Ramucirumab versus placebo as second-line treatment in patients with advanced hepatocellular carcinoma following first-line therapy with sorafenib (REACH): a randomised, double-blind, multicentre, phase 3 trial

BACKGROUND VEGF and VEGF receptor-2-mediated angiogenesis contribute to hepatocellular carcinoma pathogenesis. Ramucirumab is a recombinant IgG1 monoclonal antibody and VEGF receptor-2 antagonist. We aimed to assess the safety and efficacy of ramucirumab in advanced hepatocellular carcinoma following first-line therapy with sorafenib. METHODS In this randomised, placebo-controlled, double-blind, multicentre, phase 3 trial (REACH), patients were enrolled from 154 centres in 27 countries. Eligible patients were aged 18 years or older, had hepatocellular carcinoma with Barcelona Clinic Liver Cancer stage C disease or stage B disease that was refractory or not amenable to locoregional therapy, had Child-Pugh A liver disease, an Eastern Cooperative Oncology Group performance status of 0 or 1, had previously received sorafenib (stopped because of progression or intolerance), and had adequate haematological and biochemical parameters. Patients were randomly assigned (1:1) to receive intravenous ramucirumab (8 mg/kg) or placebo every 2 weeks, plus best supportive care, until disease progression, unacceptable toxicity, or death. Randomisation was stratified by geographic region and cause of liver disease with a stratified permuted block method. Patients, medical staff, investigators, and the funder were masked to treatment assignment. The primary endpoint was overall survival in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT01140347. FINDINGS Between Nov 4, 2010, and April 18, 2013, 565 patients were enrolled, of whom 283 were assigned to ramucirumab and 282 were assigned to placebo. Median overall survival for the ramucirumab group was 9·2 months (95% CI 8·0-10·6) versus 7·6 months (6·0-9·3) for the placebo group (HR 0·87 [95% CI 0·72-1·05]; p=0·14). Grade 3 or greater adverse events occurring in 5% or more of patients in either treatment group were ascites (13 [5%] of 277 patients treated with ramucirumab vs 11 [4%] of 276 patients treated with placebo), hypertension (34 [12%] vs ten [4%]), asthenia (14 [5%] vs five [2%]), malignant neoplasm progression (18 [6%] vs 11 [4%]), increased aspartate aminotransferase concentration (15 [5%] vs 23 [8%]), thrombocytopenia (13 [5%] vs one [<1%]), hyperbilirubinaemia (three [1%] vs 13 [5%]), and increased blood bilirubin (five [2%] vs 14 [5%]). The most frequently reported (≥1%) treatment-emergent serious adverse event of any grade or grade 3 or more was malignant neoplasm progression. INTERPRETATION Second-line treatment with ramucirumab did not significantly improve survival over placebo in patients with advanced hepatocellular carcinoma. No new safety signals were noted in eligible patients and the safety profile is manageable. FUNDING Eli Lilly and Co.

Intervening to reach adolescents and affect health

Background. Assessing the health status of adolescents is challenging for health care providers. Personal disclosure has been associated with improved health outcomes. Story-centered care was examined as an intervention for promoting adolescent disclosure during an urgent care visit. ^ Objectives. This study explored: (1) the effectiveness of story-centered care for promoting adolescent disclosure; (2) health-associated words used by adolescents to describe pressing concerns after an urgent care visit when they had standard care (SC) or story-centered care (SCC) conducted by a Nurse Practitioner (NP). ^ Methods. Subjects were randomly assigned to SC or SCC. In SC, adolescent presenting concerns were identified and treated. In SCC, presenting concerns were treated and NP-adolescent dialogue, facilitated through a screening tool, queried matters of importance to adolescent life. After the visit, adolescents wrote about pressing concerns for 15 minutes. Written words were analyzed with Linguistic Inquiry and Word Count, a software program for analyzing narrative. Ratios were calculated for the number of words (adolescent: NP) used during the urgent care visit. Analysis of variance (ANOVA) was used to evaluate gender-intervention differences in health-associated words. ^ Results. One hundred and six adolescents [Hispanic (65%), White (35%)] completed the study. Fifty-five were female; the average age was 17 (sd = 2.1) years. ^ Adolescents in the story intervention used more words (adolescent: NP, 1:1.3) than those in standard intervention (adolescent: NP, 1:2.7) in proportion to the number of words used by the NP during the urgent care visit. There were gender-intervention differences (p < .01) in positive emotion words and past-tense words in writings about pressing concerns. Males who received the story intervention used more positive emotion and less past-tense words than adolescent males with standard care. Females used more social words (p < .01) in their writings regardless of intervention group. ^ Conclusion. SCC enhanced adolescent disclosure during an urgent care visit. Adolescents will talk to health care providers during episodic visits and males may benefit more than girls may from this approach. Evidence suggests there is value in attending to both presenting and pressing concerns of adolescents. ^

