Epilepsy is the most common serious chronic neurological disorder, affecting 65 million people worldwide. Antiepileptic drugs (AEDs) constitute the main treatment for epilepsy. The introduction of 14 new AEDs over the last three decades has expanded treatment options and increased the expectations about efficacy and tolerability. However, little is known about the effectiveness of new AEDs in routine clinical practice. It is also unclear whether the treatment outcomes in epilepsy have improved in recent decades as a consequence of the availability of an increasing number of AEDs. The present work attempts to provide a comprehensive evaluation of efficacy, tolerability, and retention rate of AED treatments in everyday clinical setting. This thesis is divided into six chapters, three general chapters and three result chapters (Chapter 3, 4, and 5). Chapter 1 sorts out the background of epilepsy, pharmacological management, and adverse drug reactions. The new classification of seizures and epilepsies, AED therapy, and guidelines for initiation, selection and dosing of AEDs are described. Followed by discussion of clinically relevant adverse effects of AEDs. Chapter 2 describes the study population and definition of outcome measures. Data collection and statistical analysis were presented as well. The data of this study were extracted retrospectively by reviewing the patients’ medical records. The patients were first diagnosed with epilepsy and prescribed AED treatment at the Glasgow Epilepsy Unit between Jul 1982 and Oct 2012; then they were prospectively followed up until 30 Apr 2016 with at least one year follow-up after starting AEDs therapy. The study cohort included 1,528 patients aged 18 to 93 years (median 37), 849 (56%) were men, and 1,290 (84%) had focal epilepsy. Chapter 3 evaluates efficacy of AEDs and the changes in treatment outcomes of epilepsy over the past 30 years. This was achieved by comparing the results of current analysis to the results of three analyses conducted in 1999, 2003, and 2008 on same expanding cohort (n=470, 890, and 1,098 respectively) from the Epilepsy Unit in Glasgow. The overall efficacy rate of AEDs in this study was 62% (n=941/1,528); this was comparable to what was observed in the previous analysis of 17 years ago on the same expanding cohort in which 64% (n=301/470) of newly diagnosed epilepsy patients achieved seizure-free. Likewise, the efficacy rates of different established and new AEDs were comparable. Therefore, this provides a strong evidence that treatment outcomes in epilepsy have not improved in recent decades despite the availability of increasing number of AEDs. However, the results indicated that the use of new AEDs has increased, 41% of patients continued to take the new AEDs as a monotherapy in the current study, compared to 26% in 1999. This most likely due to their advantages in terms of tolerability. This analysis also found that family history of epilepsy, more than ten pre-treatment seizures, psychiatric conditions, alcohol and recreational drugs abuse, and failure to response to two or more AEDs were significantly associated with poor seizure outcomes. In Chapter 4, the rate and predictors of intolerable adverse effects of AEDs were assessed. This study showed that 28% (n=815/2,911) of total AEDs prescriptions were discontinued because of poor tolerability. In which the most frequent problem was tiredness (5.2%, n=152/2,911) followed by poor coordination and rash, with a 2.9% (n=86) incidence for each. Among 17 different AEDs, lamotrigine was associated with the best tolerability whether it was used as monotherapy (19%, n=109/575) or as part of polytherapy (9%, n=35/387). While topiramate was associated with the highest rate of adverse effects (39%, n=32/81) among monotherapies, and retigabine had the highest rate of adverse effects (42%, n=8/19) among AEDs used as part of polytherapy. Moreover, each AED demonstrated a distinct tolerability profile; the main intolerable adverse reaction associated with lamotrigine and carbamazepine was skin rash while valproate was poorly tolerated most frequently due to tremor and weight gain. Furthermore, levetiracetam was poorly tolerated commonly due to psychiatric and behavioural side effects whereas cognitive dysfunction was the most common reason for topiramate intolerability. Beside individual AED, poor tolerability was related to patient’s susceptibility and number of co-prescribed AEDs. Prior intolerable AEDs schedule was associated with high probability to experience intolerable adverse effects at subsequent AED schedule. Likewise, female, focal epilepsy, more than ten pre-treatment seizures, and psychiatric comorbidity were significantly associated with higher rates of adverse effects. However, older AEDs usage was not significantly associated with poorer tolerability. These may present novel findings from this study as very few studies have evaluated the predictors for poor tolerability particularly non-AEDs variables. In Chapter 5, a survival analysis was performed to identify retention rates (time to discontinuation) of lamotrigine, valproate, carbamazepine, and levetiracetam monotherapies. Lamotrigine showed the highest retention rate, with median duration of therapy of 84 months. This was significantly higher than the retention times of valproate (42 months), carbamazepine (36 months), and levetiracetam (36 months); there was no significant difference in retention rates of other AEDs. However, within six months of therapy initiation, lamotrigine and carbamazepine demonstrated the highest discontinuation rates, most probably due to rash. Few observational studies have investigated the long-term retention rates of AEDs in the UK. Therefore, the current research may present novel findings in term of population as well. In Chapter 6, study strengths and limitations are presented. Clinical implications and the future directions of research in epilepsy are described as well.

