Prediction and prevention of venous thrombosis in pregnancy

Venous thromboembolism (VTE) remains the leading cause of maternal mortality. Reports identified further research is required in obese and women post caesarean section (CS). Risk factors for VTE during pregnancy are periodically absent indicating the need for a simple and effective screening tool for pregnancy. Perturbation of the uteroplacental haemostasis has been implicated in placenta mediated pregnancy complications. This thesis had 4 main aims: 1) To investigate anticoagulant effects following a fixed thromboprophylaxis dose in healthy women post elective CS. 2) To evaluate the calibrated automated thrombogram (CAT) assay as a potential predictive tool for thrombosis in pregnancy. 3) To compare the anticoagulant effects of fixed versus weight adjusted thromboprophylaxis dose in morbidly obese pregnant women. 4) To investigate the LMWH effects on human haemostatic gene and antigen expression in placentae and plasma from the uteroplacental , maternal and fetal circulation. Tissue factor pathway inhibitor (TFPI), thrombin antithrombin (TAT), CAT and anti-Xa levels were analysed. Real-time PCR and ELISA were used to quantify mRNA and protein expression of TFPI and TF in placental tissue. In women post CS, anti-Xa levels do not reflect the full anticoagulant effects of LMWH. LMWH thromboprophylaxis in this healthy cohort of patients appears to have a sustained effect in reducing excess thrombin production post elective CS. The results of this study suggest that predicting VTE in pregnant women using CAT assay is not possible at present time. The prothrombotic state in pregnant morbidly obese women was substantially attenuated by weight adjusted but not at fixed LMWH doses. LMWH may be effective in reducing in- vivo thrombin production in the uteroplacental circulation of thrombophilic women. All these results collectively suggest that at appropriate dosage, LMWH is effective in attenuating excess thrombin generation, in low risk pregnant women post caesarean section or moderate to high risk pregnant women who are morbidly obese or tested positive for thrombophilia. The results of the studies provided data to inform evidence-based practice to improve the outcome for pregnant women at risk of thrombosis.

‘Doing’ separation in contemporary Ireland: the experiences of women who separate in midlife

This study explores the experiences of fourteen Irish women who separated in midlife. The rationale for choosing to study this age group of women is because they are the first generation of Irish women to publically separate in midlife in such large numbers. All of them entered marriage at a time when divorce was not possible in Ireland and as such they are broadly without a cultural ‘script’ for how to ‘do’ separation. An exploratory study was conducted to try to capture the processes and events that are part of the lived experiences of separation for women in midlife. In-depth interviews were conducted with fourteen women who were recruited following their attendance at post-separation courses. The participants came from predominantly middle class backgrounds. Narrative interviews were conducted which covered topics such as the attitudes to separation internalised during childhood, the genesis of the marital problems, the events that triggered the separations, the women’s emotional reactions at the time of separating and their social, housing and financial outcomes of having separated. A theoretical framework using concepts related to connectedness and fragmentation was used to analyse the data. Significant diversity was found in the experiences of the interviewees. Most of the women retained connectedness to their children, to their families of origin and to friends who were not joint friends. Significant fragmentation was found in relationships with ex-husbands, with in-laws and with joint friends. All of the women were worse off financially than if they had remained married. They felt socially isolated in the aftermath of separation. Many of the women were struggling to establish positive identities as separated women. While a few of them were very relieved that their marriages had ended, for most, separation was experienced as a painful episode in their lives.

