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.

Role of ion channels and subcellular Ca2+ signalling in arachidonic acid induced dilation of pressurised retinal arterioles

Purpose: To investigate the mechanisms responsible for the dilatation of rat retinal arterioles in response to arachidonic acid (AA). Methods: Changes in the diameter of isolated, pressurized rat retinal arterioles were measured in the presence of AA alone and following pre-incubation with pharmacological agents inhibiting Ca2+ sparks and oscillations and K+ channels. Subcellular Ca2+ signals were recorded in arteriolar myocytes using Fluo-4-based confocal imaging. The effects of AA on membrane currents of retinal arteriolar myocytes were studied using whole-cell perforated patch clamp recording. Results: AA dilated pressurised retinal arterioles under conditions of myogenic tone. Eicosatetraynoic acid (ETYA) exerted a similar effect, but unlike AA, its effects were rapidly reversible. AA-induced dilation was associated with an inhibition of subcellular Ca2+ signals. Interventions known to block Ca2+ sparks and oscillations in retinal arterioles caused dilatation and inhibited AA-induced vasodilator responses. AA accelerated the rate of inactivation of the A-type Kv current and the voltage dependence of inactivation was shifted to more negative membrane potentials. It also enhanced voltage-activated and spontaneous BK currents, but only at positive membrane potentials. Pharmacological inhibition of A-type Kv and BK currents failed to block AA-induced vasodilator responses. AA suppressed L-type Ca2+ currents. Conclusions: These results suggest that AA induces retinal arteriolar vasodilation by inhibiting subcellular Ca2+ signalling activity in retinal arteriolar myocytes, most likely through a mechanism involving the inhibition of L-type Ca2+ channel activity. AA actions on K+ currents are inconsistent with a model in which K+ channels contribute to the vasodilator effects of AA.

Pathophysiology and Pathogenesis of Diabetic Retinopathy

Diabetic retinopathy is traditionally viewed as a disease of the retinal blood vessels, although there is increasing evidence that retinal neurons and glial cells are also affected. This article describes the changes in the diabetic retina that precede the development of clinical diabetic retinopathy, including changes in the rate of retinal blood flow, alterations in the electroretinogram and breakdown of the integrity of the blood-retinal barrier. The long term lesions of diabetic retinopathy are characterised by a complex array of vasodegenerative changes that lead directly to areas of retinal ischaemia. This frequently triggers the onset of macular oedema and/or the proliferative stages of diabetic retinopathy with risk of visual impairment and blindness. Neurodegeneration has also been reported in the retina during both human and experimental diabetic retinopathy, although presently it remains unclear to what extent such changes contribute to visual loss in diabetic retinopathy.

The use of a dynamic truck-trailer drive-by system to monitor bridge damping

Bridge structures are continuously subject to degradation due to the environment, ageing and excess loading. Periodic monitoring of bridges is therefore a key part of any maintenance strategy as it can give early warning if a bridge becomes unsafe. This article investigates an alternative method for the monitoring of bridge dynamic behaviour: a truck-trailer vehicle system, with accelerometers fitted to the axles of the trailer. The method aims to detect changes in the damping of a bridge, which may indicate the existence of damage. A simplified vehicle-bridge interaction model is used in theoretical simulations to assess the effectiveness of the method in detecting those changes. The influence of road profile roughness on the vehicle vibration is overcome by recording accelerations from both axles of a trailer and then analysing the spectra of the difference in the accelerations between the two axles. The effectiveness of the approach in detecting damage simulated as a loss in stiffness is also investigated. In addition, the sensitivity of the approach to the vehicle speed, road roughness class, bridge span length, changes in the equal axle properties and noise is investigated.