The focus of this thesis was the evaluation of a treatment to help people who have a learning disability to develop socially appropriate ways of expressing anger. The inability to cope with anger has prevented some people from living an ordinary life in the community. A cognitive behavioural treatment to help people to cope with anger was developed by Novaco (1983b). The aim of the present studies was to examine whether a modification of the treatment developed by Novaco could prove beneficial for a population who have a learning disability. A set of criteria for improvement were devised to operationalise improvement in terms of clinically, as well as statistically significant change. In study 1, twelve people who have a learning disability were assessed on one self report measure and four measures completed by staff; at baseline, at the end of each stage of treatment and follow up. The subjects received approximately fifty weeks of treatment. As the follow up scores met the majority of the criteria for improvement, it was inferred that the subjects had benefited from treatment. A number of methodological modifications were suggested. In study 2, five subjects were assessed on four self report and three staff completed assessments. The four stages of treatment (self monitoring, information giving, relaxation training and problem solving) lasted 27-37 weeks. Four of the five subjects benefited from treatment as their follow up scores met the criteria for improvement. The results allowed cautious optimism about the efficacy of cognitive behavioural techniques and the use of self report measures for people who have a learning disability, who are verbal. The value of embedding this focussed treatment within a broader therapeutic framework, to encompass a wider range of emotions and strategies to cope with stress was discussed.

Pancreatic ductal adenocarcinoma (PDAC) is the most common epithelial, exocrine pancreatic malignancy. Gemcitabine, as the only chemotherapy clinically available for pancreatic cancer, proves effective only in 23.8% of patients. Recently, iron oxide-gold hybrid nanoparticles (HNPs) have received significant attention in cancer therapy, which exploit the surface chemistry and SPR of the gold with magnetic character of the iron oxide, offering imaging, heating and drug delivery potentials. In this work HNPs were synthesised using a multi-step coating process of iron oxide cores. Particles were characterised by different techniques, in terms of their size, zeta potential, morphology and their magnetic properties. Laser irradiation on HNPs was used in order to obtain optimal temperature increase, needed for drug release. It is postulated that nanoparticulate irradiation at lower temperatures can trigger drug release from the surface of the vehicle before cellular hyperthermia was initiated. Different bisnaphtalamide based anticancer drugs were conjugated onto the surface of the HNPs. Drug loading, stability and drug release studies were carried out. A pancreatic cancer targeting peptide (c(RGDfC)) was conjugated to the formulations to increase drug specific delivery and anticancer activity. In vitro biological studies were performed on two pancreatic cancer cell lines and a human monocyte cell line. Hybrid formulations (specially targeted formulation) have shown higher cytotoxicity compared with free drugs and gemcitabine on pancreatic cancer cells. Drug uptake pattern was dose responsive and time dependant on all cell lines, and hybrid formulations internalised at significantly higher concentrations than the free drugs. AFM topography images were in agreement with cellular uptake. Moreover, HNPs possessed thermoresponsive drug delivery potentials in vitro. This is the first time these novel drugs were conjugated to iron oxide-gold HNPs, which demonstrated the interesting potential of these nanoparticles to act as thermoresponsive drug carriers.

