is important to recognise that for all four audits results may be biased due to their observational nature, and the fact that they were undertaken at a single centre, with no control group. For patients with learning disabilities, small numbers, and retrospective baseline recordings for some could also have introduced bias. In Papers vii, viii and ix, findings from longitudinal studies in teenagers, people with learning disabilities and epilepsy, and newly diagnosed elderly patients attending the Epilepsy Unit, are reported. At the Teenager Clinic, 301 adolescents were reviewed over four years (Paper vii). Epilepsy was excluded in 135 (45%), five taking AEDs. A single seizure occurred in 22 others. In the 144 with epilepsy, seizure freedom for ≥ 12 months was attained in 76 (53%), but outcomes were poorer than expected. Neuroimaging was abnormal in 27 (43%). Newly diagnosed patients fared better than those taking treatment (p<0.05). More teenagers with primary generalised seizures (60%) attained remission, compared to those with focal-onset seizures (46%) (p<0.02). The retrospective natures of the analysis, and lack of control group may have biased results, thus making statistical conclusions inaccurate. Findings suggested the need for improved services. Over four years, 214 patients with learning disabilities and refractory epilepsy were followed-up (Paper viii). Although it is generally thought these individuals’ seizures are difficult to control, 59 (43%) became seizure-free for ≥ 12 months with AEDs. There was no change in quality-of-life scoring during this time, and no relationship between extent of learning disability and seizure control. The observational nature of the audit, and lack of control group may have biased results. Currently, there are few data on elderly people with epilepsy. Thus, outcomes over a 20-year period in 117 newly diagnosed senior citizens were examined (Paper ix). After starting AED treatment, 93 (79%) became seizure-free for ≥ 12 months, 73 (62%) with their first drug. Prognosis was better than in younger patients, and for those with fewer pre-treatment seizures (p=0.0078). Again bias may have been introduced because of the study’s observational nature and lack of control group. The final studies concentrate on AED-related adverse effects (Papers x, xi and xii). Bone changes have been reported with AED use. Hence, the relationship between bone mineral density, and long-term AED treatment in 78 older adults (47 post-menopausal women, 31 men), taking hepatic enzyme-inducing or non-inducing AEDs, was explored in a case-controlled study (Paper x). Men had significantly lower bone mineral density than controls at the lumbar spine (p<0.01), and neck of femur (p<0.005). Women had statistically reduced bone mineral density at the femoral neck (p<0.05). It was concluded that long-term AED treatment is an independent risk factor for reduced bone mineral density in people with epilepsy. As sodium valproate may be associated with metabolic changes and polycystic ovarian syndrome, hormone profiles were compared in 76 young men and women taking sodium valproate or lamotrigine monotherapy, to assess whether a pharmacological effect of valproate was responsible (Paper xi). Results revealed only four obese females exhibiting biochemical characteristics of polycystic ovarian syndrome (p=0.05), with obese patients of both sexes (p=0.01), and valproate-treated men (p=0.03) having higher insulin concentrations. Results are not significant when corrected for multiple comparisons. It can therefore be concluded that no differences in metabolic indices between patients taking sodium valproate or lamotrigine existed. To examine further effects on androgenic hormones, and the efficacy and tolerability of sodium valproate and lamotrigine monotherapy, a randomised, prospective study in 225 patients was performed (Paper xii). Patients were recruited if they presented with a minimum of two unprovoked seizures of any type, or a single seizure and underlying neuropathology. Of patients with partial-onset seizures, 81 received sodium valproate and 80 were randomised to receive lamotrigine. Of those with idiopathic generalised epilepsies, 30 received sodium valproate and 34 took lamotrigine. Seizure-free rates were identical in both arms at twelve months between the valproate and lamotrigine cohorts. There was a trend towards superiority for valproate (57% seizure-free) over lamotrigine (35% seizure-free) for patients with idiopathic generalised epilepsies (p=0.09), but a converse separation of outcomes for localisation-related epilepsies (43% seizure-free with valproate, 53% seizure-free with lamotrigine, p=0.24). More patients taking sodium valproate withdrew due to adverse events (p=0.046), eight because of weight gain.

