Evaluation of a Psychoeducational intervention for patients with Advanced Cancer who have Cachexia and their lay Carers (EPACaCC): study protocol

Aim: To evaluate a psychoeducational intervention for patients with advanced cancer who have cachexia and their lay carers.

Background: Cachexia is a frequent and devastating syndrome of advanced cancer. It has an impact on patients biologically, psychologically and socially and has profound impact on their lay carers. Prior research has predominately focused on the biological components of cachexia and associated potential treatment modalities. At present, there is no standardized supportive healthcare intervention in current practice that targets the psychosocial impact of this syndrome.

Design: A pragmatic multicentre randomized controlled trial.

Methods: Patient/carer dyads (n = 200) will be recruited into a randomized controlled trial of a DVD intervention for cachexia management. The sample will be recruited from two urban hospices in the UK. The primary outcome measure will be the General Health Questionnaire-12. Additional questionnaires focusing on distress, readiness to give care and coping skills will be used as secondary outcome measures. In addition, lay carers in the intervention group will be asked to participate in semi-structured interviews following the death of their loved one. Both Office for Research Ethics Committee approval and local governance approval at both hospices have been obtained as of February 2013.

Discussion: This is the first time that a psychoeducational DVD has been tested in a randomized controlled trial in this population. Dissemination of findings will make a significant contribution to international knowledge and understanding in this area. Findings will inform education, practice and policy.

Advanced strategies for ion acceleration using high-power lasers

A short overview of laser-plasma acceleration of ions is presented. The focus is on some recent experimental results and the related theoretical work on advanced regimes. These latter include in particular target normal sheath acceleration using ultrashort low-energy pulses and structured targets, radiation pressure acceleration in both thick and ultrathin targets and collisionless shock acceleration in moderate density plasmas. For each approach, open issues and the need and potential for further developments are briefly discussed. © 2013 IOP Publishing Ltd.

Intermittent chemotherapy plus either intermittent or continuous cetuximab for first-line treatment of patients with KRAS wild-type advanced colorectal cancer (COIN-B): a randomised phase 2 trial

Background: Advanced colorectal cancer is treated with a combination of cytotoxic drugs and targeted treatments. However, how best to minimise the time spent taking cytotoxic drugs and whether molecular selection can refine this further is unknown. The primary aim of this study was to establish how cetuximab might be safely and effectively added to intermittent chemotherapy.

Methods: COIN-B was an open-label, multicentre, randomised, exploratory phase 2 trial done at 30 hospitals in the UK and one in Cyprus. We enrolled patients with advanced colorectal cancer who had received no previous chemotherapy for metastases. Randomisation was done centrally (by telephone) by the Medical Research Council Clinical Trials Unit using minimisation with a random element. Treatment allocation was not masked. Patients were assigned (1:1) to intermittent chemotherapy plus intermittent cetuximab or to intermittent chemotherapy plus continuous cetuximab. Chemotherapy was FOLFOX (folinic acid and oxaliplatin followed by bolus and infused fluorouracil). Patients in both groups received FOLFOX and weekly cetuximab for 12 weeks, then either had a planned interruption (those taking intermittent cetuximab) or planned maintenance by continuing on weekly cetuximab (continuous cetuximab). On RECIST progression, FOLFOX plus cetuximab or FOLFOX was recommenced for 12 weeks followed by further interruption or maintenance cetuximab, respectively. The primary outcome was failure-free survival at 10 months. The primary analysis population consisted of patients who completed 12 weeks of treatment without progression, death, or leaving the trial. We tested BRAF and NRAS status retrospectively. The trial was registered, ISRCTN38375681.

Findings: We registered 401 patients, 226 of whom were enrolled. Results for 169 with KRAS wild-type are reported here, 78 (46%) assigned to intermittent cetuximab and 91 (54%) to continuous cetuximab. 64 patients assigned to intermittent cetuximab and 66 of those assigned to continuous cetuximab were included in the primary analysis. 10-month failure-free survival was 50% (lower bound of 95% CI 39) in the intermittent group versus 52% (lower bound of 95% CI 41) in the continuous group; median failure-free survival was 12·2 months (95% CI 8·8–15·6) and 14·3 months (10·7–20·4), respectively. The most common grade 3–4 adverse events were skin rash (21 [27%] of 77 patients vs 20 [22%] of 92 patients), neutropenia (22 [29%] vs 30 [33%]), diarrhoea (14 [18%] vs 23 [25%]), and lethargy (20 [26%] vs 19 [21%]).