Leukaemia is 11th most common cancer worldwide, associated with poor prognosis. The 10 years’ survival for leukaemia is between 44%-47%. One of the main reasons for this is the disease being diagnosed in late stages. Most of leukaemia screening techniques are invasive or give radiation. It is therefore obvious to improve prognosis and refine diagnostic techniques for early detection, and better management of its therapeutic response. Spectroscopic and spectrometric techniques are widely used by a huge group of scientists; as biochemical analysis of the disease, may provide biochemical signatures to be used in diagnostics and management of the disease. In this work, the feasibility of measuring both qualitatively and quantitatively VOCs released by PBMC, leukaemia cells and BM cells in vitro has been shown. There are clear differences in the VOCs profile even among different leukaemia cells lines as well as from leukaemia cells exposed to drugs, PBMCs and bone marrow. These differences in the VOCs release could be exploited towards a clinical application of SIFT-MS in the diagnosis and therapeutic response of the disease. Direct sampling is the most convenient method of sampling, which could avoid loss of the many important VOCs by diffusion and/or absorption. Since it is not very easy to obtain direct breath, appropriate storage of exhaled breath and transportation are very important issues to be considered. My study proved that stability over time might vary for different VOCs, especially those present in smaller concentrations. The addition of Imatinib or Nilotinib to K562 cell clones induces changes in cell biology and cellular structure which translates into changes in the S-FTIR spectra and Raman Spectra of the cells. There are remarkable differences in the biochemical composition of cells incubated at different drug concentrations and at different levels of oxygen. Further studies are needed to confirm these changes in the spectra.

Autotaxin is an extracellular phospholipase D that catalyses the hydrolysis of lysophosphatidyl choline (LPC) to bioactive lipid lysophosphatidic acid (LPA). LPA has been implicated in many pathological processes relevant to cancer, including cell migration and invasion, proliferation, and survival. Patients with ovarian cancer often present with an accumulation of ascites fluid in the intraperitoneal cavity which contains LPA at concentrations up to 80 micromolar. Autotaxin is also found at increased levels in the ascites fluid of patients with ovarian cancer and is over-expressed in ovarian cancer tumours that are resistant to chemotherapy. Maintaining a high local concentration of an autotaxin inhibitor within the peritoneal cavity is likely to be important to ensure sufficient and prolonged inhibition of autotaxin. The residence time of small molecular weight drugs in the peritoneal cavity may not be adequate because they are quickly absorbed through the peritoneal capillaries into systemic circulation. Polymers are becoming an increasingly useful tool in the delivery of drugs and have the potential to improve the properties of small molecules, including intraperitoneal residence time. In this thesis, the synthesis of polymer-autotaxin inhibitor conjugates is described, followed by the biological evaluation of the conjugates. Firstly, the synthesis of a dendrimer-S32826 conjugate and its biological evaluation is reported. S32826 is a LPA analogue with a high potency against autotaxin. This dendrimer-autotaxin inhibitor conjugate was found to inhibit autotaxin activity using two different substrates and two different sources of autotaxin, and to decrease the migration of an ovarian cancer cell line modified to overexpress autotaxin. Furthermore, the conjugate potentiated activation of caspase 3/7 induced by carboplatin. However, conjugation of the drug to the dendrimer significantly reduced its potency. Subsequently the synthesis of an icodextrin-autotaxin inhibitor conjugate and its biological evaluation was undertaken. Structure-based drug design was used to identify an appropriate locus to cross link icodextrin to an autotaxin inhibitor described by Albers et al. with a thiazolidinedione core. The icodextrin-autotaxin inhibitor conjugate was also found to inhibit autotaxin activity using two different substrates and two different sources of autotaxin. Furthermore, the conjugate was found to reduce migration of an ovarian cell line modified to over express autotaxin. Conjugation to icodextrin led to an increase in solubility and a decrease in permeability compared to the free drug. Finally, the icodextrin-autotaxin inhibitor conjugate was administered to the peritoneal cavity of mice. After 24 hours, 30% of the drug was still detected in the peritoneal cavity. These observations suggest that the drug conjugate may be useful in the treatment of ovarian cancer.