From respect for nature to agency as realisation in response to the ecological emergency

'The ecological emergency’ describes both our emergence into, and the way we relate within, a set of globally urgent circumstances, brought about through anthropogenic impact. I identify two phases to this emergency. Firstly, there is the anthropogenic impact itself, interpreted through various conceptual models. Secondly, however, is the increasingly entrenched commitment to divergent conceptual positions, that leads to a growing disparateness in attitudes, and a concurrent difficulty with finding any grounds for convergence in response. I begin by reviewing the environmental ethics literature in order to clarify which components of the implicit narratives and beliefs of different positions create the foundations for such disparateness of views. I identify the conceptual frameworks through which moral agency and human responsibility are viewed, and that justify an ethical response to the ecological emergency. In particular, I focus on Paul Taylor's thesis of 'respect for nature' as a framework for revising both the idea that we are ‘moral’ and the idea that we are ‘agents’ in this unique way, and I open to question the idea that any response to the ecological emergency need be couched in ethical terms. This revision leads me to formulate an alternative conceptual model that makes use of Timothy Morton’s idea of enmeshment. I propose that we dramatically revise our idea of moral agency using the idea of enmeshment as a starting point. I develop an alternative framework that locates our capacity for responsibility within our capacity for realisation, both in the sense of understanding, and of making real, sets of conditions within our enmeshment. I draw parallels between this idea of ‘realisation as agency’ and the work of Dōgen and other non-dualists. I then propose a revised understanding of ‘the good’ of systems from a biophysical perspective, and compare this with certain features of Asian traditions of thought. I consider the practical implications of these revisions, and I conclude that the act of paying close attention, or realising, contains our agency, as does the attitude, or manner, with which we focus. This gives us the basis for a convergent response to the ecological emergency: the way of our engagement that is the key to responding to the ecological emergency

Restoration of beta-adrenergic signaling in failing cardiac ventricular myocytes via adenoviral-mediated gene transfer.

Cardiovascular gene therapy is a novel approach to the treatment of diseases such as congestive heart failure (CHF). Gene transfer to the heart would allow for the replacement of defective or missing cellular proteins that may improve cardiac performance. Our laboratory has been focusing on the feasibility of restoring beta-adrenergic signaling deficiencies that are a characteristic of chronic CHF. We have now studied isolated ventricular myocytes from rabbits that have been chronically paced to produce hemodynamic failure. We document molecular beta-adrenergic signaling defects including down-regulation of myocardial beta-adrenergic receptors (beta-ARs), functional beta-AR uncoupling, and an up-regulation of the beta-AR kinase (betaARK1). Adenoviral-mediated gene transfer of the human beta2-AR or an inhibitor of betaARK1 to these failing myocytes led to the restoration of beta-AR signaling. These results demonstrate that defects present in this critical myocardial signaling pathway can be corrected in vitro using genetic modification and raise the possibility of novel inotropic therapies for CHF including the inhibition of betaARK1 activity in the heart.

Highly resolved absolute cross-sections for dissociative electron attachment to SF5CF3

Using two complementary experimental methods, we have measured partial (mass-resolved) cross-sections for dissociative electron attachment to the molecule trifluoromethyl sulfurpentafluoride (SF5CF3) at the gas temperature T-G = 300 K over a broad range of electron energies (E = 0.001-12 eV). The absolute scale for these cross-sections was obtained with reference to the thermal (T = 300 K) rate coefficient for anion formation (8.0(3) x 10(-8) cm(3) s(-1)). Below 1 eV, SF5- is the dominant product anion and formed through the lowest anion state which cuts the neutral SF5CF3 potential close to the S-C equilibrium distance. The highly resolved laser photoelectron attachment data exhibit a downward Wigner cusp at 86meV, indicating that the nu(4)(alpha(1)) vibrational mode is important for the primary attachment dynamics. Both SF5- and F- anions are formed with similar yields through the first excited resonance located near 3.6eV. Towards higher energies, the anions CF3-, SF4-, and SF3- are also produced. Summation of the partial cross-sections yields a total absolute cross-section for anion formation over the energy range 0.001-12 eV. This is used to calculate the dependence of the rate coefficient for dissociative electron attachment over a broad range of electron temperatures for the fixed gas temperature T-G = 300 K; good agreement is found between the calculated values and those obtained in a drift tube experiment. In addition to the experimental work, semiempirical R-matrix calculations have been Carried out for the energy dependence of the cross-section for SF5- formation. The experimental findings are semi-quantitatively recovered. (C) 2008 Elsevier B.V. All rights reserved.