Identification of damping in a bridge using a moving instrumented vehicle

In recent years, there has been a significant increase in the number of bridges which are being instrumented and monitored on an ongoing basis. This is in part due to the introduction of bridge management systems designed to provide a high level of protection to the public and early warning if the bridge becomes unsafe. This paper investigates a novel alternative; a low-cost method consisting of the use of a vehicle fitted with accelerometers on its axles to monitor the dynamic behaviour of bridges. A simplified half-car vehicle-bridge interaction model is used in theoretical simulations to test the effectiveness of the approach in identifying the damping ratio of the bridge. The method is tested for a range of bridge spans and vehicle velocities using theoretical simulations and the influences of road roughness, initial vibratory condition of the vehicle, signal noise, modelling errors and frequency matching on the accuracy of the results are investigated.

Defining the Impact of Non-Native Species

Non-native species cause changes in the ecosystems to which they are introduced. These changes, or some of them, are usually termed impacts; they can be manifold and potentially damaging to ecosystems and biodiversity. However, the impacts of most non-native species are poorly understood, and a synthesis of available information is being hindered because authors often do not clearly define impact. We argue that explicitly defining the impact of non-native species will promote progress toward a better understanding of the implications of changes to biodiversity and ecosystems caused by non-native species; help disentangle which aspects of scientific debates about non-native species are due to disparate definitions and which represent true scientific discord; and improve communication between scientists from different research disciplines and between scientists, managers, and policy makers. For these reasons and based on examples from the literature, we devised seven key questions that fall into 4 categories: directionality, classification and measurement, ecological or socio-economic changes, and scale. These questions should help in formulating clear and practical definitions of impact to suit specific scientific, stakeholder, or legislative contexts.

Drive-by bridge inspection from three different approaches

This study presents a vibration-based health monitoring strategy for short span bridges utilizing an inspection vehicle. How to screen the health condition of short span bridges in terms of a drive-by bridge inspection is described. Feasibility of the drive-by bridge inspection is investigated through a scaled laboratory moving vehicle experiment. The feasibility of using an instrumented vehicle to detect the natural frequency and changes in structural damping of a model bridge was observed. Observations also demonstrated the possibility of diagnosis of bridges by comparing patterns of identified bridge dynamic parameters through periodical monitoring. It was confirmed that the moving vehicle method identifies the damage location and severity well.

A drive-by inspection system via vehicle moving force identification

This paper presents a novel method to carry out monitoring of transport infrastructure such as pavements and bridges through the analysis of vehicle accelerations. An algorithm is developed for the identification of dynamic vehicle-bridge interaction forces using the vehicle response. Moving force identification theory is applied to a vehicle model in order to identify these dynamic forces between the vehicle and the road and/or bridge. A coupled half-car vehicle-bridge interaction model is used in theoretical simulations to test the effectiveness of the approach in identifying the forces. The potential of the method to identify the global bending stiffness of the bridge and to predict the pavement roughness is presented. The method is tested for a range of bridge spans using theoretical simulations and the influences of road roughness and signal noise on the accuracy of the results are investigated.

Dynamic Axle Force and Road Profile Identification Using a Moving Vehicle

In the interaction between vehicles, pavements and bridges, it is essential to aim towards a reduction of vehicle axle forces to promote longer pavement life spans and to prevent bridges loads becoming too high. Moreover, as the road surface roughness affects the vehicle dynamic forces, an efficient monitoring of pavement condition is also necessary to achieve this aim. This paper uses a novel algorithm to identify the dynamic interaction forces and pavement roughness from vehicle accelerations in both theoretical simulations and a laboratory experiment; moving force identification theory is applied to a vehicle model for this purpose. Theoretical simulations are employed to evaluate the ability of the algorithm to predict forces over a range of bridge spans and to evaluate the influence of road roughness level on the accuracy of the results. Finally, in addressing the challenge for the real-world problem, the effects of vehicle configuration and speed on the predicted road roughness are also investigated in a laboratory experiment.