Interpretation: Cetuximab was safely incorporated in two first-line intermittent chemotherapy strategies. Maintenance of biological monotherapy, with less cytotoxic chemotherapy within the first 6 months, in molecularly selected patients is promising and should be validated in phase 3 trials.

A feasibility study testing four hypotheses with phase II outcomes in advanced colorectal cancer (MRC FOCUS3): a model for randomised controlled trials in the era of personalised medicine?

Background: Molecular characteristics of cancer vary between individuals. In future, most trials will require assessment of biomarkers to allocate patients into enriched populations in which targeted therapies are more likely to be effective. The MRC FOCUS3 trial is a feasibility study to assess key elements in the planning of such studies.

Patients and methods: Patients with advanced colorectal cancer were registered from 24 centres between February 2010 and April 2011. With their consent, patients' tumour samples were analysed for KRAS/BRAF oncogene mutation status and topoisomerase 1 (topo-1) immunohistochemistry. Patients were then classified into one of four molecular strata; within each strata patients were randomised to one of two hypothesis-driven experimental therapies or a common control arm (FOLFIRI chemotherapy). A 4-stage suite of patient information sheets (PISs) was developed to avoid patient overload.

Results: A total of 332 patients were registered, 244 randomised. Among randomised patients, biomarker results were provided within 10 working days (w.d.) in 71%, 15 w.d. in 91% and 20 w.d. in 99%. DNA mutation analysis was 100% concordant between two laboratories. Over 90% of participants reported excellent understanding of all aspects of the trial. In this randomised phase II setting, omission of irinotecan in the low topo-1 group was associated with increased response rate and addition of cetuximab in the KRAS, BRAF wild-type cohort was associated with longer progression-free survival.

Conclusions: Patient samples can be collected and analysed within workable time frames and with reproducible mutation results. Complex multi-arm designs are acceptable to patients with good PIS. Randomisation within each cohort provides outcome data that can inform clinical practice.

Local recurrence in patients with large and locally advanced breast cancer treated with primary chemotherapy

Background: Primary chemotherapy is being given in the treatment of large and locally advanced breast cancers, but a major concern is local relapse after therapy. This paper has examined patients treated with primary chemotherapy and surgery (either breast-conserving surgery or mastectomy) and has examined the role of factors which may indicate those patients who are subsequently more likely to experience local recurrence of,disease.

Methods: A consecutive series of 173 women, with data available for 166 of these, presenting with large and locally advanced breast cancer (T2 >4 cm, T3, T4, or N2) were treated with primary chemotherapy comprising cyclophosphamide, vincristine, doxorubicin, and prednisolone and then surgery (either conservation or mastectomy with axillary surgery) followed by radiotherapy were examined.

Results: The clinical response rate of these patients was 75% (21% complete and 54% partial), with a complete pathological response rate of 15%. A total of 10 patients (6%) experienced local disease relapse, and the median time to relapse was 14 months (ranging from 3 to 40). The median survival in this group was 27 months (ranging from 13 to 78). In patients having breast conservation surgery, local recurrence occurred in 2%, and in those undergoing mastectomy 7% experience local relapse of disease. Factors predicting patients most likely to experience local recurrence were poor clinical response and residual axillary nodal disease after chemotherapy.

Conclusions: Excellent local control of disease can be achieved in patients with large and locally advanced breast cancers using a combination of primary chemotherapy, surgery and radiotherapy. However, the presence of residual tumor in the axillary lymph nodes after chemotherapy is a predictor of local recurrence and patients with a better clinical response were also less likely to experience local disease recurrence. The size and degree of pathological response did not predict patients most likely to experience recurrence of disease. (C) 2003 Excerpta Medica, Inc. All rights reserved.

Advanced Ceramic Substrate with Ordered and Designed Micro-Structure for Applications in Automotive Catalysts

This study describes an innovative monolith structure designed for applications in automotive catalysis using an advanced manufacturing approach developed at Imperial College London. The production process combines extrusion with phase inversion of a ceramic-polymer-solvent mixture in order to design highly ordered substrate micro-structures that offer improvements in performance, including reduced PGM loading, reduced catalyst ageing and reduced backpressure.

This study compares the performance of the novel substrate for CO oxidation against commercially available 400 cpsi and 900 cpsi catalysts using gas concentrations and a flow rate equivalent to those experienced by a full catalyst brick when attached to a vehicle. Due to the novel micro-structure, no washcoat was required for the initial testing and 13 g/ft3 of Pd was deposited directly throughout the substrate structure in the absence of a washcoat.