The sphingosine 1-­‐phosphate receptor modulator fingolimod / Gilenya / FTY720 has become an effective and commercially available therapeutic agent for the treatment of relapsing-­‐remitting multiple sclerosis. Fingolimod is phosphorylated by sphingosine kinase in vivo to the pharmacologically active S-­‐fingolimod phosphate. The original aim of the work was to synthesise novel phosphate delivery prodrug analogues of fingolimod and determine whether or not these novel analogues could provide an improved therapeutic profile. The principal phosphate delivery prodrug method to be investigated was phosphoramidate “ProTide” chemistry. ProTide fingolimod analogues were found to have a poor level of stability and readily degrade to unwanted cyclised structures at room temperature and when exposed to very mildly basic conditions. In order to mitigate the poor stability issues it was considered possible that forming ProTide analogues of mono-­‐alcohol S1P receptor modulators, as opposed to diol fingolimod, would lead to greater stability. The synthesis of mono-­‐alcohol S1P receptor modulator benzyl ether derivative analogues published by Tsuji et al was attempted and successfully achieved. Previously reported ProTide synthesis and in vitro testing methods were employed. Carboxypeptidase, human serum, base stability, acid stability and cell lysate processing experiments were conducted in the School of Pharmacy. Homology modelling was employed to determine S1P1 selectivity of benzyl ether derivative analogues and novel structures. ProTide benzyl ether derivative analogues were found to have a far greater level of stability than ProTide fingolimod analogues and in vitro processing experiments showed that they are processed to the desired pharmacologically active monophosphate. The research signifies the development of an entirely new family of potential therapeutic agents.

Loss of upper-limb function is a problem following stroke. Recent research has led to the emergence of new treatments but progress is hampered by lack of reliable objective measures of impairment, and understanding of the underlying impairment mechanisms associated with loss and recovery of functional activity. The aim of this research was to identify, using neuromechanical measurement methods, inter-relationships between motor impairments, and correlates of motor impairments with functional activity limitation in the upper limb of acute and chronic stroke survivors. An instrumented rig has been developed to measure impairments: muscle weakness, active range of movement, motor control accuracy in rhythmic and discrete tracking tasks, spasticity, coactivation, contracture and non-neural stiffness. In pilot studies, signal processing and data analysis techniques have been used to generate novel, clinically and physiologically relevant indices to quantify impairments. In a Main Study, 13 older impaired participants in the acute phase post-stroke, 13 in the chronic phase 14 age-matched unimpaired participants underwent rig assessments and performed a test of upper limb activity. A sub-group of impaired participants were tested on two days for test-retest reliability evaluation. Statistical tests have confirmed the validity of the impairments to distinguish between acute and chronic patients and unimpaired individuals, except coactivation during discrete movements and non-neural stiffness. Repeatability coefficients for the active test indices have been presented as benchmark values for use in future trials. The muscle activation indices showed lower repeatability which highlights the challenge of using these to measure change over time. The impairments that contributed to lower motor control accuracy were reduced extensor weakness, delayed extensor onset timing, coactivation and smaller extension AROM and PROM; coactivation was more strongly associated with motor control accuracy than with spasticity or stiffness. The most important contributors to functional activity in the acute group was extensor weakness, and in the chronic group was motor control accuracy and coactivation (rhythmic task). Contracture was important contributor in both groups, and was associated with weakness and loss of active range of movement rather than spasticity. The findings support the notion that rehabilitation strategies should focus on increasing muscle strength and prevention of contracture. However, assessment of more complex impairments like motor control accuracy and coactivation may be crucial to better target therapy, especially in the later phases post-stroke.

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Disturbances in the acid-base balance, such as acidosis and alkalosis, alone or in the presence of postprandial or pathological hyperlipidaemia can alter the pharmacological and toxicological outcomes of statin therapy. Both acid-base imbalance and hyperlipidaemia are quite common among statin users. Statins are commonly prescribed for elderly patients who have multiple co-morbidities such as diabetes mellitus, cardiovascular and renal diseases. These conditions are risk factors for the development of metabolic acidosis. In addition, patients with abnormal plasma lipoproteins levels are usually treated with statins. There is also a general consensus by clinicians to recommend such patients to use unsaturated fat and fatty acids such as olive oil for prevention of cardiovascular and atherosclerotic diseases. The use of such oils is associated with transient but significant elevation in plasma triglyceride-rich lipoproteins (TRL), mainly chylomicrons. The effect of disturbances in acid-base balance on the inter-conversion of simvastatin and pravastatin between lactone and hydroxy acid forms have been investigated in physiological buffers, human plasma, and cell culture medium over pH ranging from 6.8–7.8. The effects of such inter-conversion on cellular uptake and myotoxicity of statins were assessed in vitro using C2C12 skeletal muscle cells under conditions relevant to acidosis, alkalosis, and physiological pH. Results indicate that the conversion of the lactone forms of simvastatin and pravastatin to the corresponding hydroxy acid is strongly pH-dependent. At physiological and alkaline pH, substantial proportions of simvastatin lactone (~87% and 99%, respectively) and pravastatin lactone (~98% and 99%, respectively) were converted to the active hydroxy acid forms following 24 hours of incubation at 37°C. At acidic pH, conversion occurs to a lower extent, resulting in greater proportion of statin remaining in the more lipophilic lactone form. However, pH alteration did not influence the conversion of the hydroxy acid forms of simvastatin and pravastatin to the corresponding lactones. Furthermore, acidosis has been shown to hinder the metabolism of the lactone form of statins by inhibiting hepatic microsomal enzyme activities. Lipophilic simvastatin lactone was found to be more cytotoxic to undifferentiated and differentiated skeletal muscle cells compared to the more hydrophilic simvastatin hydroxy acid, pravastatin lactone, and pravastatin hydroxy acid. Enhanced cytotoxicity of statins was observed under acidic conditions and is attributed to increased cellular uptake of the more lipophilic lactone or unionised hydroxy acid form. Statins association with plasma lipoproteins was examined using an in silico model, artificial chylomicrons-like lipid particles, rat and human lipoprotein fractions under conditions of physiological and altered pH levels. The effect of statins association with plasma lipoproteins on cellular uptake and myotoxicity of these drugs was also assessed at different pH levels using C2C12 cells that overexpress lipoprotein lipase (LPL). Lipophilic simvastatin displayed considerable association with plasma lipoproteins. The association was more significant with the non-polar lipoprotein fractions (TRL and Low-density lipoprotein [LDL]). This association contributed to increased cellular uptake of statins by C2C12 cells through LPL-mediated process, resulting in a higher intracellular concentration of statins in hyperlipidaemic conditions. These high intracellular concentrations of statins induced significantly higher cytotoxicity in hyperlipidaemic environment comparing to normolipidaemic conditions. Furthermore, a combination of low pH environment (representing acidosis) with hyperlipidaemia enhanced the association of lipophilic statins with plasma lipoproteins and increased cellular uptake and myotoxicity of these drugs. These studies suggest that comorbidities such as hyperlipidaemia, especially when coincident with acidosis, can enhance the statin-associated muscle toxicity, and therefore require extra caution and close monitoring by prescribing clinicians. Hydrophilic rather than lipophilic statins could be a preferable choice in this patient population.