Introduction: Chronic heart failure (CHF) is associated with an increased incidence of atrial fibrillation (AF) and elevated levels of catecholamines and endothelin-1 (ET-1), each of which affects the atrial L-type calcium current (ICaL) and consequently action potentials. Hypotheses: ET-1 modulates the effects of isoproterenol (ISO) on ICaL and action potentials in human atrial myocytes. Methods: Atrial myocytes were isolated enzymatically from samples of right atrial appendage obtained from consenting patients in sinus rhythm undergoing cardiac surgery. The nystatin-perforated whole cell patch clamp technique was used at 37ºC to record ICaL and action potentials in voltage-clamp and current-clamp mode respectively. Results: The current-voltage relationship of ICaL was bell-shaped, peaking at +10 mV with a current density of -4.8±0.4 pA/pF (mean± s.e.m., n=89 cells, 34 patients). ISO, 0.1 nM to 1 µM, increased peak ICaL in a concentration-dependent manner (n=4-46 cells) with a maximum response of 250± 53% above control and an approximate EC50 of 0.06 µM. Isoproterenol at 0.05 µM significantly increased peak ICaL from -4.7± 0.4 to -12.2± 0.9 pA/pF (P<0.05, Students t-test; n=64 cells). This adrenergic effect was reversed by ET-1 at all concentrations tested from 0.01 to 10 nM and was partially reversible upon ET-1 washout and in the presence of the specific ET-A receptor antagonist, FR139317 (n=5-12 cells). Neither ET-1 alone nor the ET-B receptor agonist Sarafotoxin S6c, at 10 nM, had an effect on ICaL. Isoproterenol (0.05 µM) prolonged the action potential duration at 50% repolarisation (APD50) from 30± 7 to 46± 7 ms (P< 0.05, n=15 cells), but had no effect on APD90 nor the cellular ERP. These adrenergic effects on APD50 and SDs were also abolished by ET-1 at 10 nM (P< 0.05, n=15 cells). Superfusion with ET-1 (10 nM) alone had no significant effect on APD50, APD90, nor ERP (n=21 cells). There were no significant interactions between these electrophysiological effects and diseases states or chronic pre-operative drug therapy. Spontaneous activity, defined as a depolarisation occurring during phase 3 of action potential repolarisation or a depolarisation of greater than 3 mV amplitude during phase 4, frequently interrupted action potential recordings during, but not prior to, superfusion with ISO. Using a repetitive stimulation protocol, ISO at 0.05 µM produced spontaneous depolarisations in 5 of 7 cells studied (P< 0.05, chi-2 test). Endothelin-1 at 10 nM abolished these depolarisations in all 5 cells (P< 0.05). Superfusion with ET-1 (10 nM) alone was associated with spontaneous depolarisations in significantly fewer cells (P< 0.05, n=2 of 13 cells). In a retrospective univariate analysis, patient comorbidity and pre-operative drug therapy were not found to influence the electrophysiological effects observed. Conclusions: ET-1 reversed adrenergically induced increases in peak ICaL, APD50 and SDs in human atrial myocytes. This anti-adrenergic effect may be expected to influence the occurrence of AF in patients irrespective of comorbidity or pre-operative drug therapy.

