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.

Evaluating conditions for transboundary marine spatial planning: Challenges and opportunities on the island of Ireland

Transboundary cooperation is viewed as an essential element of Marine Spatial Planning (MSP). While much of the MSP literature focuses on the need for, and benefits of, transboundary MSP, this paper explores the political and institutional factors that may facilitate the effective transition to such an approach. Drawing on transboundary planning theory and practice, key contextual factors that are likely to expedite the transition to transboundary MSP are reviewed. These include: policy convergence in neighbouring jurisdictions; prior experience of transboundary planning; and good working relations amongst key actors. Based on this review, an assessment of the conditions for transboundary MSP in the adjoining waters of Northern Ireland and the Republic of Ireland is undertaken. A number of recommendations are then advanced for transboundary MSP on the island of Ireland, including, the need to address the role of formal transboundary institutions and the lack of an agreed legal maritime boundary. The paper concludes with some commentary on the political realities of implementing transboundary MSP.

General practitioners perceptions on advance care planning for patients living with dementia

BACKGROUND: Advance care planning (ACP) facilitates communication and understanding of preferences, nevertheless the use of ACPs in primary care is low. The uncertain course of dementia and the inability to communicate with the patient living with dementia are significant challenges for GPs to initiate discussions on goals of care.

METHODS: A cross-sectional survey, using a purposive, cluster sample of GPs across Northern Ireland with registered dementia patients was used. GPs at selected practices received the survey instrument and up to four mail contacts was implemented.

RESULTS: One hundred and thirty-three GPs (40.6%) participated in the survey, representing 60.9% of surveyed practices. While most respondents regarded dementia as a terminal disease (96.2%) only 37.6% felt that palliative care applied equally from the time of diagnosis to severe dementia. While most respondents thought that early discussions would facilitate decision-making during advanced dementia (61%), respondents were divided on whether ACP should be initiated at the time of diagnoses. While most respondents felt that GPs should take the initiative to introduce and encourage ACP, most survey participants acknowledged the need for improved knowledge to involve families in caring for patients with dementia at the end of life and that a standard format for ACP documentation was needed.

CONCLUSION: Optimal timing of ACP discussions should be determined by the readiness of the patient and family carer to face to face end of life. ACP discussions can be enhanced by educational strategies directed towards the patient and family carer that enable shared decision-making with their GP when considering options in future care.

The views of general practitioners on advance care planning for patients living with dementia

Background Advance care planning (ACP) facilitates communication
and understanding of preferences, nevertheless the use of
ACPs in primary care for patients with dementia is low. The disease’s
uncertain course and the inability to communicate with
the patient living with dementia are significant challenges for
GPs.
Aim The purpose of this study was to describe the attitudes and
practice preferences of GPs working within the UK’s National
Health System (NHS) regarding communication, and decisionmaking
for patients with dementia and their families
Methods A cross-sectional survey, using a purposive, cluster sample
of GPs across Northern Ireland with registered dementia
patients was used.
Results One hundred and thirty-three GPs (40.6%) participated
in the survey, representing 60.9% of surveyed practices. While
most respondents regarded dementia as a terminal disease
(96.2%) only 37.6% felt that palliative care applied equally from
the time of diagnosis to severe dementia. While most respondents
thought that early discussions would facilitate decision-making
during advanced dementia (61%), respondents were divided
on whether ACP should be initiated at the time of diagnoses
(39.8% in favour vs 45.8% disagreed). Interestingly, GPs who
were longer in practice placed greater importance on the presence
of an advance directive (F (2, 124) = 3.38, p = 0.037).
Discussion The timing of initiating ACP varies across individuals
requiring GPs to carefully consider strategies and receptiveness
of the patient and family carer.
Conclusion The findings promote both ongoing training in communication
and dementia management for GPs to meet the
needs of their patients living with dementia.

