Caesarean section and subsequent pregnancy outcome: a Danish register-based cohort study

Background and Aims: Caesarean section rates have increased in recent decades and the effects on subsequent pregnancy outcome are largely unknown. Prior research has hypothesised that Caesarean section delivery may lead to an increased risk of subsequent stillbirth, miscarriage, ectopic pregnancy and sub-fertility. Structure and Methods: Papers 1-3 are systematic reviews with meta-analyses. Papers 4-6 are findings from this thesis on the rate of subsequent stillbirth, miscarriage, ectopic pregnancy and live birth by mode of delivery. Results Systematic reviews and meta-analyses: A 23% increased odds of subsequent stillbirth; no increase in odds of subsequent ectopic pregnancy and a 10% reduction in the odds of subsequent live birth among women with a previous Caesarean section were found in the various meta-analyses. Danish cohorts: Results from the Danish Civil Registration System (CRS) cohort revealed a small increased rate of subsequent stillbirth and ectopic pregnancy among women with a primary Caesarean section, which remained in the analyses by type of Caesarean. No increased rate of miscarriage was found among women with a primary Caesarean section. In the CRS data, women with a primary Caesarean section had a significantly reduced rate of subsequent live birth particularly among women with primary elective and maternal-requested Caesarean sections. In the Aarhus Birth Cohort, overall the effect of mode of delivery on the rate and time to next live birth was minimal. Conclusions: Primary Caesarean section was associated with a small increased rate of stillbirth and ectopic pregnancy, which may be in part due to underlying medical conditions. No increased rate of miscarriage was found. A reduced rate of subsequent live birth was found among Caesarean section in the CRS data. In the smaller ABC cohort, a small reduction in rate of subsequent live birth was found among women with a primary Caesarean section and is most likely due to maternal choice rather than any ill effects of the Caesarean. The findings of this study, the largest and most comprehensive to date will be of significant interest to health care providers and women globally.

Cesarean section and rate of subsequent stillbirth, miscarriage and ectopic pregnancy: a Danish register-based cohort study

Background: With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. Methods and Findings: We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage. Conclusions: This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery.

The impact of first pregnancy and delivery on pelvic floor dysfunction

Background: The first childbirth has the greatest impact on a woman’s pelvic floor when major changes occur. The aim of this study was to comprehensively describe pelvic floor dysfunction (PFD) in young nulliparous women, and its correlation with postnatal pathology. Methods: A prospective study was performed at Cork University Maternity Hospital, Ireland. Initially 1484 nulliparous women completed the validated Australian Pelvic Floor Questionnaire at 15 weeks’ gestation and repeatedly at one year postnatally (N=872). In the second phase, at least one year postnatally, 202 participants without subsequent pregnancies attended the clinical follow up which included: pelvic organ prolapse quantification, a 3D-Transperineal ultrasound scan and collagen level assessment. Results: A high pre-pregnancy prevalence of various types of PFD was detected, which in the majority of cases persisted postnatally and included multiple types of PFD. The first birth had a negative impact on severity of pre-pregnancy symptoms in <15% of cases. Apart from prolapse, vaginal delivery, including instrumental delivery did not increase the risk of PFD symptoms, where as Caesarean section was protective for all types of PFD. The first birth had a bigger impact on pre-existing symptoms of overactive bladder compared to stress urinary incontinence. Pelvic organ prolapse is extremely prevalent in young primiparous women, however usually it is low grade and asymptomatic. Congenital factors and high collagen type III levels play an important role in the aetiology of pelvic organs prolapse. Levator ani trauma is present in one in three women after the first pregnancy and delivery. Conclusion: The main damage to the pelvic floor most likely occurs due to an undiagnosed congenital intrinsic weakness of the pelvic floor structures. PFD is highly associated with first childbirth, however it seems that pregnancy and delivery are contributing factors only which unmask the congenital intrinsic weakness of the pelvic floor support.

Perceptions, expectations, and informal supports influence exercise activity in frail older adults

This study aims to explore frail older adults’ perceptions of what influences their exercise behaviors. A qualitative descriptive design was used. Semi-structured, open-ended interviews were conducted with 29 frail older adults. Thematic content analysis established the findings. Frail older adults perceive exercise as a by-product of other purposeful activities such as manual work or social activities. Progression into frailty appears to be associated with a decline in non-family support, changing traditional roles within family support networks, and lower baseline activity levels. Frail older adults perceive exercise as incidental to more purposeful activities rather than an endpoint in itself. Therefore, exercise programs concentrating on functional outcomes may be more relevant for this population. Strategies that educate and promote social support networks may also benefit frail older adults.