Chronic myeloid leukaemia (CML) is a clonal myeloproliferative disorder of the haemopoietic stem cell, defined by the Philadelphia chromosome (Ph) - the outcome of a balanced, reciprocal translocation between the long arms of chromosomes 9 and 22. The novel fusion oncogene generated on chromosome 22 as a result of this translocation is called BCR-ABL. In the majority of patients, this oncogene transcribes a 210-kDa constitutively active protein tyrosine kinase, often referred to as p210BCR-ABL, which is necessary for the transformation of the disease. The introduction of the orally available, tyrosine kinase inhibitor (TKI) - imatinib mesylate (IM) - marked a major advance in CML treatment in terms of efficacy and tolerability and has now become the first line of therapy. IM acts by competing with ATP to block ABL-kinase activity, resulting in the selective apoptosis induction of BCR-ABL+ cells. However, despite the success of IM as standard therapy for CML, only a small proportion of patients obtain a complete molecular response, where they become negative for BCR-ABL transcripts by RTPCR. It is hypothesised that this minimal residual disease is the result of a primitive quiescent subpopulation of leukaemic cells, which may be the cause for relapse at a later date. Another major clinical concern is the observation of molecular resistance in IM-treated patients. Proposed mechanisms of resistance include BCR-ABL amplification, decreased intracellular IM concentrations caused by drug efflux proteins such as multi drug resistance-1 and the development of point mutations within the ABL-kinase domain. In an attempt to overcome IMresistance, a second generation of BCR-ABL inhibitors has been developed. Dasatinib (BMS-354825, Sprycel) is a TKI developed for the treatment of IM resistant or -intolerant patients with Ph+ leukaemias, which has a 325-fold greater potency than IM against cells expressing wild-type BCR-ABL, and is effective against all IM-resistant BCR-ABL mutants tested in vitro, except T315I. Previously, we showed that dasatinib induced durable inhibition of BCR-ABL and impressive clearance of Ph+ cells, however, the primitive quiescent cell population did not appear to undergo apoptosis even after several days TKI exposure. Therefore, it was still not clear whether early CML progenitor cells depend on BCR-ABL for their growth and survival. In this study we have attempted to determine whether CML stem cells are dependent on BCR-ABL TK activity for their survival and/or proliferation using dasatinib treatment and aimed to characterise the cells which survived drug exposure. We found that 10% of the CML cells were able to survive the dasatinib treatment. We also showed that maximal BCR-ABL TK inhibition was achieved in the surviving CML cells, both in the bulk population of cells and the more problematic primitive stem cell population. Those cells which survived the dasatinib treatment were found to be primitive, residing mainly in the undivided cell fraction and the very early cell divisions. Since these BCR-ABL TK-inhibited, resistant cells were also able to grow when re-cultured in cytokines and form longterm culture-initiating cell (LTC-IC) colonies; these data suggested that ~10% of primitive CD34+ CML cells are not addicted to BCR-ABL TK activity for their survival. This also suggested that these primitive, resistant CML cells appeared to survive and proliferate by BCR-ABL-independent mechanisms. Therefore, the next experiments were then designed to investigate the cellular process of autophagy as a potential means of primitive CML cell survival. Analysis of the properties of CD34+ CML cells which remained viable following dasatinib treatment, revealed the existence of cytoplasmic autophagic structures determined by electron microscopy and significantly increased autophagosome-asociated LC3-II, particularly in the cells cultured without growth factors (GF)s. This suggested that autophagy is induced following GF deprivation of CML cells and is significantly increased within these cells, upon BCR-ABL inhibition following dasatinib treatment. Furthermore, we also found that the inhibition of autophagy greatly potentiated the effect of TKI treatment on the reduction of primitive CML progenitor cells, in terms of the effective eradication of functionally defined colony forming cells and LTC-ICs. Overall, this thesis has shown for the first time that the most TKI-resistant primitive CML cells are likely to be independent of BCR-ABL TK activity for their proliferation and/or survival. Furthermore, we have shown that these resistant CML stem cells rely on the BCR-ABL independent autophagy process for survival in response to stressful conditions, such as, GF deprivation and TKI treatment.