Advanced energy efficient coordinated multi-point transmission for OFDMA

The ever-growing energy consumption in mobile networks stimulated by the expected growth in data tra ffic has provided the impetus for mobile operators to refocus network design, planning and deployment towards reducing the cost per bit, whilst at the same time providing a signifi cant step towards reducing their operational expenditure. As a step towards incorporating cost-eff ective mobile system, 3GPP LTE-Advanced has adopted the coordinated multi-point (CoMP) transmission technique due to its ability to mitigate and manage inter-cell interference (ICI). Using CoMP the cell average and cell edge throughput are boosted. However, there is room for reducing energy consumption further by exploiting the inherent exibility of dynamic resource allocation protocols. To this end packet scheduler plays the central role in determining the overall performance of the 3GPP longterm evolution (LTE) based on packet-switching operation and provide a potential research playground for optimizing energy consumption in future networks. In this thesis we investigate the baseline performance for down link CoMP using traditional scheduling approaches, and subsequently go beyond and propose novel energy e fficient scheduling (EES) strategies that can achieve power-e fficient transmission to the UEs whilst enabling both system energy effi ciency gain and fairness improvement. However, ICI can still be prominent when multiple nodes use common resources with di fferent power levels inside the cell, as in the so called heterogeneous networks (Het- Net) environment. HetNets are comprised of two or more tiers of cells. The rst, or higher tier, is a traditional deployment of cell sites, often referred to in this context as macrocells. The lower tiers are termed small cells, and can appear as microcell, picocells or femtocells. The HetNet has attracted signiffi cant interest by key manufacturers as one of the enablers for high speed data at low cost. Research until now has revealed several key hurdles that must be overcome before HetNets can achieve their full potential: bottlenecks in the backhaul must be alleviated, as well as their seamless interworking with CoMP. In this thesis we explore exactly the latter hurdle, and present innovative ideas on advancing CoMP to work in synergy with HetNet deployment, complemented by a novel resource allocation policy for HetNet tighter interference management. As system level simulator has been used to analyze the proposed algorithm/protocols, and results have concluded that up to 20% energy gain can be observed.

An accessibility planning tool for network transit oriented development : SNAP

In the academic debate regarding the influences between urban form, built environment and travel patterns, a specific idea that has taken hold is that more compact urban development around railway stations, often referred to as Transit Oriented Development (TOD), contributes to the control of vehicle travel and to more sustainable metropolitan systems. According to this general principle this work proposes a GIS accessibility tool for the design of polycentric transit oriented scenario: SNAP - Station Network Accessibility Planning tool. In the first part the state of the art on Transit Oriented Development policies in Europe is presented with a focus on three study cases. In the second part the SNAP tool is described, with remarks to the approach, the methodology and the used indicators. Furthermore the paper discusses an application to the metropolitan area of Naples.

Les TOD dans la région de Montréal : la demande et les barrières à l'offre

Le développement axé sur le transport en commun (transit-oriented development ou TOD) est un concept urbanistique souvent proposé comme solution aux problèmes associés à l’étalement urbain. La majorité des recherches sur ce concept sont descriptives ; rares sont les études qui examinent l’impact des projets de TOD sur les comportements en transport. Certains chercheurs proposent d’étudier les raisons qui expliquent la rareté de véritables TOD en Amérique du Nord. Cette approche s’appuie sur l’hypothèse que ce manque d’exemples est le résultat d’une faible demande, ou d’une multiplicité de barrières, quelles soient financière, réglementaire, politique, organisationnelle ou structurelle. Notre étude s’inscrit dans ce courant, afin d’examiner le développement de TOD dans la région métropolitaine de Montréal. L’étude empirique se concentre sur la perspective des promoteurs immobiliers quant à l’ampleur de la demande et des barrières à l’offre de TOD. La méthodologie de notre étude consiste en des entrevues avec les promoteurs immobiliers travaillant dans la banlieue montréalaise. Les résultats montrent que la demande est en croissance pour les produits ayant certaines caractéristiques de TOD, mais que la demande pour des TOD reste faible. Deux barrières principales ressortent de cette étude, soit le manque de terrains et l’offre insuffisante de service de transport en commun. On peut identifier d’autres obstacles majeurs dont le manque d’une définition commune du TOD et une structure de l’industrie de l’industrie mal adaptée à ces formes de développement. L’étude conclue que la réalisation de TOD dans le contexte montréalais requiert que les acteurs gouvernementaux assument un rôle plus proactif et visionnaire.