Initial results for CO oxidation indicate that the advanced micro-structure leads to enhanced conversion efficiency. Despite an 79% reduction in metal loading and the absence of a washcoat, the novel substrate sample performs well, with a light-off temperature (LOT) only 15 °C higher than the commercial 400 cpsi sample.

To test the effects of catalyst ageing on light-off temperature, each sample was aged statically at a temperature of 1000 °C, based on the Bench Ageing Time (BAT) equation. The novel substrate performed impressively when compared to the commercial samples, with a variation in light-off temperature of only 3% after 80 equivalent hours of ageing, compared to 12% and 25% for the 400 cpsi and 900 cpsi monoliths, respectively.

Analysis of deformation behavior and workability of advanced 9Cr-Nb-V ferritic heat resistant steels

Hot compression tests were carried out on 9Cr–Nb–V heat resistant steels in the temperature range of 600–1200 °C and the strain rate range of 10−2–100 s−1 to study their deformation characteristics. The full recrystallization temperature and the carbon-free bainite phase transformation temperature were determined by the slope-change points in the curve of mean flow stress versus the inverse of temperature. The parameters of the constitutive equation for the experimental steels were calculated, including the stress exponent and the activation energy. The lower carbon content in steel would increase the fraction of precipitates by increasing the volume of dynamic strain-induced (DSIT) ferrite during deformation. The ln(εc) versus ln(Z) and the ln(σc) versus ln(Z) plots for both steels have similar trends. The efficiency of power dissipation maps with instability maps merged together show excellent workability from the strain of 0.05 to 0.6. The microstructure of the experimental steels was fully recrystallized upon deformation at low Z value owing to the dynamic recrystallization (DRX), and exhibited a necklace structure under the condition of 1050 °C/0.1 s−1 due to the suppression of the secondary flow of DRX. However, there were barely any DRX grains but elongated pancake grains under the condition of 1000 °C/1 s−1 because of the suppression of the metadynamic recrystallization (MDRX).

Advanced Modelling and Optimization of Infared Oven in Injection Stretch Blow-moulding for Energy Saving

In the production process of polyethylene terephthalate (PET) bottles, the initial temperature of preforms plays a central role on the final thickness, intensity and other structural properties of the bottles. Also, the difference between inside and outside temperature profiles could make a significant impact on the final product quality. The preforms are preheated by infrared heating oven system which is often an open loop system and relies heavily on trial and error approach to adjust the lamp power settings. In this paper, a radial basis function (RBF) neural network model, optimized by a two-stage selection (TSS) algorithm combined with partial swarm optimization (PSO), is developed to model the nonlinear relations between the lamp power settings and the output temperature profile of PET bottles. Then an improved PSO method for lamp setting adjustment using the above model is presented. Simulation results based on experimental data confirm the effectiveness of the modelling and optimization method.

Healthcare professionals’ response to cachexia in advanced cancer

Background: Cancer cachexia is a complex metabolic syndrome characterised by severe and progressive weight loss which is predominantly muscle mass. It is a devastating complication of advanced cancer with profound bio-psycho-social implications for patients and their families. At present, there is no curative treatment for cachexia in advanced cancer therefore, the most important healthcare response entails the minimisation of the psycho-social distress associated with it. However, the literature suggests healthcare professionals’ are missing opportunities to respond to the multi-dimensional needs of this population.

Aim: The objective of this study was to explore healthcare professionals’ experience, understanding and perception of need of patients with advanced cancer who have cachexia and their families.

Methods: An interpretative qualitative approach based on symbolic interactionism was adopted. A purposive sample of doctors, nurses, specialist nurses, and dieticians were recruited from a cancer centre in a large teaching hospital in Northern Ireland. Data collection consisted of two phases: focus group interviews followed by individual semi-structured interviews.

Results: Findings from the focus group interviews were used as a framework for the semi structured interview schedule. Results centred on the influence of a variable combination of knowledge, culture, and resources on the management of cachexia in advanced cancer. Data revealed that variation in healthcare professionals’ perceptions of cachexia in advanced cancer, along with their professional ethos, influenced their response to it in clinical practice.

Conclusions: This study has revealed that cancer cachexia is a complex and challenging syndrome which needs to be addressed from a holistic model of care to reflect the multidimensional needs of patients and their families. Effective management will require a combination of knowledge, a supportive culture, and adequate resources.