Preserving patent policy space and securing access to medicines in developing countries: the role of states and pharmaceutical corporations

This thesis examines the tension between patent rights and the right to health and it recognizes patent rights on pharmaceutical products as one of the factors responsible for the problem of lack of access to affordable medicines in developing countries. The thesis contends that, in order to preserve their patent policy space and secure access to affordable medicines for their citizens, developing countries should incorporate a model of human rights into the design, implementation, interpretation, and enforcement of their national patent laws. The thesis provides a systematic analysis of court decisions from four key developing countries (Brazil, India, Kenya, and South Africa) and it assesses how the national courts in these countries resolve the tension between patent rights and the right to health. Essentially, this thesis demonstrates how a model of human rights can be incorporated into the adjudication of disputes involving patent rights in national courts. Focusing specifically on Brazil, the thesis equally demonstrates how policy makers and law makers at the national level can incorporate a model of human rights into the design or amendment of their national patent law. This thesis also contributes to the ongoing debate in the field of business and human rights with regard to the mechanisms that can be used to hold corporate actors accountable for their human rights responsibilities. This thesis recognizes that, while states bear the primary responsibility to respect, protect, and fulfil the right to health, corporate actors such as pharmaceutical companies also have a baseline responsibility to respect the right to health. This thesis therefore contends that pharmaceutical companies that own patent rights on pharmaceutical products can be held accountable for their right to health responsibilities at the national level through the incorporation of a model of civic participation into a country’s patent law system.

WORKS FOR HORN BY AMERICAN WOMEN COMPOSERS

This performance dissertation consists of three recitals featuring the music of American women composers of the 20th and 21st centuries. My purpose in presenting these recitals is to expose and explore the lesser known compositions of these composers through live public performances. I selected a cross section of composers whose compositions employed a wide range of musical styles, techniques and instrumentation. The instrumentation included not only the "standard" works for solo horn and horn and piano, but various chamber compositions as well. Of these chamber works, there exists a duet for horn and harp, a trio for violin, cello and horn, and a quartet for viola, horn, piano, and percussion. In addition to the published works chosen, it was my intent to further heighten the awareness of American women composers through the commissioning of a work specifically for this dissertation. The resulting piece was Arbor for horn and harp by Elisabeth Mehl Greene, which received its premiere on April 18, 2009. Through this project, it is my hope to have not only increased the public's awareness of these lesser known works but to have contributed to the performances of these ever growing number of works by American women composers.

Fission dynamics for capture reactions in 58,64ni + 208pb systems: New results in terms of thermal energy and neutron multiplicity correlated distributions

The neutron multidetector DéMoN has been used to investigate the symmetric splitting dynamics in the reactions 58.64Ni + 208Pb with excitation energies ranging from 65 to 186 MeV for the composite system. An analysis based on the new backtracing technique has been applied on the neutron data to determine the two-dimensional correlations between the parent composite system initial thermal energy (EthCN) and the total neutron multiplicity (νtot), and between pre- and post-scission neutron multiplicities (νpre and νpost, respectively). The νpre distribution shape indicates the possible coexistence of fast-fission and fusion-fission for the system 58Ni + 208Pb (Ebeam = 8.86 A MeV). The analysis of the neutron multiplicities in the framework of the combined dynamical statistical model (CDSM) gives a reduced friction coefficient β = 23 ± 2512 × 1021 s-1, above the one-body dissipation limit. The corresponding fission time is τf = 40 ± 4620 × 10-21 s. © 1999 Elsevier Science B.V. All rights reserved.

Structural and biological investigation of ferrocene-substituted 3-methylidene-1,3-dihydro-2H-indol-2-ones

The Knoevenagel condensation of 1,3-dihydro-2H-indol-2-one with ferrocene carboxaldehyde afforded an approximate 2:1 mixture of the geometrical isomers (E)- and (Z)-3-ferrocenylmethylidene-1,3-dihydro-2H-indol-2-one respectively in an overall 67% yield; the air and solution-stable isomers were readily separated by preparative thin layer chromatography and their structures were unequivocally elucidated in solution, by (1)H NMR spectroscopy, and in the solid phase, by X-ray crystallography; both isomers of displayed in vitro toxicity against B16 melanoma and Vero cell lines in the micromolar range and inhibited the kinase VEGFR-2 with IC(50) values of ca. 200 nM.

Synthesis of a 1,4-benzodiazepine containing palladacycle with in vitro anticancer and cathepsin B activity

The reaction of the five-membered C,N-palladacycle [(L)PdCl](2), where LH = 1-methyl-5-phenyl-1H-1,4-benzodiazepin-2(3H)-one, with 1,2-ethanebis(diphenylphosphine), dppe, leads to the formation of the bridged palladacycle. [Pd(2)L(2)(mu-dppe)Cl(2)] 3, which was characterised in solution by (1)H and (31)P NMR spectroscopy and in the solid state by X-ray crystallography. Complex 3 was tested in vitro against a number of cell lines. For example, it inhibited K562 leukaemia cells with an IC(50) value of 4.3 microM (1 h exposure) and displayed cathepsin B inhibitory action with an IC(50) value of 3 microM.

Developing “middle leaders” in the public services? The realities of management and leadership development for public managers

Purpose – This paper aims to assess the actual contribution to organisational change of management and leadership development (MLD) activity for middle managers (MMs) in public service organisations (PSOs). Design/methodology/approach – Using the case study approach, the paper compares the content and outcomes of management and leadership training interventions for MMs in two large PSOs. The organisations, a fire brigade and a train operating company, are leaders in their sectors with respect to management development and “modernisation” of their services. Findings – The paper demonstrates how, in one case, MM development was largely an exercise in regulatory compliance, with little effect on individual MMs' performance or organisational outcomes. The second case demonstrates how MMs were effectively trained to enforce specific human resource policies which contributed to the successful implementation of top-down strategy yet paid little attention to the potential leadership role of MMs. Research limitations/implications – The paper highlights the need for further contextualised research at organisational level into the outcomes of MLD, especially in terms of different public service contexts. Practical implications – The paper demonstrates the dangers of designing and implementing development programmes without sufficient regard to professional practice and the realities of managerial discretion in PSOs. Originality/value – The paper provides an in-depth and contextualised insight into the conditions for success and failure in management development interventions in PSOs.

The UK WTC9/11 evacuation study: an overview of the methodologies employed and some preliminary analysis

This paper briefly describes the methodologies employed in the collection and storage of first-hand accounts of evacuation experiences derived from face-to-face interviews from evacuees from the World Trade Centre (WTC) Twin Towers complex on 11 Septebmer 2001 and the development of the High-rise Evacuation Evaluation Database (HEED). The main focus of the paper is to present a preliminary analysis of data derived from the evacuation of the North Tower.

Influence of a fed or fasted state on the s-IgA response to prolonged cycling in active men and women

This study investigated the effect of a fed or fasted state on the salivary immunoglobulin A (s-IgA) response to prolonged cycling. Using a randomized, crossover design, 16 active adults (8 men and 8 women) performed 2 hr of cycling on a stationary ergometer at 65% of maximal oxygen uptake on 1 occasion after an overnight fast (FAST) and on another occasion 2 hr after consuming a 2.2-MJ high-carbohydrate meal (FED). Timed, unstimulated whole saliva samples were collected immediately before ingestion of the meal, immediately preexercise, 5 min before cessation of exercise, immediately postexercise, and 1 hr postexercise. The samples were analyzed for s-IgA concentration, osmolality, and cortisol, and saliva flow rates were determined to calculate s-IgA secretion rate. Saliva flow rate decreased by 50% during exercise (p < .05), and s-IgA concentration increased by 42% (p < .05), but s-IgA secretion rate remained unchanged. There was a 37% reduction in s-IgA:osmolality postexercise (p < .05), and salivary cortisol increased by 68% (p < .05). There was no effect of FED vs. FAST on these salivary responses. The s-IgA concentration, secretion rate, and osmolality were found to be significantly lower in women than in men throughout the exercise protocol (p < .05); however, there was no difference between genders in saliva flow rate, s-IgA:osmolality ratio, or cortisol. These data demonstrate that a fed or fasted state 2 hr before exercise does not influence resting s-IgA or the response to prolonged cycling. Furthermore, these results show lower levels of s-IgA and osmolality in women than in men at rest.

Seven 3-methylidene-1H-indol-2(3H)-ones related to the multiple-receptor tyrosine kinase inhibitor sunitinib

The solid-state structures of a series of seven substituted 3-methylidene-1H-indol-2(3H)-one derivatives have been determined by single-crystal X-ray diffraction and are compared in detail. Six of the structures {(3Z)-3-(1H-pyrrol-2- ylmethylidene)-1H-indol-2(3H)-one, C13H10N2O, (2a); (3Z)-3-( 2-thienylmethylidene)-1H-indol-2(3H)-one, C13H9NOS, (2b); (3E)-3-(2-furylmethylidene)-1H-indol-2(3H)-one monohydrate, C13H9NO2 center dot H2O, (3a); 3-(1-methylethylidene)-1H-indol- 2(3H)-one, C11H11NO, (4a); 3-cyclohexylidene-1H-indol- 2(3H)-one, C14H15NO, (4c); and spiro[1,3-dioxane-2,3'-indolin]- 2'-one, C11H11NO3, (5)} display, as expected, intermolecular hydrogen bonding (N-H center dot center dot center dot O=C) between the 1H-indol-2(3H)-one units. However, methyl 3-(1-methylethylidene)- 2-oxo-2,3-dihydro-1H-indole-1-carboxylate, C13H13NO3, (4b), a carbamate analogue of (4a) lacking an N-H bond, displays no intermolecular hydrogen bonding. The structure of (4a) contains three molecules in the asymmetric unit, while (4b) and (4c) both contain two independent molecules.

Preparation, properties and applications of colloidal microgels

This chapter contains sections titled: - Introduction - Microgel preparation - Characterisation of microgels - Properties and applications - Conclusions