Maximising the duration of disease control in metastatic renal cell carcinoma with targeted agents: an expert agreement.

With six targeted agents approved (sorafenib, sunitinib, temsirolimus, bevacizumab [+interferon], everolimus and pazopanib), many patients with metastatic renal cell carcinoma (mRCC) will receive multiple therapies. However, the optimum sequencing approach has not been defined. A group of European experts reviewed available data and shared their clinical experience to compile an expert agreement on the sequential use of targeted agents in mRCC. To date, there are few prospective studies of sequential therapy. The mammalian target of rapamycin (mTOR) inhibitor everolimus was approved for use in patients who failed treatment with inhibitors of vascular endothelial growth factor (VEGF) and VEGF receptors (VEGFR) based on the results from a Phase III placebo-controlled study; however, until then, the only licensed agents across the spectrum of mRCC were VEGF(R) inhibitors (sorafenib, sunitinib and bevacizumab + interferon), and as such, a large body of evidence has accumulated regarding their use in sequence. Data show that sequential use of VEGF(R) inhibitors may be an effective treatment strategy to achieve prolonged clinical benefit. The optimal place of each targeted agent in the treatment sequence is still unclear, and data from large prospective studies are needed. The Phase III AXIS study of second-line sorafenib vs. axitinib (including post-VEGF(R) inhibitors) has completed, but the data are not yet published; other ongoing studies include the Phase III SWITCH study of sorafenib-sunitinib vs. sunitinib-sorafenib (NCT00732914); the Phase III 404 study of temsirolimus vs. sorafenib post-sunitinib (NCT00474786) and the Phase II RECORD 3 study of sunitinib-everolimus vs. everolimus-sunitinib (NCT00903175). Until additional data are available, consideration of patient response and tolerability to treatment may facilitate current decision-making regarding when to switch and which treatment to switch to in real-life clinical practice.

Plac8 is required for white adipocyte differentiation in vitro and cell number control in vivo.

Plac8 belongs to an evolutionary conserved family of proteins, mostly abundant in plants where they control fruit weight through regulation of cell number. In mice, Plac8 is expressed both in white and brown adipose tissues and we previously showed that Plac8(-/-) mice develop late-onset obesity, with abnormal brown fat differentiation and reduced thermogenic capacity. We also showed that in brown adipocytes, Plac8 is an upstream regulator of C/EBPβ expression. Here, we first assessed the role of Plac8 in white adipogenesis in vitro. We show that Plac8 is induced early after induction of 3T3-L1 adipocytes differentiation, a process that is prevented by Plac8 knockdown; similarly, embryonic fibroblasts obtained from Plac8 knockout mice failed to form adipocytes upon stimulation of differentiation. Knockdown of Plac8 in 3T3-L1 was associated with reduced expression of C/EBPβ, Krox20, and Klf4, early regulators of the white adipogenic program, and we show that Plac8 could transactivate the C/EBPβ promoter. In vivo, we show that absence of Plac8 led to increased white fat mass with enlarged adipocytes but reduced total number of adipocytes. Finally, even though Plac8(-/-) mice showed impaired thermogenesis due to brown fat dysfunction, this was not associated with changes in glycemia or plasma free fatty acid and triglyceride levels. Collectively, these data indicate that Plac8 is an upstream regulator of C/EBPβ required for adipogenesis in vitro. However, in vivo, Plac8 is dispensable for the differentiation of white adipocytes with preserved fat storage capacity but is required for normal fat cell number regulation.

Traffic Control in Work Zones with Edge Drop-Offs, 2002

Pavement and shoulder edge drop-offs commonly occur in work zones as the result of overlays, pavement replacement, or shoulder construction. The depth of these elevation differentials can vary from approximately one inch when a flexible pavement overlay is applied to several feet where major reconstruction is undertaken. The potential hazards associated with pavement edge differentials depend on several factors including depth of the drop-off, shape of the pavement edge, distance from traveled way, vehicle speed, traffic mix, volume, and other factors. This research was undertaken to review current practices in other states for temporary traffic control strategies addressing lane edge differentials and to analyze crash data and resultant litigation related to edge drop-offs. An objective was to identify cost-effective practices that would minimize the potential for and impacts of edge drop crashes in work zones. Considerable variation in addressing temporary traffic control in work zones with edge drop-off exposure was found among the states surveyed. Crashes related to pavement edge drop-offs in work zones do not commonly occur in the state of Iowa, but some have resulted in significant tort claims and settlements. The use of benefit/cost analysis may provide guidance in selection of an appropriate mitigation and protection of edge drop-off conditions. Development and adoption of guidelines for design of appropriate traffic control for work zones that include edge drop-off exposure, particularly identifying effective use of temporary barrier rail, may be beneficial in Iowa.