Coordonner les transports et l'urbanisme dans un contexte urbain concret : le TOD comme instrument d'action publique, le cas de Sainte-Therese, QC

Le concept de transit-oriented development (TOD) est habituellement abordé en tant qu'ensemble fixe de caractéristiques physico-spatiales. Cette approche ne s'avere pas suffisante pour comprendre comment le TOD peut être pertinent pour coordonner les transports et l'urbanisme dans un contexte urbain concret. Afin de combler cette lacune, nous proposons d'étudier le TOD en tant qu'instrument d'action publique, adopté, produit et utilisé par les acteurs sur le territoire en fonction des enjeux, des ressources et des contraintes qui y sont présents. Ce travail exploratoire est fondé sur une étude de cas de la mise en place du TOD a Sainte-Thérese. Pour comprendre comment se sont arrimés les intérêts des acteurs impliqués et ce qui en a résulté, la collecte de données se fait a l'aide de sources écrites, mais aussi d’entretiens semi-directifs avec les acteurs clé. Les résultats de l'étude confirment la pertinence de l'approche adoptée pour aborder le TOD. Le TOD comme instrument d'action publique peut être qualifié d'opérateur de congruence, car il permet de faire converger les intérêts différents, et même potentiellement contradictoires, qui sont en jeu sur le territoire. Cependant, il n'y a pas de formule passe-partout: la production du TOD se fait en grande partie de façon incrémentale, en fonction des conditions sur le territoire. La mise en place du TOD n'exige pas nécessairement l'invention d'un nouveau cadre d'action et peut se faire en grande partie a l'aide des outils existants. Toutefois, pour pouvoir se servir pleinement de ces outils, le leadership des acteurs clé s'avere crucial.

La planification métropolitaine et le transit-oriented development (TOD) : les nouveaux instruments de la gouvernance du Grand Montréal

Cette thèse croise les concepts de planification, de gouvernance et de transit-oriented development (TOD) par une étude de la production, de la mise en débat et de l'adoption du plan métropolitain d'aménagement et de développement (PMAD) de la Communauté métropolitaine de Montréal (CMM). Elle expose les résultats de quatre années de recherche qualitative sur les impacts de l'épisode du PMAD et de la stratégie TOD de la CMM sur les pratiques planificatrices et les processus décisionnels du Grand Montréal à l'échelle métropolitaine. Elle révèle que la planification métropolitaine et l'objectif de coordination du transport et de l'aménagement en général ainsi que le PMAD et le concept de TOD en particulier y sont des instruments de gouvernance. Les chapitres 2, 3 et 4 présentent la problématique, le terrain d'enquête et la démarche méthodologique de cette recherche. Le chapitre 5 relate l'épisode du PMAD en analysant son contenu, les procédures par lesquelles la CMM l'a produit, mis en débat et adopté, les réactions des parties prenantes de la région quant à ces aspects et la façon dont elles comptent assurer le suivi de sa mise en œuvre. Le chapitre 6 illustre comment cet épisode a fait du PMAD un instrument de gouvernance pour le Grand Montréal en décortiquant le rôle de la participation publique, des médias, des acteurs des milieux régional et local, des élus, de la CMM et de la société civile de la région au sein de ce processus de changement de registre de la planification et de la gouvernance les déployant sur des bases plus stratégiques et collaboratives. Le chapitre 7 montre que cet épisode a aussi fait du TOD un instrument de gouvernance pour le Grand Montréal en détaillant les tenants et aboutissants du processus d'appropriation, de marchand(is)age et d'instrumentalisation du concept par les élites politiques et techniques à des fins de marketing territorial et de construction de capital politique ouvrant la voie à la stabilisation d'une gouvernance en matière d'aménagement métropolitain. Il se dégage de cette thèse que ces profondes transformations que subissent actuellement la planification et la gouvernance exacerbent le caractère symbiotique de la relation qui les unit.

Development Planning at the State Level in India - A Case Study with Reference to Kerala, 1957-'84

This thesis entitled “Development planning at the state level in india a case study with reference to kerala1957-84.Planning in India is a concurrent subject with the Centre and the States having well-defined domains of jurisdiction with regard to planning functions and sources of resource mobilisation.The genesis of the lack of academic interest in state level planning is in the widely held belief that in the extent scheme of Centre-State economic relations, the states have little scope for initiative in planning.Both at the theoretical and empirical levels, Kerala has attached very great importance to planning.It has been the localeof wide and deep discussions on the various dimensions of planning.In Kerala's development process, the leading sector consists of social services such as education and public healthOne point that needs special emphasis in this regard is that the high demand for education in Kerala cannot be attributed to the Keralites' ‘unique urge‘ for education. Rather, it is related to the very high level of unemployment in the state (Kerala has the highest level of unemployment in the country.In resource allocation under the Five Year Plans, Kerala attached the highest weightage to power generation, hydro-electric projects being the major source of power in the state. Nearly one-fourth of the plan resources has been claimed by hydro-electric projects.In the agricultural sector, Kera1a's level of productive use of electric power is one of the lowest.As is evident.from above, planning in Kerala has not enabled us to solve the basic problems of the state. More 'scientific' planning in the sense of applying mre sophisticated planning techniques is obviously not the answer. It, on the contrary, consists of more fundamental changes some of which can be brought about through an effective use of measures well within the power of the State Government.