Percutaneous coronary intervention (PCI) improves the blood supply to the heart by unblocking narrowed coronary arteries. Implantation of a coronary stent is usually required to scaffold the artery and improve long-term vessel patency. Drug-eluting stents (DES) have been developed to decrease the incidence of stent renarrowing, known as in-stent restenosis (ISR), the main limitation of bare metal stents (BMS). DES release potent drugs into the artery wall to inhibit cell division and attenuate ISR. However, this strategy can also impair vascular healing and increase the risk of stent thrombosis, which is a serious concern. Novel approaches to this problem are urgently required. Oxidative stress reflects a state in which reactive oxygen species (ROS) prevail over antioxidant defences. PCI causes a major release of ROS from the injured artery wall and these molecules appear to play an important role in critical signalling pathways involved in vascular repair. Numerous animal studies have found that oral antioxidants may reduce ISR and improve healing, yet these strategies have not been effective in humans. Stent-based delivery of antioxidants may offer more efficacious, targeted protection against oxidative stress than oral administration. The role of oxidative stress in endothelial repair mediated by bone marrow-derived endothelial progenitor cells (EPCs) in patients with coronary heart disease is also poorly defined. The main aims of this thesis were: to determine the in vitro effects of oxidative stress on key aspects of thrombosis and vascular healing; to evaluate a novel antioxidant-eluting stent in an in vivo porcine model; and to examine the relationship between oxidised low-density lipoprotein (oxLDL), EPCs and coronary endothelial function in patients with stable angina. Oxidative stress, generated by the xanthine/xanthine oxidase reaction, inhibited whole blood aggregation in a concentration-dependent fashion. This was probably due to an excess of ROS which impaired, rather than stimulated, thrombosis. Healthy endothelial cells (ECs) also inhibited whole blood aggregation, but this was not mitigated by oxidative stress. EC migration was assessed using an in vitro endothelial wound scratch assay. Oxidative stress was highly toxic to ECs and inhibited migratory activity. Nitrone D, a novel spin trapping antioxidant, was evaluated for its suitability as a novel DES coating. Nitrone D displayed weak antithrombotic effects, but markedly inhibited EC migration. Nitrone D was therefore unsuitable for a DES that was intended to improve re-endothelialisation. Oral probucol has established efficacy in animal models of restenosis, but not in humans. Probucol has been successfully incorporated as a dual DES coating with rapamycin in clinical trials. Succinobucol is a novel derivative of probucol with more potent antioxidant, anti-inflammatory and antiproliferative effects. A novel polymer-free succinobucol-eluting stent (SES) and succinobucol/rapamycin-eluting stent (SRES) were developed and compared to a commercially available polymer-free rapamycin-eluting stent (RES) and BMS. Pharmacokinetic studies demonstrated optimal drug elution from the SES. However, in a porcine coronary model, the SES significantly increased neointimal thickness and aggravated ISR. The RES reduced neointimal thickness non-significantly, whereas the SRES caused no difference in neointimal thickness, compared with the BMS. The SES was associated with greater inflammation and persistent fibrin deposition around the stent struts, which are signs of defective healing. There were no significant differences in endothelial regeneration between the groups. Subsequent cell culture studies found that succinobucol was toxic to ECs and smooth muscle cells. In the clinical study, circulating levels of EPCs were strongly correlated with coronary endothelial function, which is a novel finding. Plasma oxLDL levels were not correlated with EPCs or coronary endothelial function. In conclusion, ROS reflect a large array of molecules released after PCI that are multi-faceted regulators of platelets and vascular cells. As such, they represent a complex target for novel DES technologies. Excessive ROS may inhibit thrombus formation and delay re-endothelialisation. However, potent antioxidants delivered to injured arterial tissue after PCI may not necessarily encourage the physiological processes required to accelerate vascular repair. At high dose, local delivery of antioxidants may actually promote inflammation and aggravate ISR. Although oxLDL is known to induce endothelial dysfunction, it is not correlated with the number of circulating EPCs. These findings underline the complicated role of oxidative stress in vascular repair after PCI. Further studies are required to clarify whether antioxidants will ever provide advantages over existing options in the rapidly evolving field of interventional cardiology.

GPR40, GPR41 and GPR43 are a small family of GPCRs. Fatty acids were identified as the ligands for these receptors in 2003. High levels of circulating fatty acids have been linked to a variety of diseases, including type 2 diabetes mellitus, cancer, and high levels of fatty acids are produced by anaerobic bacteria at the site of infection. High levels of GPR40 have been detected in the beta cells of the pancreas and all three receptors have been shown to be expressed in immune cells. Due to the recent identification of the ligand for these receptors, their pharmacology, function and oligomerisation was investigated during this study. A [35S]GTPgammaS binding assay was developed to monitor the activation of GPR41 using a GPR41-Gαi3 Cys351Ile fusion protein. Using the fusion protein improved the signal to background ratio and allowed the potency of a variety of short chain fatty