Low-energy electron attachment to chloroform (CHCl3) molecules: A joint experimental and theoretical study

Results from a joint experimental and theoretical study of electron attachment to chloroform (CHCl3) molecules in the gas phase are reported. In an electron swarm study involving a pulsed Townsend technique with equal gas and electron temperatures, accurate attachment rate coefficients were determined over the temperature range 295-373 K; they show an Arrhenius-type rise with increasing temperature, corresponding to an activation energy of 0.11 (1) eV. In a high resolution electron beam experiment involving two versions of the laser photoelectron attachment method, the relative cross section for Cl- formation from CHCl3 over the energy range 0.001-1.25 eV at the gas temperature T-G = 300 K was measured. It exhibits clear downward cusp structure at the threshold for excitation of one quantum of the vibrational symmetric deformation mode nu(3), indicating that this mode is active in the primary attachment process. With reference to our thermal attachment rate coefficient k(T = 300 K) = 3.9(2) x 10(-9) cm(3) s(-1), a new highly resolved absolute attachment cross section for T-G = 300 K was determined. This cross section is extended to higher energies by measurements, carried out with a pulsed electron beam apparatus which also provided new data for the distinctly weaker fragment anions HCl2- and CCl2-. The resulting total absolute cross section for anion formation is used to calculate the dependence of the attachment rate coefficient k(T-e;T-G) on electron temperature T-e over the range 50-15000 K at the fixed gas temperature T-G = 300 K. In addition, we report the dependence of the relative cross section for Cl- formation on gas temperature T-G = 310-435 K). For comparison with the experimental data, R-matrix calculations have been carried out for the dominant anion channel Cl-. The results recover the main experimental observations and predict the dependence of the DEA cross section on the initial vibrational level nu(3) and on the vibrational temperature. Our results are compared with those of previous electron beam and electron swarm experiments.

A phase II study of the potent PARP inhibitor, Rucaparib (PF-01367338, AG014699), with temozolomide in patients with metastatic melanoma demonstrating evidence of chemopotentiation

PURPOSE: poly(ADP ribose) polymerase inhibition has been shown to potentiate the cytotoxicity of DNA damaging agents. A phase I study of rucaparib and temozolomide showed that full-dose temozolomide could be given during PARP inhibition. We report the results of a phase II study of intravenous rucaparib 12 mg/m(2) and oral temozolomide 200 mg/m(2) on days 1-5 every 28 days in patients with advanced metastatic melanoma. METHODS: Patients with chemotherapy naïve measurable metastatic melanoma, performance status =2 and good end-organ function were recruited. Treatment was given until progression. A two stage phase II design was used, with response rate the primary endpoint. Population pharmacokinetics and pharmacodynamics were also explored. RESULTS: Forty-six patients were recruited with 37 patients receiving at least 2 cycles and 17 patients at least 6 cycles. Myelosuppression occurred with 25 patients (54 %) requiring a 25 % dose reduction in temozolomide. The response rate was 17.4 %, median time to progression 3.5 months, median overall survival 9.9 months, and 36 % of patients were progression-free at 6 months. CONCLUSIONS: This study showed that temozolomide (150-200 mg/m(2)/day) can safely be given with a PARP inhibitory dose of rucaparib, increasing progression-free survival over historical controls in metastatic melanoma patients.