Which factors influence glycemic control in the intensive care unit?

PURPOSE OF REVIEW: Intensive insulin therapy titrated to restore and maintain blood glucose between 80 and 110 mg/dl (4.4-6.1 mmol/l) was found to improve survival of critically ill patients in one pioneering proof-of-concept study performed in a surgical intensive care unit. The external validity of these findings was investigated. RECENT FINDINGS: Six independent prospective randomized controlled trials, involving 9877 patients in total, were unable to confirm the survival benefit reported in the pioneering trial. Several hypotheses were proposed to explain this discrepancy, including the case-mix, the features of the usual care, the quality of glucose control and the risks associated with hypoglycemia. SUMMARY: Before a better understanding and delineation of the conditions associated with and improved outcome by tight glycemic control, the choice of an intermediate glycemic target appears as a safe and effective solution.

Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study.

BACKGROUND: Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality. METHODS: We performed a retrospective cohort study of 1002 randomly selected patients aged 50-80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. "Appropriate clinical action" was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values. RESULTS: 20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia. CONCLUSIONS: In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.

Is Inefficiency under control in the Justice Administration?

Efficiency in the administration of justice is found to increase over time, while the variation in the efficiency of the courts tended to remain low and fall over time. This would appear to be good news, at least for the case studied here: the civil courts of first instance in Spain between 2005 and 2009. Apart from the simple passing of time, the percentage of temporary judges in the system also determines some of the differences in efficiency between courts over time. Thus, we find that the greater the percentage of temporary judges, the lower is the efficiency of the courts. Overall, the average relative efficiency level for the period 2005 to 2009 was 97.46%, suggesting the matter is under control.

Nutrient enrichment and water depth modify consumer control in rocky shore macroalgal communities

The objective of my thesis is to assess mechanisms of ecological community control in macroalgal communities in the Baltic Sea. In the top-down model, predatory fish feed on invertebrate mesograzers, releasing algae partly from grazing pressure. Such a reciprocal relationship is called trophic cascade. In the bottom-up model, nutrients increase biomass in the food chain. The nutrients are first assimilated by algae and, via food chain, increase also abundance of grazers and predators. Previous studies on oceanic shores have described these two regulative mechanisms in the grazer - alga link, but how they interact in the trophic cascades from fish to algae is still inadequately known. Because the top-down and bottom-up mechanisms are predicted to depend on environmental disturbances, such as wave stress and light, I have studied these models at two distinct water depths. There are five factorial field experiments behind the thesis, which were all conducted in the Finnish Archipelago Sea. In all the experiments, I studied macroalgal colonization - either density, filament length or biomass - on submerged colonization substrates. By excluding predatory fish and mesograzers from the algal communities, the studies compared the strength of the top-down control to natural algal communities. A part of the experimental units were, in addition, exposed to enriched nitrogen and phosphorus concentrations, which enabled testing of bottom-up control. These two models of community control were further investigated in shallow (<1 m) and deep (ca. 3 m) water. Moreover, the control mechanisms were also expected to depend on grazer species. Therefore different grazer species were enclosed into experimental units and their impacts on macroalgal communities were followed specifically. The community control in the Baltic rocky shores was found to follow theoretical predictions, which have not been confirmed by field studies before. Predatory fish limited grazing impact, which was seen as denser algal communities and longer algal filaments. Nutrient enrichment increased density and filament length of annual algae and, thus, changed the species composition of the algal community. The perennial alga Fucus vesiculosusA and the red alga Ceramium tenuicorne suffered from the increased nutrient availabilities. The enriched nutrient conditions led to denser grazer fauna, thereby causing strong top-down control over both the annual and perennial macroalgae. The strength of the top-down control seemed to depend on the density and diversity of grazers and predators as well as on the species composition of macroalgal assemblages. The nutrient enrichment led to, however, weaker limiting impact of predatory fish on grazer fauna, because fish stocks did not respond as quickly to enhanced resources in the environment as the invertebrate fauna. According to environmental stress model, environmental disturbances weaken the top-down control. For example, on a wave-exposed shore, wave stress causes more stress to animals close to the surface than deeper on the shore. Mesograzers were efficient consumers at both the depths, while predation by fish was weaker in shallow water. Thus, the results supported the environmental stress model, which predicts that environmental disturbance affects stronger the higher a species is in the food chain. This thesis assessed the mechanisms of community control in three-level food chains and did not take into account higher predators. Such predators in the Baltic Sea are, for example, cormorant, seals, white-tailed sea eagle, cod and salmon. All these predatory species were recently or are currently under intensive fishing, hunting and persecution, and their stocks have only recently increased in the region. Therefore, it is possible that future densities of top predators may yet alter the strengths of the controlling mechanisms in the Baltic littoral zone.