acids to be determined. A GPR40-Gαq fusion protein was also generated, but basal levels of [35S]GTPgammaS binding in Gαq immunoprecipitates was high and did not increase significantly upon the addition of long chain fatty acids. Treatment of membranes expressing GPR40-Gαq with fatty acid free BSA reduced the basal [35S]GTPgammaS binding in a concentration dependent manner and allowed the responsiveness of GPR40 to fatty acids to be uncovered. This also allowed the potency of a variety of thiazolidinediones and small molecule agonists to be determined. It was found that troglitazone was the most potent thiazolidinedione tested. Rosiglitazone also acted as an agonist of GPR40, albeit with lower potency than troglitazone, whereas ciglitazone and pioglitazone displayed little potency. Using clones of Flp-In TREx HEK293 cells where GPR40-eYFP was cloned into the Flp-In locus, the expression of GPR40-eYFP could be controlled by the addition of doxycycline. Using this cell line confirmed that GPR40 mediated the rise in [Ca2+]i induced by the addition of troglitazone. The expression of GPR40 was detected in the rat beta cell line, INS-1E. Addition of lauric acid or troglitazone to these cells induced a large, transient rise of [Ca2+]i. Membranes prepared from INS-1E cells also displayed high basal [35S]GTPgammaS binding, which could be reduced by fatty acid free BSA. The combination of fatty acid free BSA and lauric acid or troglitazone increased [35S]GTPgammaS binding. The high levels of [35S]GTPgammaS binding observed in membranes expressing GPR40 may reflect the binding of an endogenous ligand to GPR40. Homology models of all three receptors based on the crystal structure of rhodopsin indicated that a conserved Arg residue in TM5 may co-ordinate the carboxylate group of the fatty acid. To confirm this observation a series of mutant receptors were generated, with the Arg residue in TM5 mutated to alanine. Neutralisation of the charge in TM5 in GPR41 and GPR43 resulted in receptors that were unable to respond to short chain fatty acids. Further mutants of GPR43 were generated in which the Arg in TM5 was replaced by Lys, Leu or Ser. None of these mutants were able mediate a rise in [Ca2+]i in response to short chain fatty acids. The equivalent mutation in GPR40 did not abolish the receptors ability to respond to long chain fatty acids. There are two further conserved basic residues in TM regions of the receptors; an Arg/Lys in TM2 and a His in TM4. These residues were also mutated to alanine. In GPR41 and GPR43, both mutants had similar function to the wild type receptors. Both GPR40 mutants were also able to respond to a variety of fatty acids measured by their ability to mediate a rise in [Ca2+]i in a FLIPR based assay system. A series of further GPR40 mutants were generated where two of the three basic TM residues were mutated. The most striking observation was found with the mutant in which the His in TM4 and Arg in TM5 mutated to alanine, this mutant was unable to mediate a rise in [Ca2+]i in response to a variety of saturated fatty acids. This may indicate that upon loss of charge in TM5 the His in TM4 compensates and vice versa. None of the small molecule agonists or thiazolidinediones were able to activate the TM4 or TM5 mutants. This indicated that the synthetic agonists of GPR40 require a more conserved binding pocket which may be due to their more rigid structure. The ability of GPR40 and GPR43 to form homo-oligmers was also investigated. It was found that GPR40 and GPR43 formed homo-oligomers as monitored by co-immunoprecipitation, FRET in single, living cells and by time resolved FRET.

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common partners with common problems. Both are chronic systemic disorders incurring significant morbidity and mortality. Although around one third of patients with HF have concurrent COPD,1 remarkably few reports have addressed this often ignored combination. The systematic review presented within this thesis defines the diagnostic challenges, prevalence and prognostic implications of HF with coexistent COPD. I then critically appraise the twin controversies of β-blockade in COPD and β-agonists in HF. The two are inextricably linked, each therapy exerting the reverse pharmacologic activity of the other. The evidence for symptomatic or prognostic benefit from either therapy is limited, and in the case of β-agonists adverse consequences appear more likely. A Cochrane meta-analysis concluded that long term cardioselective β-blockade is safe and well tolerated in patients with moderate to severe or reversible COPD.2 Although often cited,3 these conclusions are simply not true. Of the 20 randomised controlled trials included in the meta-analysis, 11 involved single doses and only one lasted longer than a month. The 9 ‘long term’ studies (defined as more than a single treatment dose) involved 147 young, predominantly male patients with moderate airways obstruction (mean forced expiratory volume in 1 second (FEV1) 1.8 litres). The effect on health status has never been assessed in any cohort with COPD. The long term impact of β-blockade on pulmonary function, symptoms and quality of life is therefore largely unknown. Most importantly, no study has included patients with HF. I randomised 