Evolution in the Concept of Development: How Has The World Bank's Legal Assistance Extended its Reach?

The World Bank's legal and judicial reforms programs have expanded considerably since it began to address the issue of governance in the early 1990s. Initially the Bank focused on legal reforms for inducing private investment. Currently, its legal assistance extends to include the criminal justice sector. Such activities cannot be directly construed from its Articles of Agreement. This paper will discuss how the Bank interpreted its Articles in order to ligitimize its expanding activities. The Bank has manoeuvred itself into the criminal justice sector by skillfully changing its concept of development without deviating from its mandate. The change can be described as an 'evolution' which has allowed the Bank to identify any area as target for its development assistance.

Product-related environmental regulation and voluntary environmental actions : impacts of RoHS and REACH in Malaysia

Voluntary environmental actions, such as the adoption of ISO 14001, are gaining increasing attention in developing countries. This study examines the mechanism of ISO 14001 diffusion in a developing economy on the basis of a unique corporate survey of manufacturing sectors in Malaysia. Product-related environmental regulations, such as REACH, are contributing to this diffusion indirectly by promoting quality control standards such as ISO 9001. The importance of foreign direct investment and global value chains for ISO 14001 diffusion is also confirmed.

Effects of RoHs and REACH regulations on firm-level production and export, and the role of global value chains : the cases of Malaysia and Vietnam

This paper uses firm-level data to examine the impact of foreign chemical safety regulations such as RoHS and REACH on the production costs and export performance of firms in Malaysia and Vietnam. This paper also investigates the role of global value chains in enhancing the likelihood that a firm complies with RoHS and REACH. We find that in addition to the initial setup costs for compliance, EU RoHS (REACH) implementation imposes on firms additional variable production costs by requiring additional labor and capital expenditures of around 57% (73%) of variable costs. We also find that compliance with RoHS and REACH significantly increases the probability of export and that compliance with EU RoHS and REACH helps firms enter a greater variety of countries. Furthermore, firms participating in global value chains have higher compliance with RoHS and REACH regulations, regardless of whether the firm is directly exporting, when the firm operates in upstream or downstream industries of the countries' supply chain.

Bio-climatic Design Handbook: designing public space to reach urban sustainability.

The "Bio-climatic Design Handbook: guidelines for the development of planning regulations" is a tool for urban planning and design professionals planning for the construction of public space taking into account bioclimatic and environmental standards. Based on environmental conditions assessment, urban design guidelines are given. These take into account various scales; from the territory to the microclimatic reality. From these general keys for the design of public space the handbook performs recommendations on specific case studies. The application of bioclimatic techniques in urban design promotes comfort in the public space and the respect for the existing environment, while it influences the energy consumption of buildings that conform this open space. The tool was developed in the context of BIOURB project, where Spain and Portugal cooperate writing this bilingual handbook. The case studies are located in this cross-border region.

On the time to reach a critical number of infections in epidemic models with infective and susceptible immigrants.

In this paper we examine the time T to reach a critical number K0 of infections during an outbreak in an epidemic model with infective and susceptible immigrants. The underlying process X, which was first introduced by Ridler-Rowe (1967), is related to recurrent diseases and it appears to be analytically intractable. We present an approximating model inspired from the use of extreme values, and we derive formulae for the Laplace-Stieltjes transform of T and its moments, which are evaluated by using an iterative procedure. Numerical examples are presented to illustrate the effects of the contact and removal rates on the expected values of T and the threshold K0, when the initial time instant corresponds to an invasion time. We also study the exact reproduction number Rexact,0 and the population transmission number Rp, which are random versions of the basic reproduction number R0.