Reactive Recruitment of Attentional Control in Math Anxiety: An ERP Study of Numeric Conflict Monitoring and Adaptation

This study uses event-related brain potentials (ERPs) to investigate the electrophysiological correlates of numeric conflict monitoring in math-anxious individuals, by analyzing whether math anxiety is related to abnormal processing in early conflict detection (as shown by the N450 component) and/or in a later, response-related stage of processing (as shown by the conflict sustained potential; Conflict-SP). Conflict adaptation effects were also studied by analyzing the effect of the previous trial"s congruence in current interference. To this end, 17 low math-anxious (LMA)and 17 high math-anxious (HMA) individuals were presented with a numerical Stroop task. Groups were extreme in math anxiety but did not differ in trait or state anxiety or in simple math ability. The interference effect of the current trial (incongruent-congruent) and the interference effect preceded by congruence and by incongruity were analyzed both for behavioral measures and for ERPs. A greater interference effect was found for response times in the HMA group than in the LMA one. Regarding ERPs, the LMA group showed a greater N450 component for the interference effect preceded by congruence than when preceded by incongruity, while the HMA group showed greater Conflict-SP amplitude for the interference effect preceded by congruence than when preceded by incongruity. Our study showed that the electrophysiological correlates of numeric interference in HMA individuals comprise the absence of a conflict adaptation effect in the first stage of conflict processing (N450) and an abnormal subsequent up-regulation of cognitive control in order to overcome the conflict (Conflict-SP). More concretely, our study shows that math anxiety is related to a reactive and compensatory recruitment of control resources that is implemented only when previously exposed to a stimuli presenting conflicting information

ADHD candidate gene (DRD4 exon III) affects inhibitory control in a healthy sample.

Background Dopamine is believed to be a key neurotransmitter in the development of attention-deficit/ hyperactivity disorder (ADHD). Several recent studies point to an association of the dopamine D4 receptor (DRD4) gene and this condition. More specifically, the 7 repeat variant of a variable number of tandem repeats (VNTR) polymorphism in exon III of this gene is suggested to bear a higher risk for ADHD. In the present study, we investigated the role of this polymorphism in the modulation of neurophysiological correlates of response inhibition (Go/Nogo task) in a healthy, high-functioning sample. Results Homozygous 7 repeat carriers showed a tendency for more accurate behavior in the Go/Nogo task compared to homozygous 4 repeat carriers. Moreover, 7 repeat carriers presented an increased nogo-related theta band response together with a reduced go-related beta decrease. Conclusions These data point to improved cognitive functions and prefrontal control in the 7 repeat carriers, probably due to the D4 receptor's modulatory role in prefrontal areas. The results are discussed with respect to previous behavioral data on this polymorphism and animal studies on the impact of the D4 receptor on cognitive functions.

Developing of the Variable Speed Drive -control in simulated parallel pumping systems

This thesis presents briefly the basic operation and use of centrifugal pumps and parallel pumping applications. The characteristics of parallel pumping applications are compared to circuitry, in order to search analogy between these technical fields. The purpose of studying circuitry is to find out if common software tools for solving circuit performance could be used to observe parallel pumping applications. The empirical part of the thesis introduces a simulation environment for parallel pumping systems, which is based on circuit components of Matlab Simulink —software. The created simulation environment ensures the observation of variable speed controlled parallel pumping systems in case of different controlling methods. The introduced simulation environment was evaluated by building a simulation model for actual parallel pumping system at Lappeenranta University of Technology. The simulated performance of the parallel pumps was compared to measured values of the actual system. The gathered information shows, that if the initial data of the system and pump perfonnance is adequate, the circuitry based simulation environment can be exploited to observe parallel pumping systems. The introduced simulation environment can represent the actual operation of parallel pumps in reasonably accuracy. There by the circuitry based simulation can be used as a researching tool to develop new controlling ways for parallel pumps.