27 patients with HF and coexistent moderate or severe COPD to receive bisoprolol or placebo, titrated to maximum tolerated dose over 4 months. Patients were elderly and predominantly male. Cardiovascular comorbidity, smoking history and pulmonary function were similar in each group (mean FEV1 1.37L vs 1.26L). There were several key findings. A reduction in FEV1 occurred after 4 months following treatment with bisoprolol compared with placebo (–70 ml vs +120 ml, p=0.01). Reversibility following inhaled β2-agonist and static lung volumes were not impaired by bisoprolol. All measures of health status exhibited a consistent non-significant improvement, including the Short Form 36 physical and mental component scores, Minnesota Living with Heart Failure Questionnaire, and Chronic Respiratory Questionnaire. The mean number of COPD exacerbations was similar in the bisoprolol and placebo groups. Although recruitment was limited, the results pose crucial questions and provide direction for larger randomised controlled trials. I analysed cross-sectional data from 61 primary care practices (377,439 patients) participating in the Scottish Continuous Morbidity Recording scheme. The prevalence of COPD in patients with HF increased year on year from 19.8% in 1999 to 23.8% in 2004. These changes may previously have been attributed to an ageing population or increasing age of presentation. However, the trend remained significant after age standardisation. A clear socioeconomic gradient was observed, with prevalence greatest in the most deprived. Consultation rates for HF or COPD in those with both conditions were greater than disease specific contact rates in patients with either condition alone. Cardiovascular comorbidity was similar in HF patients with and without COPD, despite differences in smoking history (respectively 76% vs 47%, p<0.001). This is concerning and suggests that common cardiovascular conditions are being under diagnosed (and likely under treated) in patients with HF and COPD. Although overall β-blocker prescribing increased over time, the adjusted odds of β-blocker prescription in patients with COPD was low (odds ratio 0.30 [95% CI 0.28–0.32], p<0.001). Whether the gap between patients with and without COPD is improving was previously unknown. Despite the overall improvement in beta-blocker prescribing, the relative difference in prescribing between those with and without COPD remained unchanged. By 2004, only 18% of individuals with HF and COPD were prescribed β-blockers. COPD is consistently an independent predictor of death and HF hospitalisation in patients with HF. However, the causes of increased mortality were unclear. I examined the relationship between COPD and cardiovascular outcomes in patients with myocardial infarction (MI) complicated by heart failure, left ventricular systolic dysfunction (LVSD), or both enrolled in the Valsartan in Acute Myocardial Infarction (VALIANT) trial. COPD was an independent predictor of mortality, largely due to increased non-cardiovascular (HR 1.86 [1.43–2.42]) and sudden death (HR 1.26 [1.03–1.53]). However, after multivariate adjustment COPD was not an independent predictor of atherosclerotic events (MI or stroke: HR 0.98 [0.77–1.23]). This is an important finding, as atherosclerotic consequences of chronic systemic inflammation in COPD have been postulated. These appear of limited clinical significance, at least during intermediate follow-up. Part of the adverse risk associated with COPD may be attributable to bronchodilators. The prognosis of patients with HF prescribed bronchodilators is however ill defined. I examined the prognostic implications of bronchodilator use in patients with HF enrolled in the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) programme. The diversity and magnitude of adverse outcomes associated with bronchodilator therapy was surprising. Bronchodilator use was associated with increased all cause mortality (HR 1.26 [1.09–1.45]), cardiovascular death (HR 1.21 [1.03-1.42]), death due to HF progression (HR 1.40 [1.07-1.82]) and HF hospitalisation (HR 1.49 [1.29-1.72]). Although association is not causation, it is possible that bronchodilators compound maladaptive remodeling and further depress myocardial function. Finally, β-blockers were independently associated with better survival in both VALIANT and CHARM. No significant interaction was observed between either COPD or bronchodilators and β-blockade with respect to mortality. Furthermore, β-blocker use was not associated adversely with any pre-specified outcome in patients with COPD or those prescribed bronchodilators, including non-cardiovascular mortality. Although recruitment bias and the absence of spirometry limit inference to patients with severe or reversible airflow obstruction, the results should encourage β-blockade in patients with COPD. In summary, the studies presented in this thesis extend our understanding of HF with concurrent COPD. Only large randomised controlled trials will solve the quandary of β-blockers and β-agonists. Justification for these trials evolves from observational data and smaller prospective studies such as my own. In the meantime, I hope the evidence presented will stimulate physicians to re-evaluate the management of patients with HF and COPD.