Alternative treatments to inhibit VEGF in age-related choroidal neovascularisation: 2-year findings of the IVAN randomised controlled trial

Background: Bevacizumab has been suggested to have similar effectiveness to ranibizumab for treatment of neovascular age-related macular degeneration. The Inhibition of VEGF in Age-related choroidal Neovascularisation (IVAN) trial was designed to compare these drugs and different regimens. Here, we report the findings at the prespecified 2-year timepoint. Methods: In a multicentre, 2×2 factorial, non-inferiority randomised trial, we enrolled adults aged at least 50 years with active, previously untreated neovascular age-related macular degeneration and a best corrected distance visual acuity (BCVA) of at least 25 letters from 23 hospitals in the UK. Participants were randomly assigned (1:1:1:1) to intravitreal injections of ranibizumab (0·5 mg) or bevacizumab (1·25 mg) in continuous (every month) or discontinuous (as needed) regimens, with monthly review. Study participants and clinical assessors were masked to drug allocation. Allocation to continuous or discontinuous treatment was masked up to 3 months, at which point investigators and participants were unmasked. The primary outcome was BCVA at 2 years, with a prespecified non-inferiority limit of 3·5 letters. The primary safety outcome was arterial thrombotic event or hospital admission for heart failure. Analyses were by modified intention to treat. This trial is registered, number ISRCTN92166560. Findings: Between March 27, 2008, and Oct 15, 2010, 628 patients underwent randomisation. 18 were withdrawn; 610 received study drugs (314 ranibizumab; 296 bevacizumab) and were included in analyses. 525 participants reached the visit at 2 years: 134 ranibizumab in continuous regimen, 137 ranibizumab in discontinuous regimen, 127 bevacizumab in continuous regimen, and 127 bevacizumab in discontinuous regimen. For BCVA, bevacizumab was neither non-inferior nor inferior to ranibizumab (mean difference -1·37 letters, 95% CI -3·75 to 1·01; p=0·26). Discontinuous treatment was neither non-inferior nor inferior to continuous treatment (-1·63 letters, -4·01 to 0·75; p=0·18). Frequency of arterial thrombotic events or hospital admission for heart failure did not differ between groups given ranibizumab (20 [6%] of 314 participants) and bevacizumab (12 [4%] of 296; odds ratio [OR] 1·69, 95% CI 0·80-3·57; p=0·16), or those given continuous (12 [4%] of 308) and discontinuous treatment (20 [7%] of 302; 0·56, 0·27-1·19; p=0·13). Mortality was lower with continuous than discontinuous treatment (OR 0·47, 95% CI 0·22-1·03; p=0·05), but did not differ by drug group (0·96, 0·46-2·02; p=0·91). Interpretation: Ranibizumab and bevacizumab have similar efficacy. Reduction in the frequency of retreatment resulted in a small loss of efficacy irrespective of drug. Safety was worse when treatment was administered discontinuously. These findings highlight that the choice of anti-VEGF treatment strategy is less straightforward than previously thought.

Causal Models of Clinically Significant Behaviors in Angelman, Cornelia de Lange, Prader-Willi and Smith-Magenis Syndromes

The operant learning theory account of behaviors of clinical significance in people with intellectual disability (ID) has dominated the field for nearly 50 years. However, in the last two decades, there has been a substantial increase in published research that describes the behavioral phenotypes of genetic disorders and shows that behaviors such as self-injury and aggression are more common in some syndromes than might be expected given group characteristics. These cross-syndrome differences in prevalence warrant explanation, not least because this observation challenges an exclusively operant learning theory account. To explore this possible conflict between theoretical account and empirical observation, we describe the genetic cause and physical, social, cognitive and behavioral phenotypes of four disorders associated with ID (Angleman, Cornelia de Lange, Prader-Willi and Smith-Magenis syndromes) and focus on the behaviors of clinical significance in each syndrome. For each syndrome we then describe a model of the interactions between physical characteristics, cognitive and motivational endophenotypes and environmental factors (including operant reinforcement) to account for the resultant behavioral phenotype. In each syndrome it is possible to identify pathways from gene to physical phenotype to cognitive or motivational endophenotype to behavior to environment and back to behavior. We identify the implications of these models for responsive and early intervention and the challenges for research in this area. We identify a pressing need for meaningful dialog between different disciplines to construct better informed models that can incorporate all relevant and robust empirical evidence.