District Level Planning In Kerala And Karnataka - A Comparative Study

When we consider Kerala and Karnataka States according to their levels of decentralisation. Kerala is at the beginning of the scale of decentralisation whereas Kamataka has moved far ahead along this scale. Therefore I in order to conduct a comparative study of the SUbject under analysis t Kamataka has been selected owing to the fact that it is in an advanced stage in the experience of district planning compared to Kerala , Karnataka could successfully implement district planning and it is me of the pioneering states in this regard. But Kerala has not gained much experience in the field of decentralised district planning till now. Furthermore Kerala and Kamataka states are selected for the present study due to operational reasons I besides the author I s familiarity with the socia-economic conditions of these states. Thus. an analysis of the district planning experience of Kamataka will provide constructive and valuable information. which will be of great importance to Kerala State, which is now aspiring to introduce ful.I-f'Iedge district planning by constituting elected District Coancils in every district of Kerala. Moreover. the findings and policy implications of the present study will be of immense help to planners, politicians. administrators, academicians and people at large.

Re-conceptualising public participation in spatial planning: a view through autopoiesis

This article examines the relevance of the concept of autopoiesis for public participation in spatial planning. The concept of autopoiesis within social science, as advanced by Niklas Luhmann (1995) argues for a systemic, consistent and sophisticated theory of society based on a systems view, as opposed to more familiar action-based theories (for instance as in the case of the Habermasian tradition). By examining the relevance of the concept for public participation in spatial planning, this article highlights specific aspects of public participation that draw attention to dimensions of planning that are not currently explicitly highlighted within mainstream discourses in planning

Feasibility of oncoplastic techniques in the surgical management of locally advanced breast cancer

Background: Locally advanced breast cancer (LABC) is still common in developing countries. The association between neoadjuvant chemotherapy (NC) and oncoplastic surgery (OS) might provide an oncological treatment with satisfactory aesthetic results.Purpose: The goal was to demonstrate if oncoplastic surgical techniques can be utilized to treat LABC which was submitted to neoadjuvant chemotherapy.Methods: This prospective clinical trial included breast cancer patients, clinical stage III, who underwent established NC regimen. All patients underwent preoperative planning to control the tumor size and to define the surgical technique. A detailed analysis of the pathological specimen was performed.Results: 50 patients were assessed and surgically treated. Tumor size ranged from 3.0 to 14.0 cm (median 6.5 cm). Pathologic response was rated as stable, progressive, partial response, and complete response in 10%, 8%, 80% and 2% of the cases, respectively. Seventeen (34%) patients were submitted to OS. No patient had positive margins. Skin involvement was presented in 36% of pathologic specimen.Conclusions: Oncoplastic surgical techniques for selected patients decrease the rates of radical surgery despite large tumors. (www.clinicaltrials.gov, NCT00820690). (C) 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Planning accelerated life tests under Exponentiated-Weibull-Arrhenius model

Purpose - The purpose of this paper is to present designs for an accelerated life test (ALT). Design/methodology/approach - Bayesian methods and simulation Monte Carlo Markov Chain (MCMC) methods were used. Findings - In the paper a Bayesian method based on MCMC for ALT under EW distribution (for life time) and Arrhenius models (relating the stress variable and parameters) was proposed. The paper can conclude that it is a reasonable alternative to the classical statistical methods since the implementation of the proposed method is simple, not requiring advanced computational understanding and inferences on the parameters can be made easily. By the predictive density of a future observation, a procedure was developed to plan ALT and also to verify if the conformance fraction of the manufactured process reaches some desired level of quality. This procedure is useful for statistical process control in many industrial applications. Research limitations/implications - The results may be applied in a semiconductor manufacturer. Originality/value - The Exponentiated-Weibull-Arrhenius model has never before been used to plan an ALT. © Emerald Group Publishing Limited.