Characterisation of pavement profile heights using accelerometer readings and a combinatorial optimisation technique

Pavement surface profiles induce dynamic ride responses in vehicles which can potentially be used to classify road surface roughness. A novel method is proposed for the characterisation of pavement roughness through an analysis of vehicle accelerations. A combinatorial optimisation technique is applied to the determination of pavement profile heights based on measured accelerations at and above the vehicle axle. Such an approach, using low-cost inertial sensors, would provide an inexpensive alternative to the costly laser-based profile measurement vehicles. The concept is numerically validated using a half-car roll dynamic model to infer measurements of road profiles in both the left and right wheel paths.

Theoretical investigation of the use of a moving vehicle to identify bridge dynamic parameters

Pavements and bridges are subject to a continuous degradation due to traffic aggressiveness, ageing and environmental factors. A rational transport policy requires the monitoring of this transport infrastructure in order to provide adequate maintenance and guarantee the required levels of transport service and safety. This paper investigates the use of an instrumented vehicle fitted with accelerometers on its axles to monitor the dynamics of bridges. A simplified quarter carbridge interaction model is used in theoretical simulations and the natural frequency of the bridge is extracted from the spectra of the vehicle accelerations. The accuracy is better at lower speeds and for smooth road profiles. The structural damping of the bridge was also monitored for smooth and rough road profiles. The magnitude of peaks in the power spectral density of the vehicle accelerations decreased with increasing bridge damping and this decrease was easier to detect the smoother the road profile.

Potentially inappropriate prescribing among older people in the United Kingdom

Background: Potentially inappropriate prescribing (PIP) in older people is associated with increases in morbidity, hospitalisation and mortality. The objective of this study was to estimate the prevalence of and factors associated with PIP, among those aged ≥70 years, in the United Kingdom, using a comprehensive set of prescribing indicators and comparing these to estimates obtained from a truncated set of the same indicators.

Methods: A retrospective cross-sectional study was carried out in the UK Clinical Practice Research Datalink (CPRD), in 2007. Participants included those aged ≥ 70 years, in CPRD. Fifty-two PIP indicators from the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria were applied to data on prescribed drugs and clinical diagnoses. Overall prevalence of PIP and prevalence according to individual STOPP criteria were estimated. The relationship between PIP and polypharmacy (≥4 medications), comorbidity, age, and gender was examined. A truncated, subset of 28 STOPP criteria that were used in two previous studies, were further applied to the data to facilitate comparison.

Results: Using 52 indicators, the overall prevalence of PIP in the study population (n = 1,019,491) was 29%. The most common examples of PIP were therapeutic duplication (11.9%), followed by use of aspirin with no indication (11.3%) and inappropriate use of proton pump inhibitors (PPIs) (3.7%). PIP was strongly associated with polypharmacy (Odds Ratio 18.2, 95% Confidence Intervals, 18.0-18.4, P < 0.05). PIP was more common in those aged 70–74 years vs. 85 years or more and in males. Application of the smaller subset of the STOPP criteria resulted in a lower PIP prevalence at 14.9% (95% CIs 14.8-14.9%) (n = 151,598). The most common PIP issues identified with this subset were use of PPIs at maximum dose for > 8 weeks, NSAIDs for > 3 months, and use of long-term neuroleptics.

Conclusions: PIP was prevalent in the UK and increased with polypharmacy. Application of the comprehensive set of STOPP criteria allowed more accurate estimation of PIP compared to the subset of criteria used in previous studies. These findings may provide a focus for targeted interventions to reduce PIP.

Relationship between genome and epigenome - challenges and requirements for future research

Understanding the links between genetic, epigenetic and non-genetic factors throughout the lifespan and across generations and their role in disease susceptibility and disease progression offer entirely new avenues and solutions to major problems in our society. To overcome the numerous challenges, we have come up with nine major conclusions to set the vision for future policies and research agendas at the European level.

Predictors and dynamics of postpartum relapses in women with multiple sclerosis

Several studies have shown that pregnancy reduces multiple sclerosis (MS) relapses, which increase in the early postpartum period. Postpartum relapse risk has been predicted by pre-pregnancy